BILLING 101. W. Scott Campbell, Ph.D, MBA Labpoint, LLC

Transcription

1 BILLING 101 W. Scott Campbell, Ph.D, MBA Labpoint, LLC

2 Laboratory Services Types of laboratory services Human Clinical Environmental Water

3 Human Clinical Process Overview Patient Encounter Process specimen Obtain specimen Get Paid

4 Payment Sources Grants /State Funding (becoming limited) Monthly Invoicing Very common Pertains to human clinical, environmental, water Third party, insurance billing Human clinical Topic for today

5 Insurance Payment Process Send bill for services and get paid, right? Not so fast Insurance companies have a well-oiled process sphl s need to know the rules of the road to bill insco s and get paid

6 Key Points to Understand Required Information needed to bill 3 rd parties Patient demographic information Insurance information Service and diagnostic codes (CPT/ICD) Required Policies, Processes Tax ID, Provider ID s, Facility ID Legislative authority (3 rd parties, individual tax payers) Contracts with 3 rd Party payers Required Infrastructure Systems Staff

7 Start at the Beginning Information to capture at time of service: Name, address, DOB Insurance information Company, Member ID, Group ID, Relationship to insured Guarantor information address Patient Encounter Forms to get signed: Permission to bill insurance HIPAA release/policy Medicare billing forms

8 Clinical Information to Capture Clinical Information Needed: Reason for the test Indicated by Physician/Other provider ICD-9 code (Insurance Company Will NOT pay without this code) Obtain specimen Ask at Order Entry Information (AOE) Familiar to most labs Example: specimen source

9 Information to Capture in the Lab Information Needed from Specimen Processing: Lab Services Provided put into CPT code Process Specimen Not necessarily a one to one correlation between lab processes and CPT codes. Billing codes sent to Revenue Cycle System Results back to patient and clinician

10 Send Bill Get Paid Right? Patient Encounter Process specimen Obtain specimen Get Paid Now comes the hard part You need Betty the Biller

11 How does this get done? Lab Services to Reimbursement Lab codes to CPT codes CPT current procedural terminology, 5-digit codes Not a one-to-one between CPT and bench tests The only codes acknowledged by 3 rd party payers ( exception: HCPCS) Diagnostic codes ICD-9 (Soon ICD-10); 3 to 5 character alpha numeric code Tells the reason for the lab test

12 Example - STD Gonorrhea/Chlamydia Test Local Code (STDSW) CPT Codes (two are required) 87491: Chlamydia trachomatis, amplified probe technique 87591: Neisseria gonnorrhoeae, amplified probe technique Diagnostic code V01.6: Contact with or exposure to venereal disease

13 Example Lead Screen Lead Screening Test Local Code (LEAD) CPT Codes (one is required) 83655: Lead Screening Diagnostic code V15.86: Personal history of contact with and (suspected) exposure to lead

14 Revenue Cycle Management Systems Interacts with the Laboratory Information System Stores patient billing information Stores services rendered per encounter Formats/Sends Insurance Claims Patient-based billing Accounting for entire payment cycle

15 Insurance Claims Insurance Claims CMS 1500 (Professional Services) UB04 (Institutional) Electronic Versions (x12.835) Claim formats Clean Claims Complete information patient, insurance, services Provider and Facility Codes Formatted per third-party payer specifications

16 Insurance Payments Clean claims processed; others? (Black Hole) Insurance claims paid per patient s policy Copayments, Deductibles Covered/not covered services Contractual payments vs. Charge Secondary and tertiary coverage

17 Patient Payments Patients often must pay a portion of the bill You are required to attempt collection of the patient portion of the bill Kick-back regulations Indigence

18 The New Process Patient Encounter Process specimen Get Paid Obtain specimen Third Party Billing

19 Approaches to the New Process In-house personnel Billing Services (MSO Management Service Organization) Partnering Hospitals FQHC (Federally Qualified Health Centers) Other Labs Reference or SPHL

20 Where to Get Help APHL/Labpoint Visit website: Series of informational videos from subject matter experts for various elements of the billing cycle Complete a Needs Assessment Form and a subject matter expert will contact you

21 Thank you