Few people today realize the complexity of the exact medical billing process. This has resulted in an influx of new billing services and new billing solutions. Not surprisingly, medical billing programs abound.
It is therefore important that both health care providers and those looking for work as medical billing agents recognize the advantages and disadvantages of different types of medical billing programs and what it takes to become a qualified medical bill.
Medical Billing Solid!
If anyone thinks that processing medical claims is difficult and confusing now – just wait, it will get worse.
With the expected growth in Medicaid and results-related payments (due to health care reform), and the exponential expansion of diagnostic codes (from 14,000 ICD-9 codes to more than 100,000 ICD-10 codes), complexity is growing – and accelerating.
Fortunately, there is sophisticated medical billing njit software downloads to help healthcare providers automate and manage data. But the danger is that software systems developed in response to an increasingly sophisticated medical billing process have become increasingly complex. This has created an appropriate situation for misusing these tools not only to make false claims – with the risks and penalties involved.
Types of medical billing software systems
In 2000, the Department of Health and Human Services ordered its Office of the Inspector-General to conduct a survey of various types of medical billing programs to determine how the reimbursement of medical care costs would be affected. SIGIR surveyed four types of systems and identified their strengths and weaknesses:
Essential billing programs rely heavily on user knowledge and access skills. They are widely distributed by Medicare’s financial services agents and the private sector. Most key users, if not all, claim information on fax prompts. The program processes these entries to produce an electronic claim. Typical errors include entry errors, incorrect or missing information for the patient or service provider, incorrect or incomplete diagnostic codes, or invalid current procedural terminology (CPT) codes. Basic medical billing software, developed for collective markets, usually does not allow users to customize or bypass their programs. The biggest risk of a claim error is data entry.
IT software increases the capabilities of core programs. It uses databases and associated files to remind patient, provider, diagnostic information and service. User attention can be drawn to invalid code sets, lost diagnostics, and other errors that may prevent processing of a pre-claim claim. Media programs do not seem to generate false claims. It provides tools to help service providers formulate their demands accurately. Vulnerabilities are more likely to originate from the creation and use of inappropriate software. For example, the encryption options for Office-limited actions may lead decisions to higher-value action codes.
The interactive program combines and enhances the core billing capabilities and IT software. The user can give options to correct the problems detected by the program. What distinguishes the interactive program from other medical billing programs is its ability to provide the user with the information and potential outcomes (non-payment, more pay, lower pay) of his decision.
Monopolistic software may represent the greatest risk of misuse. This type of software has been developed for a particular user. It is only possible to know the internal workings of monopolistic programs with one or a few selected people. Hidden programs can add or modify claim information that produces false or fraudulent claims. Unlike commercially available software packages, manufactured for a large market, proprietary software is created to meet the specific needs of a single client. Business programs that produce inaccurate claims have a greater chance of being disclosed and are reported by honest medical providers. Monopolistic software is fragile in Medicare because it is created and used by a select few. Monopolistic software, not commercial software, represents the greatest risk of being intentionally designed to produce incorrect or inaccurate claims.
Summary: In general, the results of the Office of the Inspector General of the Ministry of Health and Human Services were encouraging, ie companies that set up commercial billing programs with commercial trade classification “do not pose a serious risk of making false or false claims.” Monopolistic software, on the other hand, considered more “black boxes” with greater risk of misuse or fraudulent use. In all systems, the likelihood of human error greatly exceeds the chances of program error.