case study in medical billing

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What is medical billing?

August 30, 2024

Medical billing is an important element of the revenue cycle in healthcare. A healthcare facility’s ability to manage billing efficiently and accurately has a direct impact on how quickly and completely that organization will be reimbursed for the services it provides to patients.

Here we'll explore the basics of medical billing, review the steps included in most medical billing processes, and parse the differences between the related tasks of medical coding and medical billing.

What exactly is medical billing?

Medical billing involves submitting and tracking claims with payers to receive payment for medical services. It includes translating medical procedures and diagnoses into medical codes, preparing and submitting claims, and resolving any issues or denials to ensure timely reimbursement.

Medical billing is a core component of revenue cycle management (RCM), the process of effectively managing and optimizing the financial aspects of a healthcare organization. In healthcare, the revenue cycle starts when a patient schedules an appointment and ends when the provider receives payment. Shortening the time from service to payment is the goal of revenue cycle management, and an efficient and accurate medical billing process is a crucial element.

What does the medical billing process include?

Billing in healthcare is a multi-step process to ensure timely and accurate payment for services provided. While this process may differ depending on payers, payment models, and other factors, here are the common steps.

• Patient registration : Collecting patient demographic and insurance information
• Insurance verification : Confirming the patient's insurance coverage and eligibility
• Medical coding : Assigning appropriate medical codes to the services provided
• Charge entry : Recording the charges for the services provided
• Claim submission : Submitting claims to the payer for reimbursement
• Claim adjudication : The payer reviews the claim and determines the payment amount Payment posting: Recording the payment received from the payer or patient 
• Denial management : Handling any claim denials and resubmitting or appealing if necessary
• Patient billing : Generating and sending invoices to the patient for any remaining balance
• Follow-up and collections : Following up on unpaid claims and working to collect outstanding balances

Effective medical coding and billing is essential for optimizing revenue and maintaining the financial health of any healthcare organization, whether a small practice , a specialty practice like orthopedics or women’s health , or an integrated healthcare system with surgery centers, hospitals, and large practices.

Let’s take a closer look at the ins-and-outs of medical billing, along with key considerations for healthcare providers.

What’s the difference between medical coding and medical billing?

Medical billing and medical coding are two distinct but closely related processes in the healthcare revenue cycle. Medical coding involves the translation of medical diagnoses, procedures, and services into alphanumeric codes. 1 These codes are used for various purposes, including billing, reimbursement, and statistical analyses of matters like population health issues and general clinical research.

Medical billing is the process of submitting claims to insurance companies or other payers for reimbursement of healthcare services provided to patients. Medical billers use the codes assigned by medical coders to create claims and ensure that they are accurate and compliant with the payer's requirements. Alternatively, many healthcare organizations now utilize integrated healthcare technology platforms to generate codes automatically, based on clinical documentation, and incorporate them seamlessly into subsequent billing tasks. Some technology providers also offer services to take on some or all of the medical coding and billing process .

Solving the challenges of medical billing

Even though medical billing is a core process for healthcare centers, this work can be challenging to do accurately and efficiently. Arduous administrative work, ever-changing regulatory guidelines, accessing and managing the correct data, and other hurdles can slow the process and result in lower rates of reimbursement.

Thankfully, healthcare technology can help. To learn more about the common challenges behind medical billing and how innovative technologies like athenaOne are solving them, read our companion article, Solving the challenges of medical billing .

Read to see our platform in action? Reach out to an athenaOne medical billing expert to learn how an integrated healthcare platform can help you streamline the medical billing process, improve your claims accuracy, and help your practice stay focused on what matters most: delivering excellent care to patients.

AAPC, What is medical coding; https://www.aapc.com/resources/what-is-medical-coding

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Medical Coding Tutorial

• What is Medical Coding?
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• Anatomy and Physiology Fundamentals
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• What are Medical Terminologies?
• Medical Language Basics for Improved Coding Accuracy
• Medical Terminologies: Prefixes, Suffixes, and Root Words

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These are a few CPT medical coding case study questions along with their correct answers for practice. Medical coding requires accurate code selection based on the provided scenario. Remember to consult the latest CPT codebook for the most up-to-date information. Let's begin:

Case Study 1: Evaluation and Management (E/M) Coding

Scenario: A 35-year-old female patient with complaints of chest pain and shortness of breath visits the primary care physician's office. The physician performs a comprehensive history and examination, and the medical decision-making is of high complexity.

Question 1: Assign the appropriate E/M code for this encounter.

Answer 1: CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a comprehensive history, comprehensive examination, and high-level medical decision-making) would be appropriate for this encounter.

Case Study 2: Surgical Coding

Scenario: A patient undergoes a laparoscopic cholecystectomy with cholangiography due to gallstones and biliary colic.

Question 2: Assign the appropriate CPT code for the laparoscopic cholecystectomy with cholangiography.

Answer 2: CPT code 47562 (Laparoscopy, surgical; cholecystectomy) should be assigned for the laparoscopic cholecystectomy. Additionally, CPT code 47563 (Cholangiography, intraoperative, when performed, and includes the use of a cholangiogram, real-time fluoroscopic guidance, and all associated radiological supervision and interpretation; intraoperative) should be assigned for the cholangiography.

Case Study 3: Pathology/Laboratory Coding

Scenario: A patient undergoes a comprehensive metabolic panel (CMP) and complete blood count (CBC) tests at a clinical laboratory.

Question 3: Assign the appropriate CPT codes for the CMP and CBC tests.

Answer 3: CPT code 80053 (Comprehensive metabolic panel) should be assigned for the CMP. CPT code 85025 (Complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count)) should be assigned for the CBC.

Case Study 4: Radiology Coding

Scenario: A patient comes to the radiology department for an X-ray of the right ankle after twisting it during a sports activity.

Question 4: Assign the appropriate CPT code for the X-ray of the right ankle.

Answer 4: CPT code 73610 (Radiologic examination, ankle; 2 views) should be assigned for the X-ray of the right ankle.

Case Study 5: Emergency Department (ED) Coding

Scenario: A 25-year-old male patient arrives at the emergency department with a deep laceration on his left forearm. The physician performs wound exploration, extensive cleaning, and suturing.

Question 5: Assign the appropriate E/M code for this emergency department encounter.

Answer 5: CPT code 99284 (Emergency department visit for the evaluation and management of a patient, which requires a detailed history, detailed examination, and medical decision-making of moderate complexity) would be appropriate for this emergency department encounter.

Please note that medical coding is a vast field, and these case studies cover only a few scenarios. It is essential to continue studying and practicing with a wide range of real-world scenarios to gain expertise in CPT medical coding. Always verify the codes with the latest CPT codebook and any relevant official guidelines.

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Unlocking Orthopedic Practice Success: Case Studies in Medical Billing and Coding Excellence

Introduction:.

Orthopedic practices face unique challenges in navigating the complex landscape of medical billing and coding. From intricate procedure coding to dealing with insurance reimbursements, efficient revenue cycle management is crucial for their success.

In this article, we delve into real-life case studies and success stories to illustrate the transformative impact of effective medical billing and coding strategies on orthopedic practices.

Case Study 1:

Streamlining reimbursements for orthopedic procedures.

Orthopedic Practice “Precision Orthopedics,” a bustling orthopedic clinic, was grappling with frequent claim denials and delayed reimbursements for their surgical procedures. They enlisted the expertise of a medical billing and coding specialist to diagnose and remedy the situation.

The specialist conducted a thorough analysis of the clinic’s billing processes and identified several areas for improvement. By implementing rigorous documentation practices and ensuring accurate coding for each procedure, the specialist helped Precision Orthopedics streamline their claims submission process.

Within six months of implementing the recommended changes, Precision Orthopedics experienced a significant reduction in claim denials and a noticeable improvement in reimbursement turnaround times. Their revenue increased by 20% , allowing them to reinvest in patient care and practice growth initiatives.

Case Study 2:

Resolving coding complexities for orthopedic trauma cases.

Orthopedic Practice “Advanced Orthopedic Solutions,” renowned for its expertise in trauma orthopedics, faced coding challenges related to complex fracture repairs and traumatic injury treatments. Despite providing top-notch clinical care, they struggled to accurately document and code these intricate procedures.

A medical billing and coding expert collaborated closely with Advanced Orthopedic Solutions’ physicians and administrative staff to address these challenges. They provided comprehensive training on proper documentation practices and coding guidelines specific to orthopedic trauma cases.

As a result of the targeted training and ongoing support from the medical billing and coding specialist, Advanced Orthopedic Solutions saw a remarkable improvement in coding accuracy and efficiency. They reduced coding errors by 30% and achieved higher levels of compliance with insurance requirements. This not only enhanced their revenue but also bolstered their reputation as a leader in orthopedic trauma care.

Success Story:

Orthopedic practice “orthocare solutions” optimizes revenue cycle management.

OrthoCare Solutions, a multi-specialty orthopedic group, recognized the need to revamp their revenue cycle management processes to stay competitive in a rapidly evolving healthcare landscape. They partnered with a medical billing and coding firm specializing in orthopedics to overhaul their billing operations.

The billing and coding firm conducted a comprehensive assessment of OrthoCare Solutions’ revenue cycle workflows and identified opportunities for optimization. They implemented advanced technology solutions for claims processing, automated coding software, and proactive denial management strategies.

The practice achieved remarkable results through the collaborative efforts of the OrthoCare Solutions team and the Orthopedic medical billing and coding experts. They reduced their accounts receivable aging by 50% , accelerated cash flow, and improved overall practice efficiency. OrthoCare Solutions emerged as a model of excellence in revenue cycle management, setting a new standard for orthopedic practices nationwide.

Conclusion:

These case studies and success stories underscore the critical role of effective medical billing and coding practices in driving success for orthopedic practices. By partnering with skilled billing and coding specialists, orthopedic practitioners can overcome challenges, optimize revenue cycles, and deliver superior patient care.

As the healthcare landscape continues to evolve, investing in robust medical billing and coding solutions remains paramount for orthopedic practices striving for excellence. Ready to optimize your orthopedic practice’s revenue cycle? Learn from real case studies and success stories!

Contact us at 888-357-3226 or Email [email protected] to get started.

FAQ 1: How long did it take for Precision Orthopedics to see improvements in their revenue cycle after implementing the recommended changes?

Answer: Precision Orthopedics experienced noticeable improvements in their revenue cycle within six months of implementing the recommended changes. However, the timeline for seeing results may vary depending on the specific challenges and circumstances of each orthopedic practice.

FAQ 2: What specific coding errors were addressed by the medical billing and coding expert at Advanced Orthopedic Solutions, and how were they resolved?

Answer: The medical billing and coding expert at Advanced Orthopedic Solutions addressed coding errors related to complex fracture repairs and traumatic injury treatments. Through comprehensive training and ongoing support, they improved coding accuracy and compliance with insurance requirements, leading to a reduction in coding errors by 30%.

FAQ 3: What technology solutions were implemented by OrthoCare Solutions to optimize their revenue cycle management processes?

Answer: OrthoCare Solutions implemented advanced technology solutions for claims processing, automated coding software, and proactive denial management strategies. These technological enhancements helped streamline their revenue cycle workflows, reduce accounts receivable aging, and improve overall practice efficiency.

FAQ 4: How did the success of OrthoCare Solutions’ revenue cycle management optimization impact their practice growth and reputation?

Answer: The success of OrthoCare Solutions’ revenue cycle management optimization efforts had a significant impact on their practice growth and reputation. By reducing accounts receivable aging, accelerating cash flow, and improving overall efficiency, OrthoCare Solutions emerged as a model of excellence in revenue cycle management , setting a new standard for orthopedic practices nationwide.

FAQ 5: Can similar results be achieved by other orthopedic practices seeking to optimize their revenue cycle management processes?

Answer: While each orthopedic practice may face unique challenges and circumstances, the principles and strategies outlined in the case studies and success stories can serve as valuable insights for other practices seeking to optimize their revenue cycle management processes. By partnering with skilled billing and coding specialists and implementing best practices, similar results can be achieved with dedication and commitment to continuous improvement.

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Medical Billing Reimagined: A UI/UX Case Study

Toptal designer Beatriz Garcia de Prado explains how she built a digital product to replace the outdated paper forms doctors were sending to insurance companies.

By Beatriz Garcia de Prado

Beatriz Garcia de Prado is a UI/UX designer and branding expert who has worked for clients such as ABN AMRO, Ahold Delhaize, Dutch transport company Broshuis, and aperitif maker Haus. She is the former creative director of EMN & OLLA The Agency, and former managing director and art director of EMN in Bahrain. She is also the co-founder and art director of the luxury table linen brand Prado y Barrio.

All Data Health, a company that collects medical billing information from physicians and sends it to insurers for payment, hired me to redesign its billing experience in late 2020. At the time, its physician clients were accustomed to filling out paper superbills —comprehensive forms that include diagnoses, procedures, and insurance claim codes.

To increase the speed and accuracy of its claims process, company leaders wanted to entice physicians to submit online superbills (called e-superbills) through an existing physician portal, but the physicians resisted. They continued mailing paper forms to All Data Health, where billing specialists entered the data manually before submitting claims to insurers.

Doctors are notoriously wary of new technology. Security, productivity, and affordability concerns cause physicians to cling to familiar methods and tools. My mission was to reimagine the existing medical billing software and make it so user-friendly that physicians would happily abandon their paper superbills.

The Approach: Researching, Wireframing, Prototyping

As a UI / UX designer and art director who has worked on many consumer-facing products , I specialize in humanizing digital experiences. Over three months, I worked with All Data Health to update the billing system, and build a component library and style guide to accompany it.

I began, as I always do, with research and brainstorming. Then, I created an information architecture and designed a low-fidelity prototype using wireframes before moving to high-fidelity prototyping. I worked closely with the client’s developer team, updating them on my progress daily.

UX Research: Identifying How Physicians Work

Every project starts with understanding the users. First, I met with All Data Health’s CTO and managing director to learn the needs of the doctors and the company’s data-entry specialists. I have a degree in journalism from University Carlos III of Madrid and worked for four years as a journalist, so I excel at this type of fact-finding.

Together, we created three detailed personas :

• Dr. Solo : This doctor works in a big organization and often fills out forms with the same handful of diagnoses and procedures. On the e-superbill, he must have easy access to his most commonly performed procedures. Forms need to be mobile-friendly, as Dr. Solo spends a lot of time traveling between hospital floors and medical facilities, and is often without computer access.
• Dr. Office : This physician runs a small office and usually works with a nurse or an assistant. In his analog workflow, an assistant prepares the forms with the patient information, and he only has to fill in the procedures performed during the visit.
• Dr. With a Team : This doctor is akin to a small-business owner; she runs a medical office and employs additional physicians. A staff doctor fills out a portion of the paperwork, but Dr. With a Team is ultimately responsible for collecting payments from insurance companies.

Feature Analysis: Noting Best Practices

I knew that All Data Health’s billing UX had to be so intuitive that users would view it as a timesaver—or at least recognize that it didn’t add time to billing. I examined programs that broke down large projects into manageable tasks and was inspired by several aspects of TurboTax’s website:

• It keeps users focused on one task at a time. For instance, it typically asks only one question per page, such as “Did you sell any stocks, bonds, mutual fund shares, or other investments?” and provides simple “Yes,” “No,” and “I don’t know” buttons.
• Rather than overwhelm users with a lengthy form, TurboTax’s workflow is divided into categories, such as wages/income and deductions/credits. It also shows progress and sets expectations for what’s next—for instance, letting users know that upcoming questions will deal with annual earnings.
• It provides side-by-side views. Users fill out a working area on one side of the screen while seeing an overview on the other side. The overview also serves as a menu so users can navigate to various sections.

Information Architecture: Designing a Hierarchy

I wanted the billing UI to mimic the layout of the physicians’ paper form as closely as possible so it would feel familiar and help ease the transition from paper to digital. I began by breaking down the users’ process of filling out the superbill into smaller steps.

I used Miro to make a mind map of All Data Health’s physician portal in order to visualize how information was structured. Building a mind map enabled me to find flaws in the portal’s information architecture. For instance, the portal had a single drop-down menu of report options, but the list was long, which slows down decision-making. I proposed creating a handful of high-level topics and subtopics—a cleaner and more effective way to navigate. I also made a mind map of the existing e-superbill and identified areas that needed to be simplified.

I often hand-sketch wireframes before creating digital versions. This time, however, I had a clear picture of what I wanted to create, so I continued using Miro. My first iteration of the revised desktop UI had a menu at the top with four categories: Create e-superbill, Reports, Patients, and Profile. It had a dynamic navigation on the left, which changed depending on where the user was in the e-superbill.

In my proposal, the initial fill form was simple: It asked users to fill in the facility, provider, date, procedure, diagnosis, and modifiers , which offer more information about a procedure. I also implemented a visualization of the paper bill in order to orient users relative to their previous way of working.

On the mobile app, I hid the menu and created two screens, enabling users to toggle between the full form and an image of the paper bill so they know where they are in the process.

When I presented the initial wireframes, the CTO mentioned that we needed to allow for additional procedures to be added and that everything had to be linked to a diagnosis, which insurance companies require, so I create a component that enables this functionality.

Mock-ups: Defining User Flows

When we were happy with the overall look and feel of the software, we started to mock up user flows; we created one for new patients and a separate one for existing patients. In the mock-ups, we covered ideal states and basic scenarios, including patients receiving multiple diagnoses and having more than one procedure, and doctors working at different facilities. It was crucial to get client feedback at this point in the project, so I presented the mock-ups at daily stand-ups.

Final Touches: Refining Components and Aesthetics

The project’s goal was to create a product that felt similar to the paper bill and was easier for doctors to submit electronically. For instance, doctors often fill out part of a paper bill and then complete it later. For the redesigned e-superbill, I preserved that convenience by incorporating the ability to save and print when the bill is incomplete and to retrieve an unfinished bill under a Drafts tab.

In addition, I wanted to reduce the need for doctors to enter the same data repeatedly—as they would when filling out multiple paper bills. So I created a Preferences feature that auto-fills frequently performed procedures. I also included fields that use predictive text. For instance, as doctors type the patient name “Mary,” the software presents the last names of Marys in the database.

High-fidelity Prototypes

For prototypes, I shifted from Miro to Figma, which is better for design refinements. The client was far less interested in aesthetics than usability and did not want me to spend much time on visual design. I browsed the Figma community for a design system that had the essential components I needed: forms, buttons, pagination, toggles, and check boxes.

At the time, All Data Health had no in-house designer or visual guidelines, but I wanted the updated billing experience to be consistent with the company’s other brand assets, so I pulled fonts and colors from the company’s homepage. I kept my visual language light, including as little text as possible.

Key Learnings

My work on this project confirmed that it is worth the extra time and money to validate a product with the end user. In this case, the doctors did not have a chance to test the new e-superbill before it went live, which led to several fixes after release. Additionally, I learned the value of waiting until the design is complete to begin development. Although developing fast allows for a quicker product release, it can cost more in the long run as systems have to be rebuilt.

I was also able to educate All Data Health about Agile , and we even incorporated some Agile routines, such as daily stand-ups, into our process. The company’s leaders have indicated that they plan to include more Agile methodology in the future, and have asked me to design another feature that will launch in a second phase.

Overall, All Data Health considered the project a success, reporting that the time to process insurance claims was reduced by half, and errors were virtually eliminated. By transitioning physicians from a cumbersome paper bill to an electronic one, All Data Health established an efficient, effective system for its clients.

Take a look at the final e-superbill in action.

Further Reading on the Toptal Blog:

• The Best UX Designer Portfolios: Inspiring Case Studies and Examples
• The True ROI of UX: B2B Redesign Case Studies
• Haptics in Healthcare: An Opportunity for Designers to Help Revolutionize Telemedicine
• Kinder Tools: How to Improve Enterprise UX Design for Mental Health
• COVID-19: The Ultimate Design Thinking Use Case

Understanding the basics

Why is ux important in healthcare.

Healthcare UX can streamline the medical billing process for physicians, billing companies, and insurers. Good UX is especially important for doctors because it allows them to spend less time on administrative tasks and more time providing patient care. It also reduces digital fatigue and burnout among providers.

What is a mind map?

A mind map is the most common type of cognitive map. It shows how information is organized within an existing product. It is a useful tool when creating a billing UI because it lets designers see where improvements can be made in the existing structure.

What does UX research focus on?

UX research focuses on who will be using a particular digital product, as well as when and how they will use it. Good UX research provides insights to developers and designers, allowing them to create the information architecture and user flow for a website or app.

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Beatriz Garcia de Prado

Palma de Mallorca, Spain

Member since January 29, 2018

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Reliant Billing Services provides the following case studies to share how we’ve helped others conquer medical billing challenges.

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A large urgent care facility noticed that Cigna claim denials began skyrocketing in 2021. We quickly determined that Cigna had been purchased by Priority Health, which resulted in dozens of incorrect claim submissions.

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Medical billing departments navigate a wide range of denials every year. But focusing on medical billing codes allows the practice to accurately describe each patient visit to increase the odds of payment. Learn more about the nuances of Home Healthcare coding to increase profits here.

How One Practice Used Outsourced Billing to Optimize Accounts Receivables

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Real-Life Examples of Medical Coding in Practice

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Medical coding is a crucial aspect of healthcare administration, as it involves the transformation of medical diagnoses, procedures, and healthcare services into alphanumeric codes. These codes are used for various purposes, such as billing, insurance claims, and statistical analysis. In this article, we will explore real-life examples of medical coding in practice through case studies and examine how it is applied in different healthcare settings.

Real-Life Examples of Medical Coding in Practice: Case Studies

Case study 1: hospital billing.

In a hospital setting, medical coding is essential for accurate and efficient billing. Let’s consider a case where a patient undergoes surgery for gallbladder removal. The surgeon will document the procedure details, such as the type of surgery performed, any complications, and the patient’s condition. The medical coder will then assign the appropriate codes to each aspect of the procedure, such as the surgical technique, anesthesia administered, and any additional services provided. These codes are crucial for generating an accurate hospital bill and ensuring proper reimbursement from insurance companies.

Case Study 2: Insurance Claims

Medical coding also plays a vital role in insurance claims processing. For instance, imagine a patient visits a primary care physician for a routine check-up. During the visit, the physician diagnoses the patient with hypertension and prescribes medication. The medical coder will translate the diagnosis and treatment details into specific codes, such as ICD-10 codes for the hypertension diagnosis and HCPCS codes for the prescribed medication. These codes are then used by the healthcare provider to submit an insurance claim for reimbursement. Accurate coding is crucial to avoid claim denials or delays in payment.

Case Study 3: Public Health Surveillance

Medical coding is not limited to billing and insurance purposes; it also plays a significant role in public health surveillance. For instance, during disease outbreaks or pandemics, medical coders input data from patient records into relevant surveillance systems. This data helps public health agencies monitor the spread of diseases, identify trends, and develop appropriate strategies to control and prevent further outbreaks. Accurate coding ensures that accurate and timely information is available to inform public health interventions.

How Medical Coding is Applied in Various Healthcare Settings

Medical coding is applied in a variety of healthcare settings, including hospitals, clinics, private practices, and research institutions. In hospitals, it is used for billing, reimbursement, and quality improvement purposes. In outpatient settings, such as clinics, medical coding is crucial for generating accurate bills and ensuring proper reimbursement from insurance companies. In research institutions, medical coding facilitates the analysis of large healthcare databases, allowing researchers to study disease patterns, treatment outcomes, and healthcare utilization.

Medical coding serves as the backbone of healthcare administration, facilitating the smooth operation of billing, insurance claims, and public health surveillance. Through real-life case studies, we have seen how medical coding is applied in various healthcare settings, ensuring accurate documentation, reimbursement, and analysis of health-related data. The importance of accurate and up-to-date medical coding cannot be overstated, as it enables healthcare providers, insurance companies, and public health agencies to provide high-quality care, streamline administrative processes, and improve overall healthcare outcomes.

• A: Medical coding plays a crucial role in the billing process by translating healthcare services and procedures into standardized codes. These codes are used for accurate invoicing, reimbursement, and financial transactions between healthcare providers and payers.
• A: Certainly. For instance, an incorrect code for a medical procedure may result in underbilling or overbilling, leading to financial discrepancies. This can impact the revenue cycle and may even result in compliance issues.
• A: Medical coders are trained to handle complex cases by using specific coding guidelines and conventions. They may need to assign multiple codes or modifiers to accurately represent the different components of a complex procedure or service.
• A: Accurate medical coding contributes to patient care by ensuring that healthcare providers are properly reimbursed for their services. This, in turn, helps maintain financial stability, allowing providers to invest in technology, training, and resources to enhance patient care.
• A: Coded data is valuable for healthcare organizations in identifying trends, conducting quality assessments, and implementing improvements. For example, analyzing coded data can help identify areas for clinical improvement, resource allocation, and compliance with healthcare standards.

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Expert Medical Billing and Collections Guidance Helps New Practice Take Off

by Outsource Strategies International. | Published on Jun 30, 2014 | Case Studies | 0 comments

With vast professional experience in Full Cycle Medical Billing and Collections, and Verifications, OSI has helped many health care practices improve patient care and revenue. Our client is a board-certified anesthesiologist and pain management physician located in the Miami section of Florida. He wanted to set up his own practice and committed to his plan, but wasn’t sure how to engage the necessary expertise to help realize his goals.

After looking at many alternatives, he chose Outsource Strategies International because of our broad expertise in the various aspects of pain management billing and collection. He also relied on the reputation that we had with many other pain management practices that we work with.

This physician was working in a group practice, and although he found that group practice fulfilling in many ways, he decided that it was time for him to go out on his own. He shared with us that he was planning on opening his practice within the next 6 months and needed our help to implement an EHR software. He liked the fact that we could work on any software that he chose to implement. Opening his own practice was a big step, a huge financial commitment, so it was critical that he made the right decision in choosing the best partner to work with.

Outsourcing his billing, collection and verification service proved a very cost-effective solution for his practice. We first put together a team of billing experts for his project with a specially assigned project manager. At the same time, we also implemented a quality assurance schedule. Maintaining strict HIPAA compliance, all client data was transferred to OSI through our secure web-based portal. Services we provided covered the following areas:

• Patient Enrollment: Demographic and insurance information, insurance verifications and authorizations
• Billing and Reconciling of Accounts: Charge entry, cash posting, and reconciliation
• Accounts Receivable Collections: Insurance collection, patient collection, and AR follow up and collections

Our follow up team aggressively pursued all unpaid insurance claims. We evaluated denials and appealed incorrect claim denials. We followed up all patient dues and helped set up convenient payment plans for them. We were able to provide our client with the coding guidance, revenue cycle management guidelines and the billing support that he needed to get his practice off the ground. We were proud to be able to support a new provider who was branching out on his own and in helping his practice grow.

The physician reports that he is very happy with the guidance that we have provided so far. Our monthly financial summaries help him keep track of the progress. He is confident in our ability to manage his billing and collections for maximum reimbursement.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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Case Study on Medical Billing & Accounts Receivables Management

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• Medical Billing & Accounts Receivables Management

The Customer

Our customer was an urgent care practice situated in Maryland.

The Challenge

The customer asked Flatworld solutions to handle their account receivables management. This customer was also facing other problems with billing, such as:

• The billing was never completed within 24 hours
• There was a sharp decrease in collections
• The in-house billers were turning out poor quality work

Our customer was planning on outsourcing all their billing work to us within a 2 months' time frame, if they were completely satisfied with our capabilities in handling their AR management. The team at Flatworld successfully carried out the AR management operations and the customer handed all their billing activities as promised.

We were asked to use a new software called AdvancedMD to carry out the customer's operations. The team at Flatworld was cross-trained over the phone to use the practice management software.

The Project

• We were required to provide Full Service Billing
• We were asked to handle an average of 700 claims per month

The Solution

We took the following initiatives to improve the customer's productivity and collections -

• We provided the customer with a dedicated team and account manager to handle the customer's account
• The team at Flatworld consisted of an AR expert and full time employees for medical coding and medical billing
• We developed an effective AR process and medical billing process to ensure that the customer's billing was completed within 24 hours
• We followed up on all the denied claims
• The Flatworld team addressed issues with the insurance company and got them resolved
• We maintained a knowledge base of solutions and issues

The Results

Our customer was able to access the following benefits by outsourcing their medical billing requirements to Flatworld Solutions -

• We brought down the average AR days from 34 to 23 within a period of 6 months.
• We increased the collection percentage from 53% to 61% within a period of 6 months.
• By increasing the collection ratio, our customer was able to improve their cash flow.
• Since our customer now had more time and a clutter free office, they were able to concentrate more on providing better patient care.
• From the customer's end, there was a decrease in the reliance on their employees and the customer did not have to face problems of employee turnover and backlogged claims.
• There was a sharp reduction in administrative costs and an increase in operating efficiency.

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