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Medical Coding and Billing

The Billing Process

The Billing Process represents the heart – the most integral portion – of the entire revenue cycle management value chain. It greatly benefits from accurate data capture in the early stages of the Revenue Cycle Management.

In addition, at AccuMed, we take our obligation to safeguard patient information seriously. As a result, all our coders and billers abide by the Health Information Portability and Privacy Act (HIPPA), a set of global standards that protect the confidentiality and security of patient’s medical information.

Coding

Medical Coding is the process of assigning standardised codes to specific services, procedures and medications provided to a patient as part of an outpatient or inpatient treatment.

In the UAE, both the Governments of Dubai and Abu Dhabi have mandated the use of standardised medical codes as part of providers’ e-claim transactions. Medical coding is not only important in as far as regulatory compliance is concerned. It is also crucial in accurately capturing the medical services extended by the practice and in translating these services into billable items. Inaccurate coding due to untrained staff increases the chances of claims being rejected by payers.

AccuMed has a team of coding experts who are certified by some of the world’s most respected agencies, including the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC).

Our coders exhibit competency in any coding setting, including both inpatient and outpatient services, and are proficient in using industry coding standards such as the following:

  • ICD-9 and ICD-10 (International Classification of Diseases) – for diagnostic codes
  • ICD-10-AM (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification) – for diagnostic codes; specifically applicable to the Saudi Arabian healthcare market
  • CPT (Current Procedural Terminology) – for procedure codes
  • IR DRG (International Refined Diagnosis-Related Group) – for patient classification system

As the premier medical coding resource in the Middle East, we are in prime position to deliver excellent service as we expand to various regional markets, especially Saudi Arabia.

Medical and Insurance Review

Medical and Insurance reviews are conducted by a specialist team of qualified professionals with different set of medical skills and backgrounds. This team includes medical doctors, pharmacists, nurses, physiotherapists, laboratory specialists and several other paramedic staff, who have insurance expertise in reviewing medical necessity and insurance protocols.

Medical reviews are conducted to validate and assure medical record documentation is complete and billed services are justified and compliant as per the patient’s health insurance policy. The reviews also ensure that all insurance and pre-approval protocols are strictly followed for each claim thereby helping to:

  • Decrease the chances of rejection and ensure early payment;
  • Monitor physician error trends and patterns that adversely impact cash, while identifying and analysing rejection trends;
  • Identify training needs for providers to address the known defaults and decrease rejection rates; and
  • Regularly provide feedback to enhance the smooth process flow.
Billing

Medical Billing is the process of submitting and following up on claims with payers. It is often considered tedious, but is nonetheless vital to every provider, whatever the size of their practice.

Outsourcing your medical billing requirements to AccuMed means claims are prepared properly; any issues or potential errors are flagged before submission; and batches of e-claims are submitted quickly and more frequently so as to reduce the billing cycle. Accounts receivable and denials are likewise managed efficiently, with any legitimate payer denials identified and corrected for future cycles, giving providers the much-needed peace of mind.

The illustration below of a Case Study involving one of our clients will also give you an idea of how our accurate coding and billing service made a difference in the provider’s overall revenue performance. Since outsourcing their requirements to us, our partner was able to achieve extra value of AED4.2 million ( million) over and above the revenue it initially captured in the first six months of 2013.

This report highlights the actual net billing effect of outsourced revenue cycle management, enabling providers to optimise their revenue stream and gain additional value by eliminating wastage, applying correct prices for its services, and implementing accurate coding guidelines.

Resubmission

Our Resubmission team comprises highly skilled multi-disciplinary professionals with extensive experience in administrative-, medical- and insurance-related processes. Their objective is to review remittance advices received from payers for any denials and apply the necessary corrections and medical justifications through the:

  • Complete analysis of factors that led to the non- or partial payment against submitted claims;
  • Re-process claims with necessary changes and justifications and submit to the payer for re-evaluation;
  • Review the price list and contract terms with payer if rejection is related to the same;
  • Complete review of medical documents and provide medical justification to payers for services claimed; and
  • Provide suggestions for corrective steps to be implemented to reduce rejection rates.
Denial Management

The review and improvement process is a continuous cycle. The key principle driving this is to ensure engagement and effective communications of all stakeholders by:

  • Continuously assessing and analysing rejection data to identify and address any trends;
  • Analysing reasons for the rejection of claims in order to identify root causes;
  • Consistently communicating with payers to ensure that recovery is maximised;
  • Regularly updating clients regarding changes in adjudication policies of different payers; and
  • Suggesting and supporting improvements in medical documentation practice and compliance of billing processes with healthcare providers.
Reconciliation

Reconciliation of accounts – between what was billed by the provider and paid by payers following all submission and resubmission steps – is a key step in closing the revenue cycle. Our experienced finance team, supported by our team of professional medical and insurance reviewers, are tasked with auditing and financially reconciling all records to be presented to the payer for a final closure of accounts.

The reconciliation process entails:

  • Performing claims audit by analysing  reason/s for rejection;
  • Verification, validation and assessment of claims eligibility for re-consideration post resubmission;
  • Communicating with payers on findings, justification and other relevant required documents;
  • Negotiating on rejected claims for re-consideration post resubmission;
  • Supporting the ultimate objective of achieving and maintaining the lowest rejection rate; and
  • Signing off for account closure as per agreed contractual terms (quarterly, semi-annually and annually).