Physicians Billing – Medical Services

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Physician Billing

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Physician billing, also called professional billing, is the practice of charging for physician services separately from hospital overhead charges. The services could have been as an out-patient in a facility, or as an in-patient in a hospital.

 

Physician billing is a common practice, and you should expect to receive a separate bill from the specialized physicians who may have treated you or assisted in your diagnosis. They are independent, private practitioners and may be individually contracted with an HMO or PPO.

As examples, below are some of the kinds of physicians who will send you a separate bill for your treatment, if applicable:

  • Radiologists, for reading any x-rays that were taken
  • Consulting Physicians, who may have been asked to review your care for any special needs
  • Pathologists, for reading any laboratory or pathology tests taken while you were at the hospital
  • Anesthesiologists, for services you received during any surgical procedures you may have had
  • Emergency physicians, who will bill you for any Emergency Room services you received

 

In the provider-based billing model, also commonly referred to as hospital outpatient billing, patients may receive two charges on their combined patient bill for services provided at a clinic: one for the facility or hospital charge and one for the professional or physician fee.

How Will Medical Billing Services Be Affected By ICD-10?

Thirty-five years is a long time, but finally on October 1, 2015 the International Classification of Diseases, Tenth Edition (ICD-10) went into effect for the U.S. health care industry. It’s been updated to include recent developments in clinical diagnoses treatment and includes the latest in coding using medical devices. Naturally there are now many more classification choices compared to ICD-9, especially when you consider that the last update took place in 1979.

Has it been an easy transition? The jury is still out, especially when you consider that the rest of the world has been using the new ICD-10 since 1990, and other countries since 1994. Delays in the U.S. of course revolved around political issues that stretched into 2014. Of course, one of the stumbling blocks was the cost of implementation.

Another consideration is that, according to AthenaHealth, the number of diagnosis codes has increased five times over in the new edition, to approximately 69,000 codes. This increase will pose problems for any medical practice or insurance company that did not make the transition to ICD-10 by the deadline of October 1, 2015. In short, if the transition was not made, insurance claims cannot be processed.

Among physicians, other health care providers, and health insurance companies, this major change has necessitated intensive preparation, time, and effort. The huge increase in the number of codes which are more specific than ever (if a patient sprains a wrist, there are now codes for ‘left wrist’ and ‘right wrist’) will require some study and even more getting used to, as some may have the former codes memorized over so many years of use.

Health insurance companies and any other facility that pays claims will have to be aware more than ever of the possibility for fraud and mistakes, even more than in the past. The natural possibility for   duplicate billings can occur, depending on whether a billing includes diagnosis codes from both the former edition and ICD-10.  How medical necessity will be evaluated will also go through a transition as new treatment guidelines go into effect.

In short, medical billing services will also have to study the new ICD-10 and become familiar with its new focus. Given that it is now December 2015, the assumption has to be that most if not all have already done so. But again, according to AthenaHealth, as of the October 1, 2015 implementation date, 82% of practices informed that they were not yet prepared.

If you have engaged the services of a medical billing service company in your office or practice, discussions regarding how the transition will affect your business should already have been conducted. Perhaps you conducted test billings just to see how the new submissions will work, and if there was a need for submissions in both versions during the transition phase.

The biggest problem for everyone, now that we are about a month into the transition is that with dual ICDs in use, claim denial rates could rise as high as 200% and A/R backlog rates may rise as high as 40%, says AthenaHealth. Delays in payments are sure to follow. These types of delays will affect revenues on all fronts, and is probably the worst effect the entire transition may have.

Good luck to all practices, medical offices and medical billing services in implementing this change.  And while we’re on the subject, keep in mind that the next ICD update, ICD-11, is scheduled for 2017.

 




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