Frequently Asked Questions (FAQ's')
What is a clean claim in medical billing?
A clean claim is one that is complete, accurate, and compliant with payer requirements, allowing it to be processed without delays or the need for additional information requests.
How long does it take for claims to be paid?
Clean claims are typically paid within 14–30 days, depending on the payer and contract terms. Delays may occur if additional information or corrections are required before processing.
Can one billing system handle multiple healthcare locations?
Advanced billing systems can manage multiple facilities or provider locations under one platform for ensuring centralized data management, consistent reporting, and efficient claim processing for all sites.
Why is accurate medical coding essential for billing?
Accurate coding ensures healthcare providers receive proper reimbursement, reduces claim denials, and meets payer compliance standards.
What is upcoding and downcoding?
Upcoding involves billing for a higher-level service than provided, whereas downcoding assigns a lower code than the appropriate one.
Do all payers follow the same code rules?
Coding rules can vary by payer, so it is better to review each payer’s requirements before claim submission in order to prevent rejections.
How quickly should denials be addressed?
The best practice is to address denials within 48–72 hours to maximize recovery chances and maintain a healthy revenue cycle.
What is the difference between hard and soft denials?
Hard denials cannot be corrected and resubmitted, resulting in lost revenue. On the other hand, soft denials can be fixed and appealed for payment.
How often should denial data be reviewed?
Reviewing denial data weekly or monthly helps detect issues early and take corrective action promptly.
What is considered an acceptable AR aging period?
Over 90% of claims should be collected within 30–60 days, depending on payer contracts.
What reports are useful for AR management?
Aging reports, payer-specific recovery reports, and denial analysis reports are key tools.
How is AR cleanup different from regular follow-up?
Cleanup targets old, neglected claims, while regular follow-up manages ongoing current claims.
When should eligibility be checked?
Eligibility should be verified 24–48 hours before the appointment to allow time for resolving any coverage or documentation issues.
What information is required for verification?
The required details include patient name, date of birth, policy number, provider information, and planned procedure codes.
Can eligibility be checked for multiple patients at once?
Batch verification tools allow checking coverage for multiple patients in advance for saving administrative time.
What is EHR integration in medical billing?
EHR integration connects the clinical documentation system with billing software to enable seamless transfer of patient and service data for accurate claim creation and submission.
Is EHR integration compatible with all billing systems?
Compatibility is not always guaranteed, as it depends on software vendors and interface capabilities, requiring technical setup or middleware solutions.
Can EHR integration support specialty-specific billing?
EHRs can be customized for specialty workflows to ensure accurate coding and documentation.
Which services often require prior authorization?
High-cost imaging, surgeries, specialty drugs, and certain outpatient therapies commonly require prior authorization.
Can prior authorizations expire?
Authorizations often have validity periods, so services should be provided within the approved timeframe.
Are emergency services exempt from prior authorization?
Generally, emergencies are exempt, but coverage verification is still necessary afterward.
What documents are required for credentialing?
Common requirements include licenses, certifications, malpractice insurance, education history, work history, and references.
How often must credentialing be renewed?
Most payers require recredentialing every 2–3 years to maintain active status in their network.
Can credentialing be done for multiple payers at once?
Yes, providers can submit applications to multiple insurers simultaneously to speed up network inclusion.
Can one billing team handle multiple specialties?
With proper training, billing teams can adapt workflows to each area's unique requirements across multiple specialties.
Do payers have different rules for specialties?
Reimbursement rates, authorization needs, and documentation vary by specialty and payer.
How do specialty billers manage high-volume claims?
Through streamlined workflows, automation, and strict quality checks tailored to each specialty’s demands.
Are Medicaid rules the same across all states?
Medicaid regulations, covered services, and reimbursement rates vary by state, requiring state-specific billing expertise.
Can providers bill Medicaid and Medicare for the same patient?
Yes, but proper coordination of benefits is needed to ensure correct payment.
Can Medicaid eligibility change mid-treatment?
Yes, providers should verify coverage at each visit to avoid payment issues.
What factors slow down claim turnaround?
Errors, missing information, payer backlogs, and eligibility issues are a few of the factors that cause delays.
Do turnaround times vary by payer?
Yes, commercial, Medicare, and Medicaid payers have different processing speeds.
What role do payer contracts play in turnaround?
Contracts set payment timelines, so understanding them helps manage expectations.
Can patient information be shared with payers?
Patient information can be shared with payers, but only the minimum necessary data for billing purposes.
What role does audit logging play in HIPAA compliance?
Audit logging helps in tracking who accessed data and when, to ensure accountability.
Can cloud-based billing systems be HIPAA compliant?
Cloud-based billing systems can be HIPAA compliant if they meet encryption and security certification standards.
Does pricing transparency affect collections?
Pricing transparency does affect collections, as informed patients are more likely to pay on time.
What tools support transparent pricing?
Cost estimator tools, EHR integrations, and printed fee schedules are a few of the tools that help clarify charges.
Are patients entitled to written cost estimates?
Patients are entitled to written cost estimates, especially for non-emergency services under the No Surprises Act.
Allergy & Immunology
How are allergy testing codes billed? Codes depend on the number and type of allergens tested, as accurate reporting prevents underpayment or denials. Can telehealth be used for allergy follow-ups? Telehealth is often used for reviewing treatment progress and adjusting therapy, but the patient's insurance should cover it.
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