Medical Billing Service

CLAIM BASICS

Medical Claims for office visits or hospital services are professional claims.
Professional claims contain (1) patient demographic and insurance information (2) medical service information (3) provider information. You can see details required for medical claims in the CMS 1500 form used for paper claims.

Electronic medical claims start from superbills generated by EHR. Superbills have information on (1) patient demographic and insurance information (2) medical service information (3) provider information. You need to send superbills to a clearinghouse. A clearinghouse is a messenger between you and insurance companies. A clearinghouse will generate electronic medical claims (EDI 837) and submit them to each insurance company. You may need to do paperworks to enable electronic claim submission to some insurance companies such as medicare.

CLAIM FLOW

1. Claim submission from your clearinghouse.
2. Insurance acceptance vs. rejection: it could be because of the misspelled name or the incorrect insurance member ID, or incorrect insurance company payer ID etc. This is an opportunity to correct the claim before too late!
3. Insurance processing vs. denial: if it is denial, you need to find out why.
4. Insurance payment: you will receive paper checks, virtual credit cards, or bank deposits via Electronic Fund Transfer (EFT).

DIY BILLING

Billing functions from EHR and billing software are expensive and confusing.
We help DIY billing by scrubbing the superbill and entering the information into the claim.md clearinghouse.

DIY Billing workflow
1. You send EHR superbill information to us. Elation EHR is able to send superbills via API. Or you will send us CSV spreadsheet files.
2. We will customize superbills based on your rules and enter the information to a user-friendly clearinghouse such as https://claim.md or other compatible clearinghouses (We do not have any affiliations with claim.md.)
3. At https://claim.md, you can then see these claims under "Pending Approval" or "rejected claims" if the given information is not sufficient or wrong. It is easy to fix the rejected claims.
4. You will review and submit the claims.

Benefits of DIY billing.
1. You can correct mistakes in a timely fashion:
Insurance companies will reject the claim for incorrect demographic information or insurance information. If a billing company does not pick this up and update you, you may miss the limited time period allowed for claim submission and processing. Of course, the delay will affect your cash flow.
2. You can understand how each insurance company responds and pays.
Some insurance companies give you more headaches and workloads but pay less than others. You can be more selective in choosing the insurance companies you want to work with.

ELIGIBILITY CHECK

For major insurance companies, we will check eligibility information including Active/Inactive, Copay, Coinsurance, Deductible, and Out of Pocket.

1. You send us details of client information (name, date of birth, insurance carrier, and member ID) using a spreadsheet or providing us with an API access.

2. We will generate a summary of the eligibility information using https://claim.md. We only summarize the given information from https://claim.md and there might be changes or discrepancies from the actual values applied to the claim processing.

3. We will send you a spreadsheet or add the summary information into your system if we are given an API access.

WHAT DO WE OFFER?

  1. We scrub the superbill and enter the information into the clearinghouse at $200 monthly (the clearinghouse fee is separate.)
    We use a user-friendly and affordable clearinghouse, https://claim.md. We will need to check whether other clearinghouses are compatible or not.

    We offer a 14-day trial     of the claim preparation service. We can simulate the workflow during the trial time. If you are not certain about the new clearinghouse, we do not recommend real claim submissions using the new clearinghouse because insurance companies will answer back to the new clearinghouse.

  2. We help the enrollment process with payers for electronic claim submission and electronic remittance advice (ERA) at $50 monthly.

  3. We also provide insurance eligibility summary service at $200 monthly (we also offer a 14 day trial for this service.)

  4. CLAIM PREPARATION AND SUBMISSION SERVICES: If you do not want to submit claims on your own, we provide claim submission, resubmission if indicated and processing of Electronic Remittance Advice (ERA) at 4.5% of the insurance allowable amount. We will communicate with you regarding incorrect information and consequent rejections or denials. But we do not call insurance companies to enable competitive pricing.
    We use the claim.md clearinghouse to manage claims and ZOHO.books to manage patient accounts.