Pulling back the Curtain: Understanding the medical billing process

1. Pulling back the Curtain:Understanding the medical billing process Shirley Reitz, PharmD Shirley.Reitz@omedarx.com August 10, 2016

2. Key Take Aways • Medical billing is different from pharmacy billing • A provider = A provider = A provider • This is a new for the health plans as well • Success is possible

3. Pharmacy Claim Rx Switch Vendor PBM

4. Medical Claim Billing Service Clearinghouse Vendor Payer

5. Pharmacy Billing Cycle

6. Medical Billing Cycle

7. Collection & Verification Gap 1 Patient Management • Need to determine insurance eligibility, schedule appointments, and collect patient information prior to or during visit

8. Patient Care Gap 2 Clinical Documentation • Need to use industry standards and structured documentation templates to record, receive, and transmit information electronically

9. Medical Billing Cycle

10. Claims Submission Gap 3 Coding and Claims Submission • Need to use industry standards to code and submit claims Gap 4 Different Adjudicator • Need to understand medical necessity standards and contract requirements for each payer

11. Medical Billing Cycle

12. Medical claim process flow

13. Medical Claim process flow

14. Medical claim process flow

15. Medical Claims information • Regence manages 80-100,000 medical claims daily • 82-86% of medical claims auto-adjudicate • Primary reasons for encountering edits: • Payment generates (in general) within XXXX

16. Payment Gap 5 Payment Collection • Need to track claims, review denials, and ensure payments • Need to collect payments from patients

17. Success to date • Data from 1/1/16 – 7/27/16 • 2,090 claims submitted • 1,184 claims for 99211 – 99215

18. Summary