Basics of US Healthcare -Medical Billing

 In this blog I will be sharing the basics Terminology used in the Healthcare as this will help us to understand the healthcare in more detail.

Basics of US Healthcare 

Basic Terms:

• Patient: 
• The Person who visits doctor for any kind of counselling, wellness check-up or to get treated for symptom of an illness.
• Provider:  
•  Doctor who provides treatment  to the patient and charge to their insurance company for payments
• Payer: 
• The Insurance company whoh covers the patient for any disease or illness and pay to the doctor when a claim arise.
• Guarantor/Subscriber :  
• The person who has the insurance policy is guarantor/subscriber. A patient visiting a Doctor may be covered under someone's policy ex. a child, spouse under husbands policy.
• Practice: 
• A place where services are performed. sometimes it is same as the name of the clinic or Hospital.
• Patient Demographic Information:
• Some Specific information that needed to create patients account in Doctors system. 
• such as Name, Gender, Address, Phone Numbers, DOB and Insurance Information.
• Used to process claims from Insurance companies or to collect the balance amount from patient
• All the details of treatment will be recorded under this acct.
• Primary Care Physician (PCP):
• A Doctor who see the patient for the first time for a disease or illness and refer it to a specialist. Some kind of insurance plans must require a PCP.
• ex: Family Doc, a patient will first consult PCP if the services or illness is beyond the PCP skills/services then he refer that patient to Specialist.
• Specialist:
• The doctors who are specialize to treat a particular type of disease or organ (Cardiologist, Urologist)
• Referral:
•  Some insurance plans required a Referral from the PCP before seen by a specialist. Specialist needs referral from patient's PCP.
• Few insurances restrict the patients by directly not going to specialists they should visit PCP first and take referral from PCP for consulting Specialist.
• Authorization: 
• Insurance companies ask for Authorization from the Provider before Major treatment, Test or Surgery
• Without taking prior authorization claims can be denies
• Surgery, MRI, Open heart surgery-Major treatments.
• This is to check if patients policy covers particular treatment or not.
• Generally: When Provider  submits the Authorization, Insurance company will validate the insurance details and consult with the PCP if any and checks if the particular treatment is required or not, if required Insurance company will provide the authorization to proceed with the treatment.
• Policy /Plan Maximum:
• Total amount of benefits receivable to patient of family with a plan or calendar year.
• Patient Responsibilities:
• Certain cost sharing amount by insured that need to be paid directly to the provider during the policy.
• Types of Patient Responsibility:
1. Deductible :
• It is a fix amount that need to be paid by the insured or subscriber to the provider before actual policy benefits starts.
• It is a patient responsibility which needs to be paid yearly once after this the insurance company will start processing the bills(correction req)
• Fixed amount which need to be paid by patient directly to provider
2. Co-payment:
• A Fix amount that need to be paid by the policy holder directly to the provider before each visit/encounter
3. Coinsurance:
• Insurance pays certain amount of benefits to the provider on each encounter and assigns some % responsibility towards subscriber.
• This will happen after processing of claim.
• for a 100 $ charge insurance co will pay 80$ and post 20% of coinsurance which needs to be collected from patient for the service provided.
• this will be usually in percentages

What is CPT,ICD and Modifiers:

This is the base of Medical Billing as this will be used in every claims and service provided by the provider.

• CPT:
• It is called CUrrent Procedural Terminology.
• Maintained by AMA- AMerican Medical Association.
• CPT COdes are 5 digit codes with descriptive terms for reporting medical services and procedures performed by doctors.
• The purpose of the Terminology is to provide a uniform language that will accurately describe the treatment and diagnostic services provided.
• Most of these codes are solely numeric, but a few have letter as the first digit.
• Without a cpt code bill will not be generated/claimed.
• ICD:
• It is called International CLassification of Diseases
• Maintained by WHO.
• COvid19: U07.1 -icd of covid19
• Presently 10th revision which is called ICD10.
• The ICD assigns a specific code to the diagnosis of the condition or disease being treated.
• EX: when a claim is Submitted along with CPT ICD code need to be mentioned. this is to understand the type of treatment provided
• This is the uniform method so that the insurance, doctor and patients can understand what is being treated in the patient encounter.
• These codes are alphanumeric and 3 tp 7 charc ling
• Modifiers:
• Modifiers are 3 digit codes. it could be totally Numerix, alphanumeric or alphabetic.
• These codes can only be used with the procedure codes to modify or elaborate , to add nmore information or specifics to the defination of  a procedure code
• Most commin used modifiers are:
• RT: Right side
• LT: Left Sight
• 59: Distinct Procedure
• 25: Significant separately identifiable service.