Author Topic: What is third-party medical billing?  (Read 267 times)

alicecarlosmbc

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What is third-party medical billing?
« on: March 25, 2021, 08:57:10 AM »
???

Michele

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Re: What is third-party medical billing?
« Reply #1 on: March 25, 2021, 11:23:18 AM »
Third party medical billing:  a service provided by an outside company that is contracted to manage payments and claims for a medical facility
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ace

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Re: What is third-party medical billing?
« Reply #2 on: March 25, 2021, 06:31:49 PM »
I need your help,  I have a client who just started her case management business and needs payable codes (CPT"S) and amount that medicare covers and pays. All help would be appreciated
@Michelle Thanks in advance  :)

RichardP

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Re: What is third-party medical billing?
« Reply #3 on: March 26, 2021, 03:07:45 AM »
1.  The healthcare provider is supposed to deliver the care that is required for the condition diagnosed, and then bill for that care provided.  A provider is not supposed to go looking for which procedures pay the most and then perform those on their patients.

2.  A provider must be trained in order to be licensed by their state and be able to bill their services to Medicare and commercial insurers.  That training will acquaint the provider with the CPT code sets that are relevant to their practice and where to find the CPT codes and payment amounts.  Something is wrong if your client does not already know this.

3.  There is no set payment amount that is standard across all of the United States.  For the simple reason that the cost of living varies, from one region of the United States to the next.  Therefore, you must look for Code payments that are set for whatever region of the U.S. your provider is working in.  Medicare subcontracts billing work to regional Medicare Administrative Contractos (MACs).  The individual MACS provide on their websites the CMS data that includes prices for that region.  Your Medicare billing will be submitted to your regional MAC, not to CMS.

https://www.codemap.com/content.cfm?id=2620
MACs for the United States

https://www.optum360coding.com/product/48232/
Optum CPT Coding  (do not contain the payment amounts that you will find at your individual MACS)

https://www.idmed.org/idaho/UploadedFiles/IMA%20book%20order%20form%202021.pdf
Coding Resources

https://www.amazon.com/Current-Procedural-Coding-Expert-Professional/dp/1622545532
More Coding Resources

ICD-10 Diagnosis Code database.
(Click on "Indexes" and "Rules" at the top left of the page that comes up.)
http://www.icd10data.com/ICD10CM/Codes

ace - you say your client "needs payable codes (CPT"S) and amount that medicare covers and pays".

That information is available in the links I provided above.  The only thing missing is what services your client will be billing for.  Hopefully she knows what those are.  Otherwise, the links I provided will do you no good.

And - just in case you don't know:  Diagnosis Codes are free.  CPT Codes (Procedure Codes) are owned by the AMA, and are not free, except for the odd code you can find on the Internet.  That is the reason for the price on the resource material.

ace

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Re: What is third-party medical billing?
« Reply #4 on: March 26, 2021, 12:13:27 PM »
Thanks Richard for your reply. It was really helpfull. Deeply appreciated. I do have an another question, I just found out that when credentialing a Home Health agency one needs to have a reserve fund in the bank to get a HHA registered with Medicare and Medicaid. Is there a specific amount that needs to be there or how does that work ?

RichardP

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Re: What is third-party medical billing?
« Reply #5 on: March 26, 2021, 04:19:27 PM »
ace - you asked about this:  when credentialing a Home Health agency one needs to have a reserve fund in the bank to get a HHA registered with Medicare and Medicaid

In general, before one is allowed to register an HHA with Medicare or Medicaid, one must have already established said HHA with the proper authorities within the State where the HHA operates.  Those requirements no doubt vary from State to State.  So - this level of questioning is going to draw a standard response on this blog:  for answers to State-specific questions about establishing any medical facility / organization, it is best to consult a healthcare attorney who knows the requirements for that State.

In general - if you must already be a going concern, licensed / registered with that State in which you operate, it stands to reason that said HHA organization has a business account with funds in it.  Speaking from ignorance here, I assume showing Medicare that you have said business account would be part of the overall process of showing Medicare that your HHA is already an established business, licensed / registered with that State in which it operates.

I've provided some links below that can point you in a general direction.  Keep in mind that State and Federal requirements change from time to time.  So - when reading - keep the following in mind.  Some of what I've read does not account for the following change:

In March 2020, Section 3708(f) of the CARES Act amended the regulations to allow nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs) to certify and order home health services. This means that in addition to a physician, these “allowed practitioners” may certify, establish and periodically review the plan of care, as well as supervise the provision of items and services for beneficiaries under the Medicare home health (HH) benefit.

https://www.achc.org/home-health.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/HHAs

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS



Michele

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Re: What is third-party medical billing?
« Reply #6 on: March 27, 2021, 11:55:07 AM »
I have nothing to add!  Richard gave you a ton of resources.   ;D
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ace

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Re: What is third-party medical billing?
« Reply #7 on: March 28, 2021, 12:33:51 PM »
This was really helpful. Tons of thanks to the whole team of this forum for taking out the time and answering our questions :)

Michele

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Re: What is third-party medical billing?
« Reply #8 on: March 29, 2021, 10:40:12 AM »
Your welcome.  We are so thankful to the billers who take time to come on and share their knowledge!
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RichardP

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Re: What is third-party medical billing?
« Reply #9 on: March 31, 2021, 04:13:10 PM »
 ;D

alicecarlosmbc

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Re: What is third-party medical billing?
« Reply #10 on: April 13, 2021, 10:40:27 AM »
 :) :)

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Re: What is third-party medical billing?
« Reply #10 on: April 13, 2021, 10:40:27 AM »