Monday, February 16, 2009

How does a Medical Office gain insight into what their Medical Billing Service is doing with Medical Claims?

A medical office is outsourcing their claim billing to a medical billing service. The medical office has no transparency into what is happening with their medical claims and they were asking me what steps they should take to gain access to the billing services electronic medical claim clearinghouse Office Ally.

The Medical Office's concerns are the lack of insight into all electronic claims, which claims are getting submitted, are any kicking out, if they are getting claim denials what are the reasons, how often is the medical billing service actually billing their medical claims, and what percentage of claims are getting passed on to the health insurance carrier? Because of these concerns they want access to the electronic claims clearinghouse.

Let's first review how the medical claims clearinghouse Office Ally works?

  1. All data is entered into the Practice Management/Billing Software

  2. A claim file is generated

  3. The claim file is downloaded to the desktop

  4. The user logs into Office Ally

  5. The user uploads the claim file from the desktop into Office Ally Clearinghouse Software

  6. The user submits these claims electronically through Office Ally after it passes through certain claim edits

  7. Any denied claims will be received in a report format, the medical billing service should be fixing the issues in both the claim clearinghouse software and in their Practice Management Software

  8. The medical billing service should be permanently deleting the Claim File from their desktop to remain HIPAA compliant
If the medical billing service has the contract with Office Ally Clearinghouse and you are the medical office contacting them to gain access they will most likely forward you on to your medical billing service to get a user name/password. Office Ally Medical Claim Clearinghouses contract is with the billing service and not you.

If you are not on speaking terms with your medical billing service or you would rather they not know you are trying to log into Office Ally Clearinghouse than you will need to work this through another angle.

Your other option and one that you have more control over if you cannot get a user name and password into Office Ally's Clearinghouse.

The doctor has access to setting up user names/passwords with all health insurance carriers they are contracted with including BCBS, Cigna, Aetna, UHC, Humana and many more. This is the same place that you might use to check patient eligibility online but instead of clicking on the eligibility click on the claim status section.

Side Note: If the billing service has registered the doctors on these websites you will need to ask them to give you user names/passwords to access. If they ask why you need access (and they shouldn't but if they do) explain the doctor would like to monitor new coding updates, releases, fee schedules and that the front office needs access to check patients eligibility and pre-authorizations. Notify the billing service that you would like them to keep you updated with the most current user names/passwords for each health insurance carrier.

How to use your Health Insurance Carriers websites to track what your billing service is doing?

Use the online claim status screens to track your patients and identify how long it takes from the time you give the claims, medical records information to your billing service until it gets accepted by your health insurance carrier. Plus you can check for denials etc. If the patients claims are not on file with the health insurance carrier than it means that the billing service is having issues submitting claims through Office Ally (they are kicked out because information is being sent incorrectly so they do not send on to the Health Insurance Carrier).

For a list of additional Articles I have written please check out this website and scroll down until you get to the Electronic Medical Billing Clearinghouses section.

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  1. hi
    Nice blog! Really its provides very nice information.
    Keep it up.

  2. Yes! Thanks for sharing your knowledge. You have helped me out of a confusing situation more than once.

  3. Thank you so much! I am really glad you are finding my website helpful.

    I invite you and anyone else who is a medical biller, coder, collector or interested in starting in the medical billing industry to ask questions or leave suggestions of things you would like me to write blog articles about.

    Warmest Regards,

  4. Does this refer to companies like cearner or ECAOS ?

  5. Hi Felix,

    Medical offices should be aware of everything going on in their company even if they are outsourcing their billing.

    You need a way to check the work of the billing team to identify that claims are being billed, that they are being billed correctly, that they are being collected on correctly and posted to the billing software correctly.

    The best way to check this information is to have access to the Clearinghouse software. But if that is not a option (let's say it's under the billing services name) then the Dr's office can follow up with each insurance carrier and request Online Claim Status access. Spot check patient accounts daily, weekly, bi-weekly or monthly to verify accounts are getting processed correctly and in a timely matter.

    Thank you,

  6. Hi Jennifer,
    Great blog! We are in the process of opening an Independent Diagnostic Testing Facility and have signed on with a billing company. They are not what they professed to be when we signed up. I have been asked to take a billing/coding class. How feasable is this since I have don't have much medical experience. I have been a legal secretary for 10 years and homemaker for the past 10 years. Shall I continue to look for a CPC or take the a class on line. any adv will help.

  7. I am thrilled that you have enjoyed my blog! I think I would need more information to be able to help identify the best approach for you and your business.

    Medical billing and collections can be self - taught however; I am not sure how much experience you have with your Practice Management Software (which one are you using), along with experience with electronic claims.

    What Clearinghouse do you submit claims through. What type of connection do you have with your Clearinghouse (through your PM software or do you log in seperately). Also, what is your A/R like. What insurance carriers do you currently bill to - which ones are causing you the most issues.

    Every business is so unique - if you are looking for something quick I would suggest checking out this online service:

    If you need further assistance submit another comment with your contact information. I will not release it to the public but will call you to discuss your situation and try to give you further suggestions.

    Good Luck!!

  8. One thing that medical offices should do is know the processes of medical billers if they are going to outsource it. I mean it is their right and responsibility to know this things as they have that responsibility in terms of a patient's medical history privacy.