Billing for a Procedure

Billing for a Procedure

Billing remains a significant component of healthcare accounting. It entails the generation of invoices for clients for the goods or services offered to them within the healthcare facility. Billing can be done to clients on a one-time basis and regularly. This depends on the nature of the service offered to the client. Billing is a way of maintaining financial accountability within the healthcare system and applies to all services and goods obtainable from health facilities. This paper seeks to discuss the billing process.

The billing process is a convoluted, complex, multistep process that begins with registration. The establishment of the financial responsibility of the clients then follows this. Client check-in and check-out follow, at which the client is expected to fill in the insurance and personal information. The client is then checked for compliance with billing and coding. Claims are then prepared and submitted to the payer. The payer then assesses the claim to determine whether it complies with its policy provision. This process is called adjudication, and its outcomes may be either acceptance of the claim, denial of the claim, or rejection of the claim (Ekin & Damien, 2021). A billing statement is then sent to the client to enable them to pay for any remainder that the insurer may not have covered.

Billing can be utilized for false profiteering by various organizations or health entities. The federal and state False Claim Act is a statute that was enacted to impose civil liability on these organizations and thereby prevent them from making false claims from the government (Ayres & McGuire, 2016). This statute grants federal and state prosecutors authority to prosecute entities that knowingly make false claims to the government. This enactment applies to entities doing business with the government, such as insurers and health providers.

Several procedures were done on the patient. The procedure codes applicable to this patient are either CPT code 26750 or CPT code 26755. CPT code 26750 entails closed treatment for the phalanges without manipulation, while CPT code 26755 entails closed phalangeal treatment with manipulation (Tamblyn, 2016). The diagnostic code applicable to this patient is S62. 609A. This code is applicable for closed fractures of unspecified phalanges.

The claim form requires several resources. These include the full name of the claiming candidate, insurance policy number or membership number, the candidate’s date of birth as well as gender, the beneficiary of the service described in the claim form, presence of coinsurance, the purpose of the claim, and the candidate’s address (Araujo & Silberstein, 2021). All this information is essential to the payer for payment processing.

Billing remains an essential tool in healthcare accountability. The billing process is a convoluted process characterized by several steps. This process is subject to various regulations and policies. The Federal False Claim Act is an example of such regulation. This provision safeguards this process against false profiteering. Various procedures and diagnostic codes exist that define various clinical presentations. Insurance claim forms require resources such as the patient’s name and number to facilitate their processing.

References

Araujo, M., & Silberstein, S. (2021). How to File a Health Insurance Claim in 4 Steps or Less. The Balance. Retrieved 30 October 2021, from https://www.thebalance.com/if-you-have-to-file-a-health-insurance-claim-form-2645672.

Ayres, I., & McGuire, R. (2016). Using the False Claims Act to Remedy Tax Expenditure Fraud. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.2821606

Ekin, T., & Damien, P. (2021). Analysis of Health Care Billing via Quantile Variable Selection Models. Healthcare, 9(10), 1274. https://doi.org/10.3390/healthcare9101274

Tamblyn, R. (2016). Using medical services claims to assess injuries in the elderly sensitivity of diagnostic and procedure codes for injury ascertainment. Journal Of Clinical Epidemiology, 53(2), 183-194. https://doi.org/10.1016/s0895-4356(99)00136-5

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Billing for a Procedure

Billing for a procedure may be a complex process. It is essential to have a clear picture of the tasks that make up the completed billing process and the resources needed to complete the work.

Tasks:
List the steps in billing a commercial insurer for a broken finger treated in an urgent care clinic.
Describe any regulatory issues encountered in billing for this case.
Identify the procedure code and the diagnosis code for this treatment.
Identify the resources needed to fill out the claim form.