A 2012 study by the American Medical Association (AMA) found even while medical billing accuracy has improved, one in ten bills paid by commercial health insurance companies have mistakes. With millions of Americans expected to purchase health insurance by 2014 and healthcare practices facing a heavy influx of patients, the incidence of billing errors could increase. Patients, health care providers and insurers are all the victims of billing errors. Dealing with these mistakes is especially difficult because of the problems involves in tracking them, especially if a large volume of bills are involved. Several errors (both minor and major) may go unnoticed and result in claim denials, making things stressful for patients (even resulting in overpays) and costly and time consuming (resubmission processes) for healthcare providers.

Healthcare industry experts have come out with various tools for medical bill management. Here’s a look at some important recommendations:

• Online Tools – There are several online tools to help avoid medical billing errors. Entering your information on hospital bills and insurance in these web platforms would help identify billing errors automatically, track what is going on and stay informed. These tools provide alerts whenever an error is detected and allow you to ask a billing expert about how to correct the error. For instance, Smart Medical Consumer helps with analysis and management of the health care bills and insurance explanation of benefits which, the company says can save a medical consumer thousands of dollars.
• Mobile Application – With the increasing use of smartphones, people are using mobile apps for various kinds of billing purposes. Simplee has launched a mobile app in April 2013 which helps you manage and pay your medical bills through a smartphone.

  This app provides details about the errors in your bills, confirms deductibles or other insurance coverage, and helps you to pay the bill by credit, debit or FSA/HSA card. Patients can pay their bills either by check or over the phone. With this app, the patients can check their deductible status at the hospital or pay the bill while waiting inside the doctor’s office using their mobile phone.

• Billing Services – Personalized billing services such as Medical Bill Review Services, Health Proponent, HealthCPA and more can help patients identify medical billing errors, correct the errors, and fight denied claims. Annual service plans offered by Medical Bill Review Services starts at $225 per person per year. By paying an annual fee of $29.95 per year for a family (which includes your in-laws), Health Proponent offers the services of experts who can identify billing errors and negotiate bills on your behalf. HealthCPA sets up a personal online page for you where all your information is stored, after which the proprietary software and billing advocates will audit your bills and ensure that the billing charges are correct. Ongoing monitoring services are also offered.

It’s not just the patient who faces billing hassles. Even more complex are the issues faced by health care providers when they fail to get appropriate reimbursement for services rendered because the bills were erroneous. That’s why most physicians seek the assistance of a professional medical billing company to manage their medical billing and coding tasks.

Pain is a very complex phenomenon and pain management physicians have to treat patients of diverse age groups with levels of pain varying from neoplasm-related pain to post-surgical pain. Given these conditions, it is real a challenge for pain management practices to report the services and treatments they offer correctly for appropriate and timely reimbursement. New CPT codes for pain management that will become effective from January 1, 2014 are expected to help these specialists report their services and treatments more accurately. It is crucial for pain management physicians to understand these changes in order to ensure accurate pain management coding and medical claim billing.

Chemodeneravation treatment involves the injecting of botulinum toxin, atropine or other pharmacologic compounds into a neural structure or muscle to paralyze it and hamper its ability to cause the sensation of pain is crucial in pain management.
In addition to painful muscle contractions in the trunk such as those caused by tetanus, latrodectism, and abdominal rigidity, physicians can also use this treatment to treat pain response for tennis elbow.

• If the treatment is provided to the patient’s neck muscles, a new code 64616 (chemodenervation of muscle[s]; neck muscle[s], excluding muscles of the larynx, unilateral [e.g., for cervical dystonia, spasmodic torticollis]) should be reported instead of 64613 (chemodenervation of muscle[s]; neck muscle [s] [eg, for spasmodic torticollis, spasmodic dysphonia])
• If the treatment is offered for painful muscle contractions in the trunk caused by tetanus, Latrodectism (black widow spider bite) or abdominal rigidity (acute, involuntary contractions of the rectus abdominus, and internal and external oblique muscles), it should be reported with either of two CPT codes given below instead of 64614 (chemodenervation of muscle[s]; extremity and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis])
  • 64646: chemodenervation of trunk muscle(s); 1-5 muscle(s)
  • 64647: chemodenervation of trunk muscles; 6 or more muscles

The chemodenervation treatments of the extremities should be reported with one of four new codes given below.

• 64642: chemodenervation of one extremity; 1-4 muscle(s)
• +64643: each additional extremity, 1-4 muscle(s)
• 64644: chemodenervation of one extremity; 5 or more muscle(s)
• +64645: each additional extremity, 5 or more muscles

Physicians (those who are not neurologic specialists) usually initiate interprofessional consultation via telephone or the internet when a patient is suffering from acute/chronic pain and need immediate relief as there is no time to wait for face-to-face consultation. The latest CPT codes for pain management constitute the following new evaluation and management codes to report interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional, where the length of time determines the correct code.

• 99446: 5-10 minutes of medical consultative discussion and review
• 99447: 11-20 minutes of medical consultative discussion and review
• 99448: 21-30 minutes of medical consultative discussion and review
• 99449: 31 minutes or more of medical consultative discussion and review

The new Category II codes related to pain management, especially for patients having neuropathy – a common manifestation of diabetes mellitus are:

• 1500F: symptoms and signs of distal symmetric polyneuropathy reviewed and documented
• 1520F: patient queried about pain and pain interference with function using a valid and reliable instrument
• 3751F: electrodiagnostic studies for distal symmetric polyneuropathy conducted (or requested), documented, and reviewed within 6 months of initial evaluation for condition
• 3752F: electrodiagnostic studies for distal symmetric polyneuropathy not conducted (or requested), documented, and reviewed within 6 months of initial evaluation for condition

Accurate pain management medical coding using the new codes can be ensured with professional medical coding services. Expert AAPC-certified coders who are up-to-date on the latest developments on the coding scene are part of an established medical billing and coding company’s team. Seeking professional support can minimize coding errors and improve the productivity and revenue of physician practices.

In the UK, up to 1,00,000 people see general practitioners (GPs) every day about musculoskeletal complaints. According to a recent GP Online report, the failure of GPs to follow up and code symptoms such as knee pain as osteoarthritis is denying the chance of full diagnosis for patients. As a result, co-morbidities or two or more coexisting medical conditions or diseases such as depression (common in patients with osteoarthritis) are going unidentified. Coding signs and symptoms are a medical necessity and medical coding practices that neglect this prevent physicians from fully assessing the disease burden in their practice. It also prevents patients from getting the information they need to manage their condition better.

Osteoarthritis can pose serious threat to mobility and independence. A new report published by Arthritis Research UK says that the numbers of people who faced osteoarthritis related disabilities in the UK increased by 16% during 1990-2010. With the increasing incidence of obesity and the growth in the elderly population, it is estimated that around 8.3 million people could be affected by knee osteoarthritis in the UK by 2035.

Experts say that GPs are usually reluctant to code pain in parts of the body as an arthritic disease without further tests. However, as mentioned in the Arthritis Research report, there is there is no simple test to determine whether an individual has osteoarthritis. Diagnosis tends to be based on a blend of various patient reported symptoms such as joint pain and restricted movement, radiographic or magnetic resonance imaging (MRI) of the joint, and clinical exclusion of certain rare medical conditions or diseases which might cause similar symptoms. Though damage to joint cartilage and bone thickening typical of osteoarthritis can be evaluated using x-ray, such findings often do not correlate with other symptoms including joint pain. The levels of pain may vary across patients with similar damage to the joint and so the diagnosis of osteoarthritis differs greatly between individual GPs and across general practices. Rather than diagnosing the condition as ‘osteoarthritis’, GPs often use symptom labels such as ‘knee pain’.

All this is will deter standardized data collection and hold back diagnosis rates. Patients do not get a full diagnosis so that they are unaware of how to manage the condition better. For example, depression levels are high in patients with chronic arthritis and GPs who are alert to this can plan their services accordingly.

Primary care experts need to support the efforts to make a positive diagnosis and code this in the patient’s record. The Arthritis Research report recommends that GPs have to minimize variation in diagnosis and coding adopt standardized coding for osteoarthritis in community care and hospital outpatient departments. It also suggests that GPs stay alert to osteoarthritis and musculoskeletal pain in individuals with heart or lung disease or diabetes. There is a view that steps to improve the medical coding on practice computer systems can increase diagnosis rates and help assess the disease burden more effectively.

The article in TIME Magazine entitled ‘Bitter Pill: Why Medical Bills Are Killing Us’ by Steven Brill has received overwhelming responses from social media channels. Most users have welcomed this work and expressed their concerns over precariously rising health care costs in U.S.

Steven Brill’s research tells us that as technology advances, the costs of medical care are increasing rather than going down, as one would expect. Advanced tests ordered in the case of almost all type of health conditions are very expensive. Burgeoning outpatient costs are a major issue and Brill tells of a one-day $87,000 outpatient bill. Patients’ family members are even seeking the help of medical billing advocates to negotiate large medical bills!

Brill wonders why Medicare cannot be extended to everyone and paid by charging people under 65 the type of premiums charged by private insurance companies. Unless Medicare steps in, American people will become powerless buyers in health care market with little visibility into health care pricing, little choice of hospitals or services for they are billed, no chance to know about chargemasters, and no choice of drugs, lab tests or CT scans they need to get. The Medicare payment system (with RAC audits, review plans, error-rate reduction plans) is far better than those of private insurers. However, he says that Medicare may not be a realistic systemwide model for reform and systemic overhaul that displaces private insurers is not a solution. He points out that Medicare is under handcuffs while negotiating the prices for drugs or durable medical equipment on account of comparative-effectiveness research.

He does admire the best provisions of Obamacare – extricating the exclusions for pre-existing conditions, restricting co-pays for preventive care and ending annual or lifetime payout caps – but is more concerned that these provisions will result in rising premiums which would raise costs further. He makes several suggestions to reform the system such as tightening antitrust laws related to hospitals so that they cannot become so powerful that insurance companies cannot negotiate prices with them, taxing hospital profits at 75%, outlawing the chargemaster, and setting price limits or profit-margin caps on patented ‘wonder’ drugs.

It’s no wonder that Brill’s article evoked an overwhelming response on social media. If we look at Twitter responses, we can see most of them are furious at scary costs and discuss their experiences at hospitals. From certain responses, we can infer that the article did spread the awareness of Medicare benefits.

The Facebook responses also welcome this article. Some of them support a single payer system with strong enforcement for accessing health care. On the whole, the social media responses show that people are demanding a complete revamp in health care system.

Previous studies regarding electronic health records had created a lot of confusion regarding the possibility of cost reduction through Electronic Health Record (EHR) implementation. The main concern highlighted in those studies was that the EHR system would make it easy for doctors to order additional tests which will increase the spending eventually. However, a new study led by Julia Adler-Milstein, University of Michigan in Ann Arbor reveals that electronic health records can bring about some reduction in spending per patient at a doctors’ office. According to the researchers, doctors’ offices that started using EHRs can expect to spend around $5 less for providing healthcare services to each patient per month, compared to those offices that continued to rely on paper records.

It is estimated that the U.S government is ready to spend around $30 billion for encouraging doctors and other healthcare providers in the country to use computerized medical records. The research found that extensive use of EHRs will result in less expensive and appropriate care, fewer medical errors, and better efficiency.

The data on around 48,000 patients with EHRs (from three communities in Massachusetts) and 131,000 patients with paper records (from six other communities) between January 2005 and January 2009 were used for the research. Even though there was no change in the total cost of medical care, a small difference did emerge in the case of ambulatory care delivered at doctors’ offices. In the beginning, the average cost estimated for a patient’s ambulatory care per month was around $121.93. At the end of the study, the cost increased to $140.46 and $135.77 for offices that use paper records and EHRs respectively.

According to the researchers, the cost savings obviously came from reduced amount of money spent on radiology and lab tests. The expenses related to implementing EHRs, which would be paid by doctors’ offices are not factored in the cost savings. EHRs themselves may not help save money. It is required to devise a strategy that includes both EHR and healthcare delivery methods for actual cost savings.

If doctors’ offices implement servers and other facilities for maintaining electronic health records in-house, their costs will add up. The better option is to outsource the billing and health record maintenance. A professional medical billing company can launch EHRs on behalf of doctors’ offices, monitor all healthcare delivery methods and manage the billing properly. In this way, the company can take up the entire responsibility of billing staffs and reduce the administrative costs in physicians’ offices. This will eventually reduce the amount spent for patients each month.

Shared medical appointments! What does this increasingly popular paradigm hold for patients, physicians and payers? As a patient, you may be wondering whether you will have to discuss intimate health details in front of strangers. You may have to, and that may be awkward. However, it is seen that a number of patients do endorse these shared appointments because they are beneficial. For instance, Cleveland Clinic has been offering shared medical appointments for more than ten years now and they say that 85% of the patients who have tried these appointments want to return. According to the American Academy of Family Physicians, a notable increase from 6% to 13% was recorded in the percentage of family physician practices offering group visits during the period 2005 – 2010.

Why Patients Prefer SMA (Shared Medical Appointments)

Patients who have scheduled and attended shared medical appointments say that they felt a remarkable sense of comfort, and even motivation to share similar experiences. Whether diabetes care, weight loss, physicals or even skin cancer, patients who tried SMA don’t prefer to back to individual visits.

From the patient’s point of view, medical appointments can provide more in-depth information on their health condition. Take for instance your individual visit for diabetes care. Due to the limitation in time (probably 10 to 15 minutes), the physician can only give an overview regarding how you can improve your health condition. In group visits, the physicians can talk more about how you can reduce your weight and get your blood pressure under control. You can spend more time with your physicians and communicate with them effectively. Apart from getting answers to your questions, you can listen to others’ questions and gain more information.

Armed with more medical information, you can pay more attention to your health and also find out whether you have any risky health condition. For example, experts say that melanomas, dangerous forms of skin cancer are 98% curable if detected early. During a group visit, you can get more information about melanomas and safe sun practices so that you can either avoid melanomas or diagnose them early. Even though group visits cost the same as individual visits, they can reduce the chance of developing serious medical conditions which require costly care. In fact, group visits are an excellent option for patients to learn more ways to prevent serious diseases and avoid expensive treatment later on. Shared appointments are particularly beneficial for people with chronic conditions such as asthma, hypertension and diabetes.

Shared Medical Appointments – the Physician Perspective

If you think from the physicians’ viewpoint, this option is a really favorable one. Physicians can see more patients at the same time, which will reduce their effort and improve the returns. You can imagine the amount of time and effort required for a physician to repeat his advice on lowering blood pressure or keeping glucose levels in check to ten diabetic patients individually. Group visits allow doctors to see all these patients with common conditions at the same time and provide this advice. It will also reduce the hassles of patient scheduling as the same date can be allotted for all patients having similar symptoms.

Even hospitals are trying new ways of managing patient flow and giving a breather to their physicians. Healthcare organizations across the US have started implementing shared medical appointments to effectively handle large volume patient influx. Usually, group visits are scheduled for patients with conditions such as diabetes, HIV and liver disease among others.

Payers Also Welcome the Group Visit Model

Improving the quality of healthcare while reducing the cost involved – this is definitely an attractive proposition. Most insurers now cover shared medical appointments and doctors are also considering allotting shared medical appointments for prenatal visits, obstetrical appointments as well as for behavioral conditions such as attention deficit-hyperactivity disorder. However, group visits may not be beneficial for every patient as they are not effective to address emergency conditions that must be taken care of by a specialist immediately.

In a nutshell, the main benefits associated with shared medical appointments are:

• Improved access to quality healthcare
• Increased physician and patient satisfaction
• Improved clinical outcomes
• Reduced costs
• Fewer hospital admissions

To summarize, SMA is proving to be advantageous for all parties involved – the patient, the physician and the payer. Patients get to spend more time with their physician, receive more quality care and also interact with other patients with similar health conditions. This enables them to understand why and how to control their condition and improve their quality of life. Physicians can reduce the frustration associated with appointment scheduling. They will be less overwhelmed and be able to spend more time with their patients. Payers also are happy that they are providing coverage for improved level of healthcare.

A new study published in the BMJ Quality & Safety Journal by a group of researchers at the Johns Hopkins University School of Medicine found diagnostic errors to be the most common and costly medical mistakes.

The researchers evaluated payment data related to medical malpractice from the National Practitioner Data Bank, a comprehensive electronic collection of all malpractice settlement payments made by U.S practitioners since 1986. They found that diagnostic errors constituted 28.6% of 350,706 paid malpractice claims outranking other mistakes including treatment (27.2%), surgery (24.2%), obstetrics (6.5%), medication, (5.3%) and anesthesia (3%). Not only that, they were more likely to risk the lives of patients (40.9%) compared to other medical errors. Missed diagnoses were found to be the most common type of error compared to wrong and delayed diagnoses. Also, more diagnostic error claims were found in outpatient care than inpatient care (68.8 percent vs. 31.2 percent); and more lethal diagnostic errors were in inpatient care than outpatient (48.4 percent vs. 36.9 percent).

According to the research findings, misdiagnoses resulted in permanent disabilities to around 80,000 to 160,000 patients each year. Dr. David Newman-Toker (associate professor of neurology at the Johns Hopkins University School), one of the researchers says that most medical misdiagnoses are preventable. It is challenging too at the same time. In his opinion, this is mainly because of inadequate scientific knowledge and lack of technology (for instance, there is no technology to diagnose breast cancer as early as when the first cancer cell appears). He further points out that ordering every possible test for every possible occasion may provide you with accurate diagnosis, but it would simultaneously increase the healthcare costs. Here are Newman-Toker’s recommendations to reduce diagnostic errors.

• Encourage resource alignment when it is required to order costlier tests. For example, if you are trying to diagnose a stroke in patients, you need an MRI instead of a CT. MRIs are expensive but you don’t need to get them on 40% of the patients. Get them on 5% to 10% of the patients and you would be investing the resources more appropriately.
• Hospitals will have to be convinced to make their rate of medical diagnostic errors public, for which legislation or financial incentives from federal government or other regulatory bodies may be needed.
• Apart from treatments, more research should be funded for providing better diagnostic tests.

As per Dr. Hardeep Singh, a patient safety researcher at the Houston Veterans Affairs Health Services Research Center of Excellence and assistant professor of medicine at Baylor College of Medicine in Houston, diagnostic errors that occur outside of malpractice claims are equally important and it is required to conduct a research on them too. He is currently working on refining Electronic Health Records (EHR) to trace anomalous findings on test results. A recent report published in healthland.time.com talks about a survey carried out by the Michael E. DeBakey Veterans Affairs Medical Center in Houston, which revealed one third of primary care practitioners surveyed (around 2,590) reported missing alerts from EHR system designed to alert on abnormal test results. The efficiency of EHR system can be improved by accessing the required information with easier methods and training personnel on how to use the system.

The ICD-10 transition is expected to improve the accuracy of diagnoses as the new codes will provide a greater detail of health conditions and thereby more specificity in medical coding. The number of codes will increase to 90,000 from 17,000 to cover new diseases and procedures. The ICD-9 codes represent the closest health condition to be treated, not the very exact cause. As a result, physicians may need to look for more details which will eventually delay the treatment. On the other hand, ICD-10 codes can clearly express the severity of a condition (for e.g. pressure ulcers) by a single code. This will minimize diagnostic errors and confusion and ensure correct and timely treatment.

Let us consider the ICD-9 code 250.50 (Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled). Here the condition is unspecified. At the same time, there are four ICD-10 codes (given below) to specify this condition which gives a clearer insight.

• E11.311: Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
• E11.319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
• E11.36: Type 2 diabetes mellitus with diabetic cataract
• E11.39: Type 2 diabetes mellitus with other diabetic ophthalmic complication

The combination codes in ICD-10 which signify two diagnoses or a diagnosis with an associated secondary process/complication with a single code can be used to express multiple elements of a diagnosis. This improves coding efficiency as providers need not check several codes to diagnose a disease. ICD-10 is beneficial to healthcare providers in that they are ensured accurate payment thanks to more accurate medical coding and clean claims. Busy physicians can seek the help of a medical coding specialist to help with medical billing and coding.

It is a matter of concern that diagnostic errors are among the leading reasons for medical malpractice and its costly outcomes. With more awareness of this hazardous trend, providers can take effective measures to curtail the same and ensure patient safety. Wrong diagnoses also lead to erratic medical coding, which in turn not only compromises patient safety and care, but also has a negative impact on reimbursement and practice revenue.

A significant trend has emerged in angel investments in the United States. Angel investor groups are heading towards healthcare, if research on the first quarter of the current financial year is to be believed. The mean deal has actually dropped from $860,000 to $800,000. The median round is now at $680,000. With regard to co-investment of angels though, the median round size is $1.5 million, a figure that has been quite steady for the previous five quarters. Three out of four angel group deals are syndicated.

More Geographic Spread of Investment

Greater geographic investment distribution and syndication have been the main trends in angel investing according to Rob Wiltbank of the Angel Resource Institute. This is based on the Halo Report, the latest quarterly survey of the various investment activities of angel groups in the first quarter of the present financial year. Wiltbank suggests that this information points to the cropping up of new attractive ventures in the United States.

Angel investors have been carrying out more activity beyond Boston and Silicon Valley. There was more angel investment money spent in the southwest region of the United States than in the state of California. Companies based in New York and the region of the Great Plains had the biggest rise in deals involving angel groups from the previous year.

Rise in Healthcare Sector Deals

More angel investment groups were into healthcare deals. Nineteen percent of all angel investment deals and 23% of angel investment dollars were spent on the healthcare sector. This was a significant growth over last year’s first quarter.

Among all the angel groups the following investors put in the most money per deal in the past year – Golden Seeds, Golden Angels Investors, Nashville Capital Network, Tech Coast Angels, Houston Angel Network, Oregon Angel Fund and Jumpstart New Jersey Angel Network.

When it comes to reimbursement benefits, accurate and timely medical billing is necessary so that you can avoid clashes with payers. With many healthcare providers having adopted the new ICD-10 coding system before the official October 2014 deadline, billing staff is also required to update their knowledge about the new coding system. The pressure of existing work and the new requirements can really affect the functioning of your in-house billing staff. This holds true whether you have separate billing staff or have assigned the work to your office staff.

Here are some reasons why your internal staff may be unhappy about the working condition at your practice.

• Work all the time – When you are away for a vacation, your medical staff such as nurses are relieved of heavy workload since most of their work is patient-driven or physician driven. But that is not the case with your medical biller who has to work constantly all the time at your office checking insurance claims, battling with insurers, sending medical bills and medical records, answering calls and so on.
• It’s all in the hands of your medical biller – It’s your biller’s responsibility that you get the reimbursement benefits for the services rendered. It means when the medical bills hit the biller’s desk, he has to check for any missing information and errors. Most often the missing information is the updated insurance related data. With the entry of EHRs, billers have to hunt for missing data such as incomplete notes within the electronic records. Sometimes the biller has to wait for the EHR until the physician and nurses complete the electronic notes.
• Waging “war” with the insurance company – Another reason why your biller may be rather frustrated is that he might have engaged in a “war” with an insurance company. This happens when a biller normally calls an insurance customer service representative to verify the status of an unpaid claim. The rep assures your biller that the claim will be processed in 10 to 15 working days. If the check is not received within the assured time interval, your biller calls again and this time another rep may take the call and claim that they have neither record of the medical claim being received nor any previous calls made by the biller. The wait time at the insurance company is much longer now, causing major delays in payments and making your clients unhappy.
• Not getting the help they need – Since you and your medical staff are busy with patient care, your biller may not be get enough help when it is needed. This can affect the billing process and the revenue stream of your practice.
• More responsibilities than actually assigned – Medical billing specialists cannot be expected to handle medical coding too, though they should have some basic awareness. So if your billing specialist is doing coding too, then that means he or she had way too much responsibility. Coding tasks should be assigned only to AAPC-certified coders.

If your billing staff is not happy, this can reduce their efficiency and affect your the revenue of your practice. Why not let your office staff focus on other core aspects of your business? It is best to leave complex tasks such as medical billing and coding to professionals in the industry. Partner with a reputable medical billing company that has the right resources including professional billers, excellent infrastructure and state-of-the-art medical billing software to provide you the best services.

Physicians and organizations need to know that only patients have the provision under the ERISA law to appeal. Medical billers and healthcare providers have no rights at all – this is indeed the stipulation as per ERISA. Here are a few points that must be remembered with regard to ERISA, and which you can expect a medical billing company to know:

• If the healthcare provider does not have a contract with the insurance company of the patient, the provider does not have any claim with the company. The claim is being sent not for the healthcare provider to be paid but for the benefit to be paid to the patient.
• If the healthcare provider does not have a contract with the insurance provider of the patient, the insurance company does not have any legal obligation to send the patient’s benefit payment to the healthcare provider.
• The only obligation of the insurance company is to its member or the patient’s employer. It has to pay the patient’s benefit according to the contract terms between the insurance provider and the member or employer.
• As mentioned before, the right to appeal rests only with the member. If the insurance provider or medical biller does send an appeal, it is purely of the incorrect payment or denial of the patient’s benefit and not of the debt that is owed to the insurance provider.
• It isn’t the insurance provider but the patient who owes the healthcare provider for the received services. The insurance company does not have any obligation to pay the healthcare provider who is non-contracted.
• In the case of the healthcare provider being contracted with the insurance company of the patient, any kind of adverse benefit determination becomes a contractual matter between the provider and the particular insurance company. ERISA does not have any say here. Appeals made by the healthcare provider are according to the conditions of the contract the provider has with the insurance provider.
• If the claim is denied though, it is a benefit being denied. The contracted healthcare provider needs to review the benefit manual of the patient to determine whether the denial is right or wrong. If the insurance company has paid the patient less, this is still a contractual matter and not an ERISA matter.

A medical billing company will have a clear idea regarding key points of ERISA (Employee Retirement Income Security Act). The experts at a medical billing and coding company are knowledgeable regarding ERISA and many such Federal and State regulations. Physicians and healthcare organizations seeking reliable medical billing services from a reputable medical billing firm definitely stand to benefit.