What Is a Medical Billing Expert and Why Do Doctors Need Them

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• What Is a Medical Billing Expert and Why Do
  Doctors Need Them?
• You perform an appendectomy on a patient who
  comes into the ER with acute appendicitis. Its
  a routine procedure youve done countless times
  before. The surgery is smooth, the patient
  recovers well, and you send them home after a
  couple nights in the hospital. But then you get
  a letter from the insurance company saying they
  wont pay your full bill because your charges
  exceed the reasonable amount for an
  appendectomy in your area. Your billing staff did
  everything right. So why is your reimbursement
  being denied and questioned? This sort of
  frustrating situation is exactly why partnering
  with a medical billing expert can be a lifesaver
  for doctors like you.
• How Can Medical Billing Experts Help Out Doctors?
• As a doctor, you rely on receiving accurate
  insurance reimbursement to keep your practice up
  and running. Medical billing is complicated, with
  new codes and rules coming down the pike all the
  time. Even the most organized billing staff can
  make occasional mistakes.
• Medical billing experts can have your back by
• Auditing your billed codes against the care you
  provided to ensure everything matches up
  properlythis means you get paid fully for all
  services delivered.
• Catching any duplicate claims or up coded levels
  of service that could raise audit red flags. They
  proactively prevent issues.
• Pinpointing the appropriate usual and customary
  charge ranges for your specialty and area, so
  you dont get hit with denials for excessive
  billing.
• Appealing claim denials and negotiating
  reasonable settlements if disputes come up with
  insurance companies. Their know-how really
  strengthens your position.
• Staying current on the endless coding changes so
  your bills stay compliant. This avoids penalties
  and audits down the road.
• Why Might Your Medical Bills Get Flagged for
  Review?
• Even if youre running an ethical practice, there
  are lots of reasons your medical bills could
  still attract scrutiny
• Accidental coding errors since CPT, ICD-10, and
  EM codes are incredibly complex.
• Impossible to master them all.
• Staff mistakes leading to issues like duplicate
  claims or up coded service levels. These usually
  arent intentional.
• Your charges exceed benchmarks over time as you
  raise rates normally. You may not realize the
• gap has widened.
• Genuine unfamiliarity with the nonstop changes to
  billing codes and rulestheres always a
  learning curve.

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• If an insurance company wont pay your full bill
  because they think your charges are too high,
  here are systematic steps a medical billing
  expert can take to fight it
• Closely review your billed codes against the
  medical records. Verify they accurately reflect
  the
• services you provided. Appeal anything fishy.
• Check your charges align with the typical range
  for your specialty and area, based on current
  benchmarks. Share this data with the insurer.
• If your charges modestly exceed benchmarks,
  negotiate an acceptable reimbursement amount
  with solid justification.
• For higher variances, compile data on expenses
  like malpractice insurance and overhead. Submit
  this to substantiate going above the norm.
• Leverage medical billing experts independent
  knowledge of fair pricing standards during
  appeals and talks with the insurer. This lends
  credibility to your position.
• Following this process methodically gives you the
  best shot at resolving disputes favorably and
  maintaining your revenue stream.
• Why Defining Usual and Customary is Tricky
• Business
• A big challenge in settling on appropriate
  medical fees is confusion around whats
  considered usual and customary or reasonable.
• The American Medical Association says UCR is
  doctors full, non-discounted charges on their
• standard fee schedules. This sets the ceiling.
• But insurance companies define it as the average
  amount they actually pay in-network doctors for
  that service after discounts. This is often way
  lower than full charges.
• With no universally accepted UCR definition,
  billing experts must rely heavily on
• benchmarking data to pinpoint acceptable fee
  ranges based on trends. But experts dont all
  have access to the same resources, so UCR
  standards vary.
• Navigating this messy landscape takes serious
  skills. Having billing experts in your corner
  levels the playing field when insurers claim your
  prices are unreasonable. Their
• savvy negotiating can help protect your bottom
  line.
• Why Let the Experts Handle Your Medical Billing
  Disputes