CHAPTER TWO

LITERATURE REVIEW

2.4.1 Introduction

This research work is limited to hospital billing system including diagnosis, prescriptions, bills

and payments. It also covers the fundamentals of diagnosis, how it’s conducted and methods of

conducting it. The act of medical billing, history of billing, billing process, billing services,

electronic health records and their impact in revolutionizing the medical world are all discussed

in this chapter.

2.4.2 Diagnosis

According to Halder (2015), diagnosis is the identification of the nature and cause of a certain

phenomenon. Diagnosis is used in many different disciplines with variations in the use of logics,

analytics, and experience to determine "cause and effect". In systems engineering and computer

science, it is typically used to determine the causes of symptoms, mitigations.

Diagnosis takes several forms. It can be a matter of naming the malady, lesion, dysfunction or

incapacity. It’s going to indicate either degree of abnormality on a time or reasonably

abnormality in an exceedingly classification. It’s influenced by non-medical factors like power,

ethics and money incentives for patients or doctors.

2.4.3 Clinical Diagnosis

Another way to see if a toddler contains a special want is to check if the kid is also known by a

specific diagnosis. Though it's not the first approach that professionals outline patients with

special desires, providing identification is usually useful. A diagnosis is the art or act

of distinguishing a condition, disorder or illness from its signs and symptoms.

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2.4.4 Diagnosis Methods

In addition to a whole medical and medicine analysis, variety of tests also won’t establish an

identification of MG. A characteristic of MG is that patients have weakness that comes on with

an activity and improves following rest, to look for weakness with activity, a practitioner may

need a patient do a sustained task, like trying upwards (which induces the eyelids to stay

elevated) to check if the eyelids begin to droop (referred to clinically as ptosis) once

the eyelids square measure open for many minutes (Holmes, 2013).

Blood tests square measure wont to identification and pre diabetes as a result of early within the

disease kind two polygenic disorders might haven't any symptoms. All polygenic disorder blood

tests involve drawing blood at a health care provider’s workplace or industrial facility and

causation the sample to a work for analysis. Work analysis of blood is required to make sure

check results square measure is correct (Allen, 2015). Cancer is suspected to support human

symptoms, the results of a physical communication nation, and generally the results of screening

tests. Sometimes, x-rays obtained for different reasons, like Associate in Nursing injury, show

abnormalities which may be cancer. Confirmation that cancer is gift needs different tests (termed

diagnostic tests). When cancer is diagnosed, it's staged. Staging may be a method of describing

however advanced the cancer has become, together with such criteria as however massive it's

and whether or not it's unfold to neighboring tissues or additional distantly to liquid body

substance nodes or different organs (Nulan, 2009).

2.4.5 The Act of Medical Billing

Medical billing is the process of submitting and following up on claims with health insurance

companies in order to receive payment for services rendered by a healthcare provider. The same

process is used for most insurance companies, whether they are private companies or

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government sponsored programs: Medical coding reports what the diagnosis and treatment were,

and prices are applied accordingly. Medical billers are encouraged, but not required by law, to

become certified by taking an exam such as the CMRS Exam, RHIA Exam and others.

Certification schools are intended to provide a theoretical grounding for students entering the

medical billing field (Tom, 2013).

2.4.6 History of Billing

For several decades, medical billing was done almost entirely on paper. However, with the

advent of medical practice management software, also known as health information systems, it

has become possible to efficiently manage large amounts of claims. Many software companies

have arisen to provide medical billing software to this particularly lucrative segment of the

market. Several companies also offer full portal solutions through their own web-interfaces,

which negates the cost of individually licensed software packages. According to “Chrissy

(2014)”, due to the rapidly changing requirements by health insurance companies, several

aspects of medical billing and medical office management have created the necessity for

specialized training. Medical office personnel may obtain certification through various

institutions that may provide a variety of specialized education and in some cases award a

certification credential to reflect professional status.

2.4.7 Billing Process

The medical billing process is an interaction between a health care provider and the insurance

company (payer). The entirety of this interaction is known as the billing cycle sometimes

referred to as Revenue Cycle Management. Revenue Cycle Management involves managing

claims, payment and billing. This can take anywhere from several days to several months to

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complete, and require several interactions before a resolution is reached. The relationship

between a health care provider and insurance company is that of a vendor to a subcontractor.

Health care providers are contracted with insurance companies to provide health care services

(Paulson, 2013). The interaction begins with the office visit: a physician or their staff will

typically create or update the patient’s medical record. After the doctor sees the patient, the

diagnosis and procedure codes are assigned. These codes assist the insurance company in

determining coverage and medical necessity of the services. Once the procedure and diagnosis

codes are determined, the medical biller will transmit the claim to the insurance company

(payer). This is usually done electronically by formatting the claim as an ANSI 837 file and

using Electronic Data Interchange to submit the claim file to the payer directly or via a

clearinghouse. Historically, claims were submitted using a paper form; in the case of

professional (non-hospital) services Centers for Medicare and Medicaid Services. At time of

writing, about 30% of medical claims get sent to payers using paper forms which are either

manually entered or entered using automated recognition or OCR software (Pitch ford, 2015).

The insurance company (payer) processes the claims usually by medical claims examiners or

medical claims adjusters. For higher dollar amount claims, the insurance company has medical

directors review the claims and evaluate their validity for payment using rubrics (procedure) for

patient eligibility, provider credentials, and medical necessity. Approved claims are reimbursed

for a certain percentage of the billed services. These rates are pre-negotiated between the health

care provider and the insurance company. Failed claims are denied or rejected and notice is sent

to provider. Most commonly, denied or rejected claims are returned to providers in the form of

Explanation of Benefits (EOB) or Electronic Remittance Advice. Upon receiving the denial

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message the provider must decipher the message, reconcile it with the original claim, make

required corrections and resubmit the claim according to “Alan (2012)”.

This exchange of claims and denials may be repeated multiple times until a claim is paid in full,

or the provider relents and accepts an incomplete reimbursement. There is a difference between a

“denied” and a “rejected” claim, although the terms are commonly interchanged. A denied claim

refers to a claim that has been processed and the insurer has found it to be not payable. A denied

claim can usually be corrected and/or appealed for reconsideration. Insurers have to tell you why

they’ve denied your claim and they have to let you know how you can dispute their decisions. A

rejected claim refers to a claim that has not been processed by the insurer due to a fatal error in

the information provided. Common causes for a claim to reject include when personal

information is inaccurate (i.e.: name and identification number do not match) or errors in

information provided (i.e.: truncated procedure code, invalid diagnosis codes, etc.) A rejected

claim has not been processed so it cannot be appealed. Instead, rejected claims need to be

researched, corrected and resubmitted (Scott, 2014).

2.4.8 Medical Billing Services

In many cases, particularly as a practice grows, providers outsource their medical billing to a

third party known as a medical billing service. One goal of these entities is to reduce the amount

of paperwork for a medical staff and to increase efficiency, providing the practice with the ability

to grow. The billing services that can be outsourced include: regular invoicing, insurance

verification, collections assistance, referral coordination and reimbursement tracking. Healthcare

billing outsourcing has gained popularity because it has shown a potential to reduce costs and to

allow physicians to address all of the challenges they face daily without having to deal with the

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daily administrative tasks that consume time (Lowery, 2013). Medical billing regulations are

complex and often change.

Keeping your staff up to date with the latest billing rules can be difficult and time-consuming,

which often leads to errors. Another main objective for a medical billing service is to use its

expertise and coding knowledge to maximize insurance payments. It is the responsibility of the

medical billing service you choose to ensure that the billing process is completed in a way that

will maximize payments and reduce denials. Practices have achieved significant cost savings

through Group purchasing organizations (GPO), improving their bottom line by 5% to 10%. In

addition, many companies are looking to offer EMR, EHR and RCM to help increase customer

satisfaction, however as an industry the CSAT levels are still extremely low (Luna, 2011).

2.4.9 Electronic Health Record Management

An electronic health record (EHR), or electronic medical record (EMR), refers to the

systematized collection of patient and population electronically-stored health information in a

digital format. These records can be shared across different health care settings. Records are

shared through network-connected, enterprise-wide information systems or other information

networks and exchanges. EHRs may include a range of data, including demographics, medical

history, medication and allergies, immunization status, laboratory test results, radiology images,

vital signs, personal statistics like age and weight, and billing information (Habib 2010).

EHR systems are designed to store data accurately and to capture the state of a patient across

time. It eliminates the need to track down a patient's previous paper medical records and assists

in ensuring data is accurate and legible. It can reduce risk of data replication as there is only one

modifiable file, which means the file is more likely up to date, and decreases risk of lost

paperwork. Due to the digital information being searchable and in a single file, EMR's are more

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effective when extracting medical data for the examination of possible trends and long term

changes in a patient. Population-based studies of medical records may also be facilitated by the

widespread adoption of EHR's and EMR's in “Patrick and Kierkegaard (2011)”.

2.4.10 Terminology

The terms electronic patient record (EPR) and EMR have often been used interchangeably,

although differences between the models are now being defined. The electronic health record

(EHR) is an evolving concept defined as a more longitudinal collection of the electronic health

information of individual patients or populations according to “Gunter, et al (2005)”. The EMR

is, in contrast, defined as the patient record created by providers for specific encounters in

hospitals and ambulatory environments, and which can serve as a data source for an EHR. It is

important to note that an "EHR" is generated and maintained within an institution, such as a

hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and

other health care providers, employers, and payers or insurers access to a patient's medical

records across facilities. (Please note that the term "EMR" would now be used for the preceding

description, and that many EMR's now use cloud software maintenance and data storage rather

than local networks.) In contrast, a personal health record (PHR) is an electronic application for

recording personal medical data that the individual patient controls and may make available to

health providers (Scot, 2009).

2.4.11 Comparison with Paper-based Records

A study estimates its electronic medical record system may improve overall efficiency by 6% per

year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the

cost of only a few "unnecessary" tests or admissions. Many people disputed these results,

publicly asking "how such dramatic claims of cost-saving and quality improvement could be

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true”. A 2014 survey of the American College of Physicians member sample, however, found

that family practice physicians spent 48 minutes more per day when using EMRs. 90% reported

that at least 1 data management function was slower after EMRs were adopted, and 64% reported

that note writing took longer. A third (34%) reported that it took longer to find and review

medical record data, and 32% reported that it was slower to read other clinicians' notes (Henry,

2009).

The increased portability and accessibility of electronic medical records may also increase the

ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users

versus paper medical records, as acknowledged by the increased security requirements for

electronic medical records included in the Health Information and Accessibility Act and by

large-scale breaches in confidential records reported by EMR users. Concerns about security

contribute to the resistance shown to their widespread adoption (Scot, 2009).

Handwritten paper medical records may be poorly legible, which can contribute to medical

errors. Pre-printed forms, standardization of abbreviations and standards for penmanship were

encouraged to improve reliability of paper medical records. Electronic records may help with the

standardization of forms, terminology and data input. Digitization of forms facilitates the

collection of data for epidemiology and clinical studies (Hammerstein, 2010).

EMRs can be continuously updated (within certain legal limitations). If the ability to exchange

records between different EMR systems were perfected ("interoperability") would facilitate the

co-ordination of health care delivery in non-affiliated health care facilities. In addition, data from

an electronic system can be used anonymously for statistical reporting in matters such as quality

improvement, resource management and public health communicable disease surveillance.

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2.4.12 Benefits of EMR in Ambulances

Ambulance services in Australia have introduced the use of EMR systems. The benefits of EMR

in ambulances include: better training for paramedics, review of clinical standards, better

research options for pre-hospital care and design of future treatment options.

Automated handwriting recognition of ambulance medical forms has also been successful. These

systems allow paper-based medical documents to be converted to digital text with substantially

less cost overhead. Patient identifying information would not be converted to comply with

government privacy regulations. The data can then be efficiently used for epidemiological

analysis (David, 2010).

2.4.13 Technical Features of EMR

a) Digital formatting enables information to be used and shared over secure networks

b) Track care (prescriptions) and outcomes (blood pressure)

c) Trigger warnings and reminders

d) Send and receive orders, reports, and results

e) Decrease billing processing time and create more accurate billing system

f) Health Information Exchange; Technical and social framework that enables information to

move electronically between organizations.

Using an EMR to read and write a patient's record is not only possible through a workstation but,

depending on the type of system and health care settings, may also be possible through mobile

devices that are handwriting capable, tablets and smart phones. Electronic Medical Records may

include access to Personal Health Records (PHR) which makes individual notes from an EMR

readily visible and accessible for consumers (Milewski, 2009).

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Some EMR systems automatically monitor clinical events, by analyzing patient data from an

electronic health record to predict, detect and potentially prevent adverse events. This can

include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any

other data from ancillary services or provider notes. This type of event monitoring has been

implemented using the Louisiana Public health information exchange linking state wide public

health with electronic medical records. This system alerted medical providers when a patient

with HIV/AIDS had not received care in over twelve months. This system greatly reduced the

number of missed critical opportunities (Magnus, 2011).

2.4.14 Philosophical Views of EHR

Within a meta-narrative systematic review of research in the field, there exist a number of

different philosophical approaches to the EHR. The health information systems literature has

seen the EHR as a container holding information about the patient, and a tool for aggregating

clinical data for secondary uses (billing, audit etc.). However, other research traditions see the

EHR as a contextualized artifact within a socio-technical system. For example, actor-network

theory would see the EHR as an actant in a network (Potts, 2010), while research in computer

supported cooperative work (CSCW) sees the EHR as a tool supporting particular work.

Several possible advantages to EHRs over paper records have been proposed, but there is debate

about the degree to which these are achieved in practice.

2.4.15 Quality

Several studies call into question whether EHRs improve the quality of care (Potts, 2009),

(David, 2010). However, a recent multi-provider study in diabetes care, published in the New

England Journal of Medicine, found evidence that practices with EHR provided better quality

care.

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EMR's may eventually help improve care coordination. An article in a trade journal suggests that

since anyone using an EMR can view the patient's full chart, then it cuts down on guessing

histories, seeing multiple specialists, smooth transitions between care settings, and may allow

better care in emergency situations. EHRs may also improve prevention by providing doctors

and patients’ better access to test results, identifying missing patient information, and offering

evidence-based recommendations for preventive services (Christopher, 2011).

2.4.16 Time

The implementation of EMR can potentially decrease identification time of patients upon

hospital admission. A research from the Annals of Internal Medicine showed that since the

adoption of EMR a relative decrease in time by 65% has been recorded (from 130 to 46 hours)

“Elizabeth et al (2006)”.

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