Definition of Healthcare

The process of taking necessary and preventative medical support for anyone’s wellness. It can be done with surgery,
medicine administration, day care procedures, urgent or emergency services etc. which is offered by healthcare management
systems such as hospitals, specialist doctor/providers, emergency services, hospice, ambulatory services etc.

Overview Of American Medical Billing Industry

THE U.S. MEDICAL BILLING SERVICES MARKET SIZE WAS VALUED AT USD 4.64 BILLION IN 2020 AND IS
EXPECTED TO REACH USD 8 BILLION BY 2026, VALUED AT A CAGR OF 9.52%
The U.S. Medical Billing Services Market Share, Size & Trends Analysis Report By Service Type (Light Service, Full
Service, and Boutique Service), By System Type (Open, Closed, & Isolated), By End User (Hospital & Health Systems,
Physician Groups, Home Health Providers, Telemedicine Providers, Hospice Providers, and Others) Industry Analysis
Report, Regional Outlook, Growth Potential, Price Trends, Competitive Market Share & Forecast, 2021–2026
U .S . ME D IC AL B I LL IN G S E R V I CE S MA RK E T R E P OR T S C O P E
REPORT ATTRIBUTE DETAILS

MARKET SIZE (REVENUE) USD 8 BILLION (2026)

CAGR 9.52% (2021-2026)

BASE YEAR 2020

FORECAST YEAR 2021-2026

MARKET SEGMENTS Service Type (Light Service, Full Service, and Boutique), System Type (Open, Closed, & Isolated) End User (Hospital &
Health Systems, Physician Groups, Home Health Providers, Telemedicine Providers, and Hospice Providers)

U.S. MEDICAL BILLING SERVICES MARKET OVERVIEW

The U.S. medical billing services market was valued at USD 4.64 billion in 2020 and is expected to reach USD 8.00
billion by 2026, growing at a CAGR of 9.52%. The medical billing services are used to process, submit, and follow up
on health insurance claims to save the staff time. The medical practices were introduced with the new pandemic
realities in 2020, in which they had to adjust to the new billing and payment tracking updates. At the same time, the
practices were forced to provide the treatments due to the country's shortage of resources as the number of COVID-19
cases surged in the industry. This caused the surge in demand in the medical billing market in the U.S.Medical billing
company serves more than 65 EMS agencies with varied call volumes across New York and PA. For instance, MedEx
established itself as a leader in Emergency Medical Service (EMS) billing.
KEY HIGHLIGHTS

 Cloud-based solutions are revolutionizing the US medical billing industry.

 There are many benefits of cloud-based billing services or medical billing software, such as improves efficiency,
cost amortization, and easy access.
 The evolving needs of the end-users in the industry are driving the demand for medical billing services.
 The shift towards value-based solutions in the industry is driving healthcare companies to shift towards the
latest medical billing techniques.
U.S. MEDICAL BILLING SERVICES MARKET SEGMENTATION
This research report includes a detailed segmentation by

 Service Type
 End-User
 System Type
U.S. MEDICAL BILLING SERVICE MARKET SEGMENTS

 In 2020, the light service medical billing segment accounted for 65.56% of the US medical billing service
market. The light service companies majorly perform the work of reviewing rather than maintaining the entire
process first-hand. They have skilled professionals in place to handle the billing process. The full-service
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 companies provide services that include formulating the repeatable processes to the realization of the actual
revenue for the practice

 The open system is largely preferred, as they are accessible by the healthcare providers and can be shared
with other third-party companies to process the cases file for claims. Many physician groups, many hospitals
prefer using this as they usually outsource their medical billing process as it is more user-friendly.

 Hospitals and healthcare systems are the biggest end-users in the medical billing service market in the US. The
evolving needs of the hospitals and health systems drive the constant demand. There are many advancements
introduced in the services and the products that are used and in the products in the developing stage. These
trends will fuel the industry for the next few years.
VENDOR ANALYSIS

 The key companies in the industry are Kareo, Athenahealth, Practice Fusion, CareCloud, and eClinicalWorks
 Vendors are coming up with an integrated technology platform, a high-quality provider network, and
sophisticated consumer engagement strategies.
 The shift towards value-based solutions in the medical billing outsourcing market is driving healthcare
companies to shift towards the latest medical billing techniques.
 MedEx established itself as a leader in Emergency Medical Service billing (EMS billing).
The U.S. medical billing service report includes in-depth coverage of the industry analysis with revenue
and forecast insights for the following segments:
Segmentation by Service Type

 Light Service
 Full Service
 Boutique Service
Segmentation By System Type

 Open
 Closed
 Isolated
Segmentation By End User

 Hospital & Health Systems

 Physician Groups
 Home Healthcare Providers
 Telemedicine Providers
 Hospice Providers
 Others
Overview of American Health Care Industry

Health care is one of the biggest industries in the United States. It continues to expand day by day. As
per 2019 data around 91.4% of its people are covered by the insurance out of which 66.5% are covered
under Private or employer sponsored health plans and 34.8% are covered under the government health
plans and rest 8.6% are uninsured. Even more than 20% of people have availed dual insurance facility
to cover all the medical expenses.

Definition of Insurance

Insurance is an arrangement of a company and policy holder by which a company or the state undertakes to provide
a guarantee of compensation for specified loss, damage, illness, or death in return for payment of a specified premium.

Types Of Insurances
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 Life Insurance
 Property Insurance
 Automobile Insurance
 Accidental Insurance
 Medical Insurance

Types of Health Insurance in USA

I. Federal Employees Health Benefits Program

II. Indian Health Service
III. Medicaid / State Health Insurance Assistance Program (SHIP)
IV. Medicare
V. Prescription Assistance (SPAP)
VI. Military Health System / TRICARE
VII. State Children’s Health Insurance Program (CHIP)
VIII. Program of All-Inclusive Care for the Elderly (PACE)
IX. Veterans’ Health Administration
X. Commercial / Private Health insurance.

 Private health coverage Types: These are the different types of Insurance policies that are offered
by Private Insurance companies. The term ‘Private Insurance companies’ here means insurance
companies that are not owned by the government. They may be Limited Liability Companies
(LLC) or Publicly Listed Companies (PLCs). This article will focus on the insurance policies and
types that are offered by the Private Insurance Companies. Some of them are listed below.

1. Health Maintenance Organization (HMO)

2. Preferred Provider Organization (PPO)
3. Exclusive Provider Organization (EPO)
4. Point-of-Service Plan (POS)
5. Catastrophic Plan
6. High-Deductible Health Plan With or Without a Health Savings Account

 You have many different choices when you look for health insurance. If you’re buying from a
sponsored issuer or from an insurance broker, you’ll probably choose from health plans
differentiated by the level of benefits that they offer. They are usually: bronze, silver, gold, and
platinum.
 Bronze plans usually have the least coverage, and platinum plans usually have the most. If you
are under 30 years old, you may also be able to buy a high-deductible, catastrophic plan.
 How are insurance policies different? Each one pays a preset share of costs for the average
policyholder. The details can vary across policies or insurance companies. In addition,
deductibles- which is the amount you pay before your policy covers 100% of your health care
expenses — differ according to plan and also the insurance company.
 Platinum Plan: covers 90% on average of your medical costs; you only pay 10%
 Gold Plan: covers 80% on average of your medical costs; you only pay 20%
 Silver Plan: covers 70% on average of your medical costs; you only pay 30%
 Bronze Plan: covers 60% on average of your medical costs; you only pay 40%
 Catastrophic Policies: Catastrophic policies pay only after you have reached a very high
deductible ($7.350 as at 2018). Catastrophic plans must also pay for the first three primary care
visits and also your preventive care hospital visits for free, even if you have not yet reached your
deductible premium.
 You will also see that some insurance brands are associated with the care levels. They may have
been pioneers in these kinds of policies thus causing a close association with the insurance

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 policies. We will not mention those here in order to maintain neutrality.
Each insurance company may offer one or more of these four very common types of plans:

 1. Health maintenance organizations (popularly called HMOs)

 2. Preferred provider organizations (popularly called PPOs)
 3. Exclusive provider organizations (popularly called EPOs)
 4. Point-of-service (popularly called POS) plans
 5. High-deductible health plans (popularly called HDHPs), which may be linked to health savings
accounts (HSAs)

Types of Health Insurance in USA

 Take a minute to learn how these plans are different. Being familiar with the types of policies can
help you pick the one that best fits your budget and meets your peculiar health care needs. To
learn the specifics about a company’s particular health policy or product, it is always best to
consult a customer care agent. However, we have briefly written a summary of benefits.

1. Health Maintenance Organization (HMO)

 An HMO is a kind of Insurance Company that offers health insurance policies. They deliver all
health services through affiliation with a network of healthcare providers, hospitals, clinics, and
such and such facilities. With an HMO, you may have the following:
 Very little opportunity to choose your health care providers
 The least amount of paperwork and forms to fill when compared to other plans
 You may be assigned a primary care doctor to manage your health and also to refer you to
specialists when the need arises. The care is covered by your insurance policy.
 HMOs will usually require a referral before you can see a specialist.
 Your HMO (Health insurance provider) usually dictates What doctors you can see. If you see a
doctor who is not in the HMO’s network, you may have to pay the full bill by yourself. Emergency
services obtained at an out-of-network hospital must be covered at the same rates with your
HMO’s doctors, but non-participating doctors who treat you in such circumstances in the hospital
can bill you.
What you pay: Fees and Rates-

 Premium: This is the basic fee you pay each month for insurance.
Deductible: Your policy may require you to pay (or save) the amount of a deductible before it
covers Health care except for preventive care.
Copays and/or co-insurance cover for each type of care. A copay is a flat fee charged, such as
$15, that you pay when you get health insurance. Coinsurance is when you pay part of the
charges for Health care, for example, 20% of total health care costs. These charges usually vary
according to your insurance policy and the insurance company.

2. Preferred Provider Organization (PPO)

 A Preferred Provider Organization (PPO) is a health insurance provider very similar to an HMO in
that it works by affiliating itself with a network of doctors, hospitals, and such medical facilities.
The major difference between an HMO and a PPO is that when you sign up with a PPO you get
to choose the doctors that you want, provided that you have the money to pay for such cover.
When you sign up with a PPO you get the following:
 A moderate amount of power to choose your health care providers –a lot more than an HMO; you
do not need to get a referral from a primary care doctor before you can see a specialist.
 Higher costs from your pocket if you see out-of-network doctors as against when you see in-
network providers
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 More forms to fill than with other plans if you see out-of-network providers. These forms are
usually about money.
 You can usually see any doctors in the PPO’s network; you can also see out-of-network doctors,
but the only thing is that you’ll pay more.

What you pay- Costs Implications:

 Premium: This is the basic cost you pay each month for insurance cover.
 Deductible: Some PPOs may have a deductible fee. If so, you may likely have to pay a higher
deductible if you go out to see an out-of-network doctor.
 Copay or coinsurance: A copay is a flat rate, such as $15, that you pay when you get medical
care. Coinsurance is when you pay a percentage of the charges for care, and then your insurer
pays the balance. for example, you may pay 20%.
 Other costs: If the out-of-network doctor you visit charges more than others in the area do, you
may have to pay the balance of the fee after your insurance pays its share.
 Paperwork involved. There’s little to no paperwork involved with a PPO if you see their affiliated
doctor. If you use an out-of-network doctor or hospital, you’ll have to pay the facility. Then you
have to file a claim to get the insurer to pay you back.

3. Exclusive Provider Organization (EPO)

 Exclusive Provider Organization (EPO) is a kind of health insurance provider that offers very
limited insurance cover, using a very limited number of doctors and health facilities.
With an EPO, you usually have:
 Freedom to choose your health care providers (doctors and hospitals) — more than an HMO; you
do not have to get a referral from a primary care doctor in order to see a specialist.
 No coverage for doctors outside insurers network; if you see a hospital that is not in your plan’s
network – except during an emergency – you will have to pay the full cost yourself.
 Lower premium than a PPO, even when offered by the same insurer
You can see Any doctors in the EPO’s network; however, there is no coverage for out-of-network
providers.
 What you pay with this plan:
 Premium: This is the fee you pay each month for insurance cover.
 Deductible: Some EPOs may have a deductible amount that you pay before your plan kicks off.
 Copay or coinsurance: A copay is a flat fee that is charged, such as $15, that you pay when you
get medical care. Coinsurance is when you pay a certain percent of the charges for medical care,
for example, you may need to pay 20%.
 Other costs: If you see an out-of-network provider you will have to pay the full bill by yourself.
 Paperwork involved. There’s usually little to no paperwork with an EPO Once you sign up and pay
your premiums on the time you are good to go.
 4. Point-of-Service Plan (POS)
 A POS plan is a special insurance policy that blends feature of an HMO with a PPO. With the
POS plan, you may likely have:
 A lot more freedom to choose your doctors than you would in an HMO
 A moderate number of forms and papers if you see out-of-network providers
 A primary care doctor who treats you for a long time. He coordinates your care and also refers
you to specialists
 You can see any in-network providers that your primary care doctor refers you to.
 You can also see out-of-network doctors; however, you’ll pay more.

What you pay- Costs Involved:

 Premium: As usual, this is the cost you pay each month for insurance.
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  Deductible: Your plan may require you to pay the amount of deductible fee overtime before it
covers any care that goes beyond preventive services.
 Copays or coinsurance: You will likely pay either a copay, such as $15, which is a percent of the
charges for your policy. Copayments and coinsurance are usually higher when you use an out-of-
network doctor.
 Paperwork involved. If you go out-of-network for care, you will have to pay your medical bill. Then
you submit a claim to your POS insurer to pay you back.
 5. Catastrophic Plan
 If you are less than the age of 30 you can purchase a catastrophic health plan. With a
catastrophic health plan, you may likely have:
 Lower premium fees. They usually do not charge much premiums.
 They usually offer 3 primary care visits before the deductible applies
 They usually offer Free preventive care; they give this even if you haven’t met the deductible
 You can usually see Any doctors in the insurer’s network; individual policies may also have
additional rules on the specialists.
 What you pay- Cost Implications
 Premium: As usual, this is the cost you pay for each month for insurance cover.
 Deductible: A catastrophic health plan usually has a deductible of about $7,350 for an individual
and about $14,700 for a family (as at 2018.) After you reach that deductible fee, the plan will then
pay 100% of your medical costs for covered benefits in your policy.
 Paperwork involved. You will absolutely want to keep track of your premiums and expenses to
show you have met the deductible.

1. Commercial / Private Health insurance.

Commercial Health insurance or Private health insurance is an insurance which is paid by individuals
or their employers other than the government. It covers;

 Employee
 Student
 Tourist

2. Government health plans

There are two types of government health insurance plans:
1. Federal government plans: Federal government plans are those insurance plans which are funded
and managed by federal government of USA.

It includes:
1) Medicare:
Medicare, the single largest health benefits programs in the United States, is a federal program
authorized by Federal Government. Center of Medicare and Medicaid Services (CMS, formerly HCFA) is
responsible for the operation of the Medicare program.
Eligibility for Medicare
1. Age: People who are age 65 or over,
2. who (or whose spouse) have contributed a small part of salary to SSA (Social Security
Association) for at least 10 years and who are permanent citizens of US.
3. Disability: People under age 65, with certain disabilities
4. Kidney failure: People of any age with permanent kidney failure requiring dialysis or a transplant.
5. Hospice Condition.

Railroad Medicare:
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Patients who are retired railway workers have special Railroad Retirement cards with ID numbers
containing an alpha prefix.
if they are 65 or older and they receives Social Security or Railroad Retirement benefits, or could
receive Social
Security or Railroad Retirement benefits but has not filed for them, or they or their spouse had Medicare-
covered government employment.

2) Tricare:
 CHAMPUS: Tricare is available for the people who are Either working in Uniform services( Army,
Navy or Air force) known as CHAMPUS (Civilian health and Medical program for Uniform
services)

 CHAMPVA: The people who are either retired from Uniform services or are dependents of people
in Uniform services are covered by CHAMP VA. (Civilian health and Medical program for
Veterans Affairs)

3. State government plans

State government plans are governed by CMS but are funded and governed by states in US.
It includes
1) Medicaid
2) IHS/THS

Medicaid:
People who are below state poverty line are covered by the State Medicaid, the policy and guidelines
are governed by CMS.

IHS/THS:
I.H.S: Indian health service is available for the Native Red Indians or the tribal of US.

4. Automobile Insurance.
When you suffer a loss that's covered by your insurance, such as an automobile accident, you submit
a request to your auto insurance company to pay or reimburse you for expenses, damages and other
financial obligations.

Automobile insurance is of two types;

1) Comprehensive Plan (1st party)
2) Third Party Plan

Comprehensive Plan (1st party) Covers;

 Owner of the vehicle
 Damage of the vehicle
 Any third person (Vehicle & owner) who was injured by the vehicle.

Third Party Plan covers;

 Any third person (Vehicle & owner) who was injured by the vehicle.

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 5. NO-FAULT
Insurance that pays for health care services resulting from bodily injury regardless of who is at fault for
causing the accident. Basically, no-fault insurance is what its name suggests: there's no fault placed in
the event of an accident. The drivers involved would submit a claim to their own insurance companies
and receive compensation from them rather than target one another, trying to figure out who's to blame.

6. WORKER’S COMPENSATION
Worker’s Compensation is a State insurance program that provides health care and income to
employees when the employee suffers a work related injury, illness or death. Insurance laws in each
state require employers to purchase Worker’s Compensation insurance to cover their employees.

Eligibility
 Medical condition develops due to working environment.
 Medical condition develops within the working premises.
 Medical condition develops during the discharge of the duty.


What is medical billing

Medical billing is the process of generating healthcare claims to submit to insurance companies for the
purpose of obtaining payment for medical services rendered by providers and provider organizations.
After translating a healthcare service into a billing claim, the medical biller follows the claim to ensure the
organization receives reimbursement for the work the provider performed. Some times they also need to
send a bill to patient in order to get payment of patient responsibilities (including uninsured or termed
plans).

3 P’s Of Medical Billing Company

Patient  Provider  Payer

Steps of Revenue Cycle Management

Patient  Front Desk(Schedule appointment, Demographic input)  Provider Consultation

 Coding(To convert procedures and diagnosis into codes) Billing (To check patient eligibility with the
insurance and generate a claim or bill according to provider contract)  Insurance (For payment approval)
Payment Posting (To post the payment or denial)  A/R (To submit corrected claim in case of denial
and or for reprocess the claim to insurance to get payment)  Patient (incase of patient responsibilities)

Medical Billing Terminology

 Insurance: Insurance is a contract that protects the insured from the loss of health, property, life,
etc.
OR

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 Insurance Company guarantees payment to the insured for unforeseen events (e.g., death,
accident and illness) in return of the payment of the premiums). There are different types of
insurance: Property, life, and health. The latter is discussed at length in this manual.

 SGHP (Small Group Health Plan): A group health plan that covers employees of an employer
that has 2 to 51 or more employees. In some states small groups are defined as 2 to 100 or more.

 LGHP (Large Group Health Plan): A group health plan that covers employees of an employer
that has 51 or more employees. In some states large groups are defined as 101 or more.

 EGHP (Employer Group Health Plan): A group health plan is defined an employee welfare
benefit plan established or maintained by an employer or by an employee organization (such as a
union), or both, that provides medical care for participants or their dependents directly or through
insurance, reimbursement, or otherwise.

 Premium: A monthly fee is called premium.

OR
The amount you or your employer pays in exchange of the insurance coverage.

 Subscriber: The person who pays the premium to purchase an insurance policy.

 Insured / Beneficiary: A person who is eligible for the benefits under an insurance coverage. He
is either the person who pays the premium or a dependent of that person.

 Dependent: The spouse and children of the subscriber who are eligible for medical care under
the insurance contract.

 Patient: A patient is any recipient of health care services. The patient is most often ill or injured
and in need of treatment by an advanced practice registered nurse, physiotherapist, physician,
physician assistant, psychologist, podiatrist, veterinarian, or other health care provider

 Office Visit: A doctor's visit, also known as "physician office visit," is a meeting between a patient
with a physician to get health advice or treatment for a symptom or condition.

 Benefits: Amount payable by the insurance company to the insured when the insured suffers a
loss.

 Provider: A health care practitioner is called a provider. The physician who provides medical
treatment to a patient for any illness is the provider. He is also called the rendering physician.

 Claim: A claim is a request made to the Insurance Company by the billing office on behalf of the
physician for reimbursement of services provided to their members.

 Primary Insurance: Primary Insurance is the insurance carrier who is responsible to pay first of a
patient‘s treatment under the coordination of benefits.

 Secondary Insurance: Secondary insurance is the insurance carrier who is second responsibility
for the payment. When a person is a member of two different insurance companies, only does
secondary insurance play a role

 Tertiary Insurance: Tertiary insurance cover the remaining healthcare costs such as deductibles
and co-pays left over after the primary and secondary claims have been processed.

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 BIRTHDAY RULE
Birthday Rule determines coverage by primary and secondary policies when each parent subscribes to a
different health insurance plan.

Child of divorced parents:

1) The custodial parent’s plan is the primary.
2) If the parents are remarried, then the parent’s plan is the primary, the custodial step-parents plan is
the secondary, and the noncustodial parent’s plan is the tertiary.
3) If the court order specifies that a particular parent must cover the child’s medical expense then that
parent’s plan is the primary.

Child living with both parents:

If each parent subscribes to a different health insurance plan, the primary and the secondary policies are
determined by applying the birthday rule. Physician’s office staff must obtain birth date of both the
policyholder of each policyholder because the birthday rule states that the policyholder whose birth
month and day occurs earlier in the calendar year holds the primary policy for the children.
The year of birth is not considered when applying the birthday rule determination.

Example: Which policy is primary for the child if both parents have insurance
Birthday of mother is 03/06/59.
Birthday of father is 03/20/57.
Answer: Mothers policy is primary as her birthday is earlier in the calendar year.
Example: Birthday of both parents is on the same date.
Father’s policy took effect 03/06/86.
Mother’s policy took effect 09/06/92.
Answer: Father’s policy is primary because it has been in effect 6 years longer.

*If the policyholders have identical birthdays, the policy in effect in the longest is
considered primary.

 Coordination of Benefits (COB): COB occurs when a patient is covered by more than one
insurance plan. In this situation one insurance company will become the primary carrier and all
other companies will be considered secondary and tertiary carriers that may cover costs left after
the primary carrier has paid.

 Explanation of Benefits (EOB): A document attached to a processed medical claim wherein the
insurance company explains the services they will cover for a patient’s healthcare treatments.
EOBs may also explain what is wrong with a claim if it’s denied.

 Electronic Remittance Advice (ERA): The digital version of EOB, which specifies the details of
payments made on a claim either by insurance company or required by the patient.

 AOB: (Assignment of Benefits): The patient or guardian signs the Assignment of Benefits form
so that the physician or medical provider will receive the insurance payment directly. This form will
also be submitted at the front office

 ROI (Release of Information): The patient authorizes the provider to release his personal and
medical information for the purpose of medical billing.
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  Advance Beneficiary Notice (ABN) or Waiver of Liability: A written notice given to the patient
by the Provider in advance of any service or supply furnished for which payment may be denied
or reduced by Medicare as not reasonable and medically necessary. This notification serves as
protection for both the Provider and the patient. GA modifier is used to denote waiver of liability. It
is also called as Advance Beneficiary Notice
OR
An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice you should
receive when a provider or supplier offers you a service or item they believe Medicare will not
cover. ABNs only apply if you have Original Medicare, not if you are in a Medicare Advantage
private health plan

 COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985): A federal program that
allows a person terminated from their employer to retain health insurance they had with that
employer for up to 18 months, or 36 months if the former employee is disabled & after Medicare
will provide benefits.

 Spend Down: This amount is called excess income. Some of these people may qualify for
Medicaid if they spend the excess income on medical bills. This is called a spend down. For
example, a person over 65 is denied Medicaid because her monthly income is $50 more than the
limit for Medicaid eligibility.

Medicare Secondary Payer (MSP)

Medicare Secondary Payer (MSP) refers to situations where the Medicare program does not have
primary responsibility for paying a beneficiary’s health expenses because the beneficiary may be entitled
to other coverage that should pay primary health benefit.

Given below are cases when Medicare is the secondary payer:

1. Individuals who are aged 65 or older and working, with coverage under an employer sponsored or
employee organization group health plan.
2. Individuals who are aged 65 or older and covered by a working spouse’s employer group health
plan. The working spouse can be of any age.
3. Individuals who are under age 65, have Medicare because of disability, and covered under a
group health plan (GHP) because of their current employment or the current employment of a
family member.
4. Individuals who have Medicare because they have permanent kidney failure and are covered
under a Group Health Plan (GHP) because of their current employment or the current
employment of a family member.
5. Individuals who have Medicare because they have permanent kidney failure and are covered
under a Group Health Plan (GHP) because of their former employment.
Medicare is only secondary for a 30-month coordination period in this situation.

 Primary Care Physician (PCP): A primary care provider (PCP) is a health care practitioner who
sees people that have common medical problems. This person is usually a doctor, but may be a
physician assistant or a nurse practitioner.

 Rendering Physician: The rendering provider is the healthcare provider who actually performed
(or rendered) the services. For a solo practice, usually the billing provider and the rendering
provider are the same entity.

 Referring/Ordering Physician: The Referring/Ordering is the healthcare provider who refers the
patient to specialist.
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 New Patient: Any patient who is visiting the physician for the first time or subsequently after a
break exceeding the period of 3 years is called a new Patient.

 Established patient: An established patient is one who is visiting the Physician within a period of
3 years from the date of his last visit.

 In-patient: A person admitted to a hospital for medical care for more than 24 hours.

 Outpatient: A person who receives treatment in a physician’s office or a hospital but does not
require hospitalization.

 Fee Schedule: A list of all medical procedures and their respective allowed amounts for any INS
co is that INS Company’s “FEE SCHEDULE”.

 Billed amount: The amount charged by a physician as a compensation for his / her services.

 Allowed amount: The fixed payable amount set by the insurance companies for different
services performed by the physicians.

 Paid amount: The final amount paid by the insurance companies for different services performed
by the physicians.

 Patient Responsibility: This refers to the amount a patient owes a provider after an insurance
company pays for their portion of the medical expenses.

 Write off / Adjustment: The difference between a physician’s billed amount and the participating
insurance company’s allowed amount will be written off after the insurance company pays the
allowed amount. This is called write-off or disallowance.

 Effective Date: The date from which a person is eligible for medical benefits under his insurance
contract. The insurance company is responsible for the person’s medical bill from this day.

 Termination Date: The date from which a person is non-eligible for medical benefits under his
insurance contract. The insurance company will stop paying the person’s medical bill from this
day.

 Insurance Identification Number: This is a unique identification number assigned to each

subscriber. The claims and any correspondence for that subscriber and his dependents will be
sent under his ID#. The insurance companies use this number to access the subscriber’s account
in their computer systems.

 Date of Onset / Diagnosis: The Date of onset / Diagnosis is a medical term referring to the age
at which an individual acquires, develops, or first experiences a condition or symptoms of a
disease or disorder.

 Pre-existing condition: In the context of healthcare in the United States, a pre-existing condition
is a medical condition that started before a person's health insurance went into effect.

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 Waiting Period: The time between the effective date of a contract and the date the Plan will
assume liability for certain services---frequently with respect to preexisting condition.

 Global Period: A global period is a period of time starting with a surgical procedure and ending
some period of time after the procedure. Many surgeries have a follow-up period during which
charges for normal post-operative care are bundled into the global surgery fee. For minor surgery
the Global period is 10 days & 90 days for major surgery.

 ESRD (End Stage Renal Disease): Kidney failure, also called end-stage renal disease (ESRD),
is the last stage of chronic kidney disease. When your kidneys fail, it means they have stopped
working well enough for you to survive without dialysis or a kidney transplant

 Black Lung Program: The Black Lung Benefits Act (BLBA) is a U.S. federal law which provides
monthly payments and medical benefits to coal miners totally disabled from pneumoconiosis
(black lung disease) arising from employment in or around the nation's coal mines.

 DME (Durable Medical Equipment): Durable Medical Equipment (DME) is any equipment that
provides therapeutic benefits to a patient in need because of certain medical conditions and/or
illnesses.

 WCB (Worker’s Compensation Board): Workers' compensation is a form of insurance providing

wage replacement and medical benefits to employees injured in the course of employment in
exchange for mandatory relinquishment of the employee's right to sue his or her employer for the
tort of negligence.

 Hospice: Hospice is a special concept of care designed to provide comfort and support to
patients and their families when a life-limiting illness no longer responds to cure-oriented
treatments. Hospice care neither prolongs life nor hastens death.

 Crossover Claim: When claim information is sent from a primary insurance carrier to a
secondary insurance carrier in an electronic format.

 Clean Claim: A "clean claim" means a claim that does all of the following: Identifies the health
professional, health facility, home health care provider, or durable medical equipment provider
that provided service sufficiently to verify, if necessary, affiliation status and includes any
identifying numbers

 Dirty Claim: A claim submitted with errors or one that requires manual processing to resolve
problems or is rejected for payment

 LCD (Local Coverage Determination): Medicare administrative contractors (MACs) and the
Centers for Medicare & Medicaid Services (CMS) sometimes develop policies to limit Medicare
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 coverage of specific items and services. MACs issue local coverage determinations (LCDs) that
limit coverage for a particular item or service in their jurisdictions only.

 NCD (National Coverage Determination): A national coverage determination (NCD) is a United

States' nationwide determination of whether Medicare will pay for an item or service.

 NDC (National Drugs Code): The NDC, or National Drug Code, is a unique 10-digit, 3-segment
number. (Format- 0777-3105-02. First Four digits indicate “Labeler, Next four “Product Code” &
last two “Package Code”) it is a universal product identifier for human drugs in the United States.
The code is presented on all nonprescription and prescription medication packages and inserts in
the US.

 Interest Payments: Insurance pays interest on charges for which they delays processing and
payment. Insurance company pays amount of interest along with the payment.
Interest payments will begin on the 18th day after the date of receipt of a clean electronic claim
for participating physicians and 25th day after the date of receipt of a clean electronic claim for
non-participating physicians and all suppliers. For all providers, including participating and non-
participating physicians and suppliers, interest payments will begin on the 28th day after the date
of receipt of a clean paper claim.

 Offset: Insurance offset is the amount that the insurance company believes they have overpaid
earlier for a particular charge, DOS, and patient. First, they would attempt to recover the
overpayment by requesting a refund from the provider. If the physician does not reply or issue a
refund, they would automatically adjust it from the next check issued to the provider.

 Refund: This is a process by which any Excess payment received from the insurance or from the
patient is returned back as a refund.

 Covered Service: A healthcare provider's service or medical supplies covered by patient health
plan. Benefits will be given for these services based on patient plan.

 Non-Covered Services: Insurance companies do not pay for all medical services, even those
that might be helpful to a patient. When a service is not covered by patient insurance policy,
patients are responsible for paying the bill.

 Untimely Filing / Untimely Submission: Claims have a specific timeframe in which they can be
sent off to an insurance company for processing. If a provider fails to file a claim with an
insurance company in that timeframe, it is marked for untimely submission and will be denied by
the company.

 Participating / In Network Provider: A Participating Provider is one who accepts the payment of
the insurance company’s allowed amount as full payment, for any of the insurance company’s
beneficiaries regardless of how much he billed for his services.

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 Non-Participating / Out Of Network: A Non-Participating Provider is one who has not agreed to
accept the carrier determined, allowed rate as payment in full for covered services performed and,
therefore, expects to be paid the full amount of the fees charged for the services performed.

 Clearing House: A clearing house is a private third party company that act as a association
between provider & insurance. They receive claim from provider & forward to insurance for
processing.

 Electronic Data Interchange (EDI): Is the electronic data interchanged of business information
using a standard formats. It’s a process which allows one company to send information to another
company electronically rather than with paper.

 Payer ID Number: A Payer ID is a unique ID number that is assigned to an insurance company

for the purpose of transmitting claims electronically.

 TPA (Third Party Administrator): A third-party administrator (TPA) is an organization that

processes insurance claims or certain aspects of employee benefit plans for a separate entity.

 IPA (Independent Practice Association): An independent practice association (or IPA) is a US

term for an association of independent physicians, or other organization that contracts with
independent physicians, and provides services to managed care organizations on a negotiated
per capita rate, flat retainer fee, or negotiated fee-for-service basis.

 HPSA (Health Professional Shortage Areas): Physicians who render covered services in areas
where there is a shortage of physicians known as Health Professional Shortage Areas (HPSAs)
get incentive payments. These physicians receive an additional 10% of the 80% of the Medicare
allowable charge for both assigned and unassigned claims. A “QU” modifier is put on the claim for
services rendered in an urban HPSA, while a “QB” modifier is used for a rural HPSA.

 PHI (Protected Health Information): Protected health information (PHI) under US law is any
information about health status, provision of health care, or payment for health care that is
created or collected by a "Covered Entity" (or a Business Associate of a Covered Entity), and can
be linked to a specific individual.

 HIPAA (Health Insurance Portability and Accountability Act): The Health Insurance Portability
and Accountability Act was passed in 1996 by the US Congress, sets the standard for protecting
sensitive patient data. Any company that deals with protected health information (PHI) must
ensure that all the required physical, network, and process security measures are in place and
followed.

 HITECH Act (The Health Information Technology for Economic and Clinical Health): In a
recent revision of the act in 2009, was signed into law on February 17, 2009, HIPAA was
extended with the Health Information Technology for Economic and Clinical Health (HITECH) Act.
HIPAA and HITECH are similar rules, as both address the security and privacy of healthcare
regulations and also to promote the adoption and meaningful use of health information
technology.
Page 15 of 44
 Appeal: Appeal occurs when a patient or a provider tries to convince an insurance company to
pay for healthcare after it has decided not to cover costs for someone on a claim. Medical billing
specialists deal with appeals after a claim has been denied or rejected by an insurance company.

 Carve-Out: a service not covered in a health insurance contract. It is usually reimbursed

according to a different arrangement or rate formula than those services specified under the
contract umbrella.
Example:
1. A program that excludes certain services—usually from an organization’s capitated rate—and
tends to focus on one disease in depth;
2. An arrangement in which some benefits (e.g., mental health) are removed from coverage
provided by an insurance plan, but are provided through a contract with a separate set of
providers;
3. A population subgroup for which separate healthcare arrangements are made.

 Referral: Some insurance contracts require a referral for patients who have met a specialist. This
should come from the primary care physician, stating his diagnosis and reasons for sending the
patient to meet a specialist. This referral acts as a kind of a second opinion on the patient’s
medical condition. It also helps in keeping the insurance co.’s costs down by filtering the number
of patients who really require a specialist’s supervision.

 Authorization/Pre-authorization/pre-certification: Some insurance contracts require a

preauthorization/pre-certification for specific services. Pre-certification is a method of pre-
approving all elective hospital admissions, surgeries, and other services as required by an
insurance company. Approval is essential to receiving payment.

 Sequestration Reduction: On April 1, 2013, The Centers for Medicare and Medicaid Services
(CMS) began to impose a mandatory two percent payment reduction in the Medicare FFS
Program – also known as “Sequestration.”

 DRG (Diagnosis Related Group): A Diagnosis-Related Group (DRG) is a statistical system of

classifying any inpatient stay into groups for the purposes of payment. The DRG classification
system divides possible diagnoses into more than 20 major body systems and subdivides them
into almost 500 groups for the purpose of Medicare reimbursement.

 72 Hour Rule: The 72-hour (3-day) rule requires all diagnostic or outpatient services rendered
during the DRG payment window (the day of and three calendar days prior to the inpatient
admission) to be bundled with the inpatient services for Medicare billing.

 CLIA (Clinical Laboratory Improvement and Amendment Act): CLIA established quality
standards for all the entire laboratory testing to ensure the accuracy, reliability, and timeliness of
patient test results regardless of where the test was performed. All physicians who perform
laboratory tests must register with the CLIA program. Performing tests without CLIA approval is a
violation of the Clinical Amendment Improvement Act of 1988 and claims submitted by
Independent laboratories that have not enrolled in the CLIA program are being denied.

 EHR (Electronic Health Record): An Electronic Health Record (EHR) is an electronic version of
a patient’s medical history that is maintained by the provider over time, and may include all of the
key administrative clinical data relevant to that persons care under a particular provider, including
demographics, progress notes, problems, medications, etc.
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 EMR (Electronic Medical Record): An electronic medical record (EMR) is a digital version of the
traditional paper-based medical record for an individual. The EMR represents a medical record
within a single facility, such as a doctor's office or a clinic.

 QMB (Qualified Medicare Beneficiary): The Qualified Medicare Beneficiary (QMB) program is
one of four Medicare Savings Programs (QMB, SLMB “Specified Low-Income Medicare
Beneficiary”, QI “Qualified Individual”, and QDWI “Qualified Disabled Working Individual”)
established by Medicare to help low-income Medicare beneficiaries pay their Medicare Part A
premiums, Medicare Part B premiums and a portion of Medicare coverage costs such as
deductibles and co-insurance.
A Medicare beneficiary who qualifies for the QMB program will automatically qualify for the
Medicare Part D Extra Help program that provides financial assistance with Medicare Part D
prescription drug coverage (monthly premiums, deductibles, and drug costs).

Types of Care / Services

 Preventive
 Consultation
 Evaluation and Management (E&M)
 Pre-operative Care
 Surgery
 Post-Operative Care
 Curative
 Diagnostic
 Rehabilitation
 Ambulatory Care

Type of Providers
 Nursing Physician
 Ambulance
 Physician (Physician claim billed on CMS 1500 Form)
1. PCP (Primary Care Physician) Also Known as Referring / Ordering Physician.
2. Specialist
 Hospital (Hospital claim billed on UB-92 Form)
 Pathologist
 Physiotherapist/ Chiropractors
 Allergy and asthma
 Anesthesiology -- general anesthesia or spinal block for surgeries and some forms of pain control
 Cardiology -- heart disorders
 Dermatology -- skin disorders
 Endocrinology -- hormonal and metabolic disorders, including diabetes
 Gastroenterology -- digestive system disorders
 General surgery -- common surgeries involving any part of the body
 Hematology -- blood disorders
 Immunology -- disorders of the immune system
 Infectious disease -- infections affecting the tissues of any part of the body
 Nephrology -- kidney disorders
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  Neurology -- nervous system disorders
 Obstetrics/gynecology -- pregnancy and women's reproductive disorders
 Oncology -- cancer treatment
 Ophthalmology -- eye disorders and surgery
 Orthopedics -- bone and connective tissue disorders
 Otorhinolaryngology -- ear, nose, and throat (ENT) disorders
 Physical therapy and rehabilitative medicine -- for disorders such as low back injury, spinal cord
injuries, and stroke
 Psychiatry -- emotional or mental disorders
 Pulmonary (lung) -- respiratory tract disorders
 Radiology -- x-rays and related procedures (such as ultrasound, CT, and MRI)
 Rheumatology -- pain and other symptoms related to joints and other parts of the musculoskeletal
system
 Urology -- disorders of the male reproductive system and urinary tract and the female urinary
tract

Parts Of Medicare Plan

 Medicare Part A (Hospital Insurance): It covers hospital bills e.g., (room charges, etc.). It is
billed on UB-92 form.
 Medicare Part B (Supplemental Medical Insurance): It covers physician’s services, outpatient
hospital services, durable medical equipment’s and clinical laboratory tests. It is billed on CMS
1500 form.
 Medicare Part C: Medicare covers all healthcare services through a provider organization such
as a hospital or a private practice. Patients must be enrolled in Medicare Parts A and B to qualify
for Part C.
 Medicare Part D: Part D was created in 2003 with the passage of the Medicare Prescription
Drug, Improvement, and Modernization Act. It covers many prescription drug costs and is paid for
by monthly premiums of Medicare enrollees.

Types of commercial Insurances Plan

1) Indemnity Plan
2) Managed care Plan

1. Indemnity Plan
Indemnity Plans are a type of healthcare insurance set up as a fee-for service plan. The coverage
offered by most traditional insurers is in the form of an indemnity plan. The patient pays medical care
provider directly for services and then files claims to be reimbursed by the plan.
An indemnity plan offers maximum flexibility because the patient can visit any doctor, hospital, or other
health care provider he/she chooses in any part of the country.
There is no need to choose a primary care physician (PCP) to coordinate health care and also a referral
is not required to visit a specialist.

With the indemnity plan, the patient pays reasonable and customary, deductible, coinsurance amount,
and up to an out-of-pocket maximum.

The plan reimburses patients for covered medical services as long as the expenses are reasonable and
customary for the area in which they live. In an 80/20 plan, after the deductible is paid, the plan will
cover 80% of expenses and the participant must pay the remaining 20%. In a 90/10 plan, after the
deductible is paid, the plan will cover 90% of expenses and the participant must pay the remaining
10%.The provider uses balance billing.
On the other hand, it’s the most expensive way to go, and not every employer offers this plan.

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2. Managed care Plans
A large portion of insured Americans receive coverage through their employer, usually through managed
care plans. These insurance plans work with a specific group of doctors, hospitals, pharmacies, labs,
equipment vendors, and other care providers. Individuals insured under managed care plans seek
medical services within this managed care network. The four main components of managed care are
health maintenance organizations, preferred provider organizations, exclusive provider organization and
point of service plans.

1. HMO
2. PPO
3. EPO
4. POS
1. Health Maintenance Organization (HMO)
 HMO is a network of participating physicians of insurance company.
 If a member opts for the HMO plan, He/she is assigned a Primary Care Physician.
 If an HMO member falls Sick, he/she first needs to visit the Primary Care physician for his/her
initial treatment. If PCP finds that patient needs to be treated by any specialist for the same
illness, Patient is referred by PCP to an in-network specialist.
 Patient cannot visit a specialist without the referral by PCP and in such cases; insurance
company is not obligated to pay for the claims.
 Expenses incurred by the member of HMO plan are a fixed monthly premium and a small co-
payment per visit.
 This is generally the least expensive managed health care plan option available.

2. Preferred Provider Organization (PPO)

 A PPO is a network of contracted participating physicians and hospitals agreeing to render
services at discounted rates.
 A PPO plan provides both in-network and out-of-network benefits.
 Unlike an HMO, there is no primary care physician (PCP).
 The patient can directly see a specialist, without a referral from the PCP, within the Network.
 Also he can see a provider out-of-network.
 Expenses incurred by the member of PPO plan, when he sees an in-network provider, are
premium, a small co-payment per visit and lower co-insurance.
 The patient incurs higher out-of-pocket expenses when he sees an out-of-network provider.
 He pays deductibles, higher co-pays, higher coinsurance and balance bill.
 This plan is more flexible and expensive than an HMO plan as the patient has the choice of
seeing both an in-network provider and an out-of-network provider.

3. Exclusive Provider Organization (EPO)

 EPO plans combine the flexibility of PPO plans with the cost-savings of HMO plans. You won't
need to choose a primary care physician, and you don't need referrals to see a specialist.
 But you'll have a limited network of doctors and hospitals to choose from. And EPO plans don't
cover care outside your network unless it's an emergency.
 It's important to know who participates in your EPO plan's network. If you go to a doctor or
hospital that doesn't accept your plan, you'll pay all costs.

4. Point of Service (POS)

 POS plans are almost a hybrid of HMO and PPO plans.
 Like an HMO, the patient needs to first visit a PCP. If PCP finds that patient needs to be treated
by any specialist, patient is referred by PCP to an in-network specialist.
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  However, like a PPO, a POS plan lets a patient to see an out-of-network provider without a
referral from the PCP. But he incurs higher Out-of-pocket expenses when he sees an out-of-
network provider.
 He has to pay deductibles, higher co-pays, higher coinsurance and balance bill.
 This is the most flexible plan available among the managed care plans.

Types Of Reimbursement Methods

The mixture of reimbursement schemes seen in health care practices today greatly adds to the
complexity of the practice’s administrative billing operations. Many practices must work concurrently with
three reimbursement methods:

1. Capitation
2. Fee-for-Service
3. Episode of care

1. Capitation
 Method of payment whereby a physician or hospital is paid a fixed amount for each person in a
particular plan regardless of the frequency or type of service provided.
 Capitation is the method used by HMOs and some managed care plans.
 Capitation is usually described in the HMO/managed care literature as the PMPM payment (per
member per month payment).
 This reimbursement method was initially provided only to primary care physicians. In some parts
of the country capitation is paid to selected health care specialties.

2. Fee-for-Service
 It is the longstanding traditional form of reimbursement.
 The payment is made according to the reasonable and customary fee for each service provided.
 Payment for services may be made by the patient or from a third-party payer (e.g., individual or
corporation, government or private health insurance, etc.).

3. Episode of Care Reimbursement / Global Payment / Case Rate Payment

It is a payment method in which the health care provider receives one lump sum for all services
rendered to the patient for a specific illness. One example of reimbursement is in the global
surgical fee paid to physicians who perform major surgery. These global surgical fee payments
cover the following services:
 A preoperative visit
 The surgery
 Normal postoperative care
Reimbursement for any surgical complications is usually paid on a strict fee-for-service basis.
Neither of these two hospital reimbursement methods affects the services and claims for
physician services.

Page 20 of 44
 Out Of Pocket Expenses
A medical bill or part of medical bill paid by patient out of his pocket because of non-payment of his
insurance company is called Out of pocket expenses. Deductible, co-pay, co-insurance and balance bills
are “Out of pocket expenses”.

Deductible: A specified amount of annual out-of-pocket expense for covered medical services that the
insured must incur and pay each year to a health care provider before the insurance company will pay
benefits.

Co-Insurance: A specified percentage of the insurance determined allowed fee for each service, the
secondary insurance or the patient must pay the healthcare provider.

Co-payment: A provision in a insurance policy requiring the patient to pay a specified dollar amount to a
health care provider for each visit and/or medical services they receive.

Types Of Second Insurance Plan

Supplemental Insurance Plan: Supplemental health insurance is a type of insurance policy that plugs
coverage gaps in your regular health insurance. These gaps include deductibles, co-payments and
additional expenses not covered by regular health insurance

Secondary Insurance plan: A Secondary Health Insurance is a policy that is used to cover medical
expenses that are not covered under your Primary Health Insurance. Usually, a Primary Insurance will
include deductibles and out-of-pocket expenses that you will have to cover yourself.

Medigap Plan: A Medigap policy is health insurance sold by private insurance companies to fill gaps in
Original Medicare coverage. Medigap policies can help pay your share (like coinsurance, copayments,
or deductibles) of the costs of Medicare-covered services.

 TIN / Tax ID (Tax Identification number): A Tax Identification number is a unique 9 digit
number. A TIN is a tax processing number issued by the IRS (Internal Review Service) to
individuals who are required to have a U.S. tax payer identification number but who do not have
and are not eligible to obtain an SSN from the Social Security Administration. Tax id is generally
of 9 Digit.

 NPI (National Provider Identifier): A National Provider Identifier or NPI is a unique 10-digit
identification number issued to health care providers in the United States by the Centers for
Medicare and Medicaid Services (CMS). The NPI has replaced the unique provider identification
number (UPIN) as the required identifier for Medicare services, and is used by other payers,
including commercial healthcare insurers.

 PTAN (Provider Transaction Access Number): A PTAN is a Medicare-only number issued to

providers by MACs (Medicare Administrative Contractors) upon enrollment to Medicare. All
Medicare claims have to bill using PTAN number.

 UPIN (Unique Physician Identification Number): A unique physician identification number, or

UPIN, was a six-character alpha-numeric identifier used by Medicare to identify doctors in the

Page 21 of 44
 United States. They were discontinued in June, 2007 and replaced by National Provider Identifier
or NPI numbers.
 Taxonomy Code: Taxonomy codes are administrative codes set for identifying the provider type
and area of specialization for health care providers. Each taxonomy code is a unique ten
character alphanumeric code that enables providers to identify their specialty at the claim level.

 W-9 Form: A W-9 form is an IRS form (Internal Revenue Service), also known as "Request for
Taxpayer Identification Number and Certification", which is used by an individual defined as a
"U.S. person" or a resident alien to verify his or her taxpayer identification number (TIN).

 Social Security Number (SSN#): In the United States, a Social Security number (SSN) is a nine-
digit number issued to U.S. citizens, permanent residents, and temporary (working) residents
under section 205(c)(2) of the Social Security Act,

Place of Service Codes

It describes the nature of services rendered to the patient. Such as inpatient hospital, Outpatient
hospital, Skilled nursing facility, Doctors Office, Emergency room, etc., Each Place of service has a
payer specified two digits POS code, which must be reported in the claims. A list of POS codes
available. Certain services can be performed only in specified places. Given below is the list of place of
service codes.

Code Place of Service Name

11 Office
12 Home
21 Inpatient Hospital (other than Psychiatric)
22 Out Patient Hospital
23 Emergency Room Hospital
24 Ambulatory Surgical Center
26 Military Treatment Facility
25 Birthing Center
31 Skilled Nursing Facility
32 Nursing Facility
Custodial care facility (long-term basis no medical
33
component)
34 Hospice (Other than Patient's home)
41 Ambulance - Land
42 Ambulance - Air or Water
50 Federally qualified Health Center
51 Inpatient Psychiatric facility
52 Psychiatric facility partial hospitalization
53 Community Mental Health Center
54 Intermediate care facility/mentally retarded
55 Residential substance Abuse treatment facility
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive inpatient rehabilitation Facility
62 Comprehensive outpatient rehabilitation Facility
65 End Stage renal disease treatment facility
71 State or Local public health clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility

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 Coding
Coding: Coding is a process of reporting diagnoses, procedures and services as numeric and
alphanumeric characters on the insurance claim form.

CPT (Current Procedural Terminology): Current Procedural Terminology (CPT) is a medical code set
that is used to report medical, surgical, and diagnostic procedures and services to entities such as
physicians, health insurance companies and accreditation organizations.

 CPT was developed by the American Medical Association (AMA), which also revises it annually.
 CPT codes are standardized codes used to identify the treatment performed for a patient.
 This coding system is used by insurance carriers and medical offices (clinics, private homes,
hospitals, nursing facilities, hospice, etc.) to identify the services, procedures, and treatments
performed for patients by the medical staff.
 CPT codes reported on the claims must be mapped with the appropriate ICD-10 codes to prove
medical necessity of procedure performed or services rendered.
 CPT codes are filled in the 24D section of the CMS-1500 form (its units are filled in the Section
24G of the same form.
 In the current CPT book, codes are grouped into six major sections:

1. Evaluation and Management (E/M) 99201--99499

2. Anesthesia 00100--01999, 99100--99140
3. Surgery 10040--69990
4. Radiology 70010--79999
5. Pathology and Laboratory 80048--89399
6. Medicine 90281—99199

Individual sections are then broken down further. For example:

 E & M Office visit New patient Code 99201 – 99205

 E & M Office visit Establish patient Code 99211 - 99215
 E & M Consultation Code 99241 – 99245
 E & M In-Patient Consultation Code 99251 – 99255
 E & M Initial Care Code 99221, 99222 & 99223
 E & M Subsequent Care Code 99231, 99232 & 99233
 E & M Discharge Code 99238 & 99239

ICD-10-Codes (International Classification of Diseases)

 ICD-10- code stands for International Classification of Diseases, Clinical Modifications 10th
edition, which is a book, published by World Health Organization (WHO).
 The National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid
Services (CMS) oversee all the changes and modifications to the ICD-9-CM.
 The coders assign ICD-9-CM codes to diagnoses, signs, and symptoms (i.e., a patient’s medical
condition) documented by the health care provider.
 It Consists of Seven alpha numeric digit. The first three digits Code identify the condition; the next
three digits identify the etiology and last digit extension or side of the body.

 Downcoding: Downcoding occurs when an insurance company finds there is insufficient

evidence on a claim to prove that a provider performed coded medical services and so
they reduce or remove those codes. Downcoding usually reduces the cost of a claim.

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  Upcoding: Upcoding is the fraudulent practice of ascribing a higher ICD-10 code to a
healthcare procedure in an attempt to get more money than necessary from the insurance
company or patient.

 Undercoding: Undercoding means potential revenue is left on the table because you
didn't accurately code the procedure performed and missed out on reimbursement.

 Overcoding: Overcoding of CPT codes is the reporting of a higher code than what
accurately represents the work done by the physician.

Modifiers
Modifiers are the two digits alphanumeric codes that are adopted by the physician to confirm to the
carrier that the procedure performed was different or modified due to certain unavoidable circumstances.
Below is the list of Modifiers used in coding.

List of Common Modifiers

 21---Prolonged Evaluation and Management Services
 22---Unusual Procedural Services
 23--- Unusual Anesthesia
 24---Unrelated Evaluation and Management Service by the Same Physician During a
Postoperative Period
 25---Significant, Separately Identifiable Evaluation and Management Services by the same
physician on the Same Day of the Procedure or other services
 26---Professional Component
 29---Global Billing
 32---Mandated Services
 47---Anesthesia by Surgeon
 50---Bilateral Procedure
 51---Multiple Procedures
 52---Reduced Services
 53---Discontinued procedure/service
 54---Surgical Care Only
 55---Postoperative Management Only
 56---Preoperative Management Only
 57---Decision for Surgery
 58---Staged or Related Procedure or Service by the Same Physician During the
 Postoperative Period
 59---Distinct Procedural Service
 62---Two Surgeons
 63---Procedure Performed on Infants
 66---Surgical Team
 76---Repeat Procedure by Same Physician
 77---Repeat Procedure by Another Physician
 78---Return to the Operating Room for a Related Procedure During the Postoperative Period
 79---Unrelated Procedure or Service by the Same Physician During the Postoperative Period
 80---Assistant Surgeon
 81---Minimum Assistant Surgeon
 82---Assistant Surgeon (When Qualified Surgeon not Available)
 90---Reference (Outside) Laboratory
 91---Repeat Clinical Diagnostic Laboratory Test
Page 24 of 44
 99---Multiple Modifiers
 TC---Technical Component
 LT---Left Side
 RT---Right Side
 QW---CLIA Waiver Test
 GW---Unrelated Services Done By Physician During Hospice Condition
 GV---Related Services Done By Physician during Hospice Condition
 AI---Principal Physician
 AS---Assistant Physician

Practice Management Software

1. What is PMS
PMS (Practice Management Software): Medical practice management software (PMS) is a
category of healthcare software that deals with the day-to-day operations of a medical practice. Such
software frequently allows users to capture patient demographics, schedule appointments, maintain
lists of insurance payers, perform billing tasks, and generate reports.

2. Structure of PMS
I. Pt. Demographics Section
Patient Demographics sheet contains all the basic demographic information about an individual or
patient. Patient demographics ( PD ) include Patient name, Date of birth, Address, Phone
number, Doctor information, Social security number (SSN) and Sex. Patient Demographic also
contains Guarantors or emergency contact information, Health insurance information. Each piece

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 of information is important because correct and quality entry of such information will directly
impact physician’s monthly revenue. This sheet is also called as face sheet of a charge or claim.

II. Insurance/Payer section

Payers section contains data on the patient's payers, whether’ third party' insurance, self-pay,
other payer or guarantor, or some combination of payers, and is used to define which entity is the
responsible fiduciary for the financial aspects of a patient's care

III. Claims Section

Claim section contains data on the patient services given by health care provider. It includes
information such as procedure code, diagnosis code, date of service, unit of services, Modifier,
patient name, insurance information. Caller need to review/analyze all information before calling
insurance company for payment.

IV. Notes Section

It is a section in which AR caller has to document information about the claim. Information needs
to be document in a short and clear language so, when it requires other caller can review the old
follow up status and take next follow up accordingly.

What is First Party/Direct Account

First party/Direct account means healthcare provider has directly out sourced the work to billing
company (India/USA) & that company is working on behalf of the particular healthcare provider.
Most of the providers on first party account provide access for all changes such as; patient billing,
patient calling, adjustment, appeals etc.

What is Third Party Account

Third party account means healthcare provider has out sourced the work to billing company
(USA) & that company has given the work to third company. Now the thirds company is working
on behalf of the particular healthcare provider. On third party account provide do not provide any
access and for all changes they have to be in touch with the mediator company such as; patient
billing, patient calling, adjustment, appeals etc.
Denial And Rejection

Denied Claims: Denied claims have been deemed unpayable by an insurance company. Usually, insurers
explain why a claim was denied in the explanation of benefits (EOB) statement associated with the claim. Missing
information, billing errors, and questions about patient coverage are some of the main reasons claims are denied.
However, denied claims can be appealed successfully in some cases. Clearly it is better to avoid them in the first
place, though.

Rejected Claim: Rejected claims are sent back because of errors, not because the insurer concluded they were
unpayable. For example, if your medical billing software provides incorrect information that your billing staff
doesn't catch, the claim will be rejected. Correcting errors and resubmitting rejected claims is common, but as with
denied insurance claims, preventing claim rejections in the first place is the preferable option.

General Reason For Rejection

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 Rejection
Invalid Type Bill
Invalid Admission Type
Invalid Admission Source
From date is greater than through date
Total days must equal covered plus non-covered days
Invalid NPI
Invalid Patient Date of Birth
Invalid Admit Date
Invalid Admission Type
Invalid Admission Source
Adjustment DCN missing or DCN on non-adjustment
Invalid Patient Name
Invalid Principal Diagnosis
Admitting Diagnosis required
Invalid Patient Gender
Invalid Admit Hour
Invalid Discharge Hour
Invalid From Date
Invalid Through Date
Line non-covered charge must not be greater than line
charge
Invalid Facility Zip
Invalid Bill Provider Zip
Invalid Bill Provider Address
Patient last name cannot be spaces
Invalid Subscriber Date of Birth

General Reason For Denial

 The claim will be denied if the patient’s coverage is not effective at the time of the service. The
coverage may have terminated before the date of the patient’s service.

 The claim will be denied if the coverage is secondary to the patient.

 The claim will be denied if the insurance company is unable to identify the patient in their records.
This could be due to incorrect policy identification number or an incorrect policyholder’s name.

 The claim will be denied if it is sent past the filing limit. All insurance companies have a filing limit
counted from the date of service. In this cases charge will either be adjusted off or written off. If
the billing office can show the insurance company a proof of previous filing, the denial will be
reconsidered.

 Some insurance companies have specific procedures that their policies do not cover. If a charge
is denied as a non-covered service, the patient can be billed.

 A claim can be denied if there is any information missing or incorrect on the claim like the
provider#, patient’s address group# etc.

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  A claim can be put on hold or denied if the insurance company requires information from the
patient.

 An insurance company may deny a claim stating that the procedure performed does not match
the diagnosis.

 Some insurance company which requires a pre-certification or a referral for the treatment
performed will deny the claim or make a low payment if these are not attached to the claim or if
the claim does not contain the pre-certification or referral#.

 An insurance company may deny a claim stating that the service is inclusive in another code or
when multiple units of the same code are billed. In these cases, the insurance is questioning the
utilization of one code, when another code. Here the billing office can review the claim by sending
additional information like the doctor’s notes, reports or operative notes which prove that the
patient’s condition demanded these additional services or units.

 In the case of a managed care network where a patient’s policy states that he can only see
specific physicians, if the rendering physician is not a part of the network, the claim will be denied
stating that the patient went out of network.

 When more than one unit of a service is performed in a day, the insurance may pay only one unit
and deny the rest as duplicates.

 Some insurance coverage’s have a limit on the payable benefits per year. For e.g., if a policy
covers all charges up to $10,000 for a calendar year, the patient is responsible for all charges
after the insurance has paid the $10,000. When the insurance has met its maximum, it will deny
the claim stating that the maximum benefits have been met.

Common Denial And Their Resolution

Necessary information to collect from insurance for Paid and Denied Claim

Paid Claim:-

 Representative Name
 Allowed Amount
 Paid Amount
 Patient Responsibility (Co-pay, Co-insurance or Deductible)
 Check / EFT#
 Check / EFT date,
 If payment made through check then ask Bulk amount of the check
 Verify check mailing address
 Verify check cashed date (Check is outstanding & insurance have incorrect check mailing
address in their system first, try to update new address over the call. If representative does not
ready to add & want us to send W-9 form. Request your client to send updated W-9 form.)
 If claim billed with multiple CPT’s then ask all the CPT is been paid or not. (If any of the CPT’s
denied, work on denial & rebill denied CPT to insurance)
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  If claim paid more than 25 to 30 days before, then request for copy of complete EOB.
 Claim Number
 Reference Number for the call

Denied Claim:-

 Representative name
 Denial date
 Denial reason
 Claim number
 Reference Number for the call

___________________________________________________________________________________
_______

Claim NOT On File

 Claim was billed out from the system but insurance has not received it.
 It may be stuck in either System Rejection, Clearing House Rejection or, Payer EDI rejection.
 Search for rejection and correct the error.
 Re send claim out from system to insurance for processing.
___________________________________________________________________________________
_______

Exceeding Timely Filing Limit (TFL)

 Ask insurance representative for claim received & denial date.

 Filing limit for that carrier.
 Check the first claim bill date to insurance from system.
 If, insurance have received the first billed claim under filing limit, request to send it back for
reprocessing.
 If Insurance has not received the first submission;
 First Party A/c – Rebill claim with proof of timely filing (Commercial Insurance)
 Third Party A/c - Inform client saying to resubmit claim with Proof Of Timely Filing (Commercial
Insurance)
(Medicare and Medicaid will never pay claims after filing limit expired)
 If, claim billed first from system after the filing limit then;
 First Party A/c – Adjust the balance as untimely submission.
 Third Party A/C - Inform client saying to adjust the balance as untimely submission.
___________________________________________________________________________________
_______
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 Diagnosis Code Is Inconsistent With The Procedure Billed

 Ask insurance representative whether Dx is inconsistent with patient policy or Insurance

guidelines.
 If it’s inconsistent with patient policy;
 Ask insurance representative which Dx is inconsistent.
 Remove that Dx from claim level & resubmit claim for processing.
 If claim billed only with one Dx inform client saying resubmit with payable Dx or appeal with
Medical Notes.
 If it’s inconsistent with Insurance guidelines;
 Ask insurance representative which Dx is inconsistent.
 Remove that Dx from claim level & resubmit claim for processing.
 If claim billed only with one Dx;
 First Party A/c – Adjust the balance as Dx inconsistent.
 Third Party A/C - Inform client saying to adjust the balance as Dx Inconsistent.
___________________________________________________________________________________
_______

___________________________________________________________________________________
_______

Claim Not Covered By This Payer / Contractor. You Must Send Claim To Correct
Payer / Contractor

 This denial means, insurance says patient has HMO / Advantage Plan / Replacement policy.
 We can check HMO / Advantage Plan / Replacement policy information by two ways.
1) Health Plan portal
2) Calling health plan insurance representative.
 After getting HMO insurance name, we need to call HMO / Advantage Plan / Replacement policy
insurance to get Insurance ID#, Group#, Claim Mailing Address, Effective date of the policy,
Electronic Payer ID & Filing limit for the claim.
 After collecting all information; create a new Carrier HMO / Advantage Plan / Replacement on
patient account & bill all the patient account claims that can be covered by new policy.
___________________________________________________________________________________
_______

Claim Not Covered By This Payer / Contractor As Per Co-Ordination Of Benefits

 This denial means, insurance says patient has another insurance as primary.
 Check in system is there are two different insurance on patient account and claim billed to correct
payer as primary or not.
 If it’s billed to incorrect payer as primary then change the insurance order in system & bill claim to
correct payer as primary.
 If patient have only one payer information on account and patient age is 65 years or above then
patient will be having Medicare as primary.
 Check patient eligibility on Medicare portal and bill all claims to Medicare that can be covered
from effective date.

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  If patient have only one payer information on account and patient age is less than 65 years then
mention to insurance representative there isn't any other insurance as primary & request them to
send claim back for reprocessing (Insurance might denied claim incorrectly).
 If insurance denied claim correctly then;
 First Party A/c – Call patient to collect primary insurance information. If patient doesn’t respond on
call then bill balance to patient.
 Third Party A/c – Inform client saying to call patient for primary insurance information or bill
balance to patient.
___________________________________________________________________________________
_______

Pending For Medical Notes / Not Medically Necessity

This denial means, insurance says the submitted procedure or Dx was not necessary to
perform on date of service.
 Insurance need Medical Notes which proves the necessity for the billed procedure or Dx.
 First Party A/c – Request medical notes from client and send to insurance to show necessity
for the billed procedure and Dx to get paid.
 Third Party A/c – Request client to send claim with medical notes to show necessity for the
billed procedure and Dx to get paid.
___________________________________________________________________________________
_______
___________________________________________________________________________________
_______

Missing Referral On Claim

 Referrals are only required when patient Primary Care Physician is referring patient to a
specialist.
 Ask representative is there any referral on file. If it’s there then, request them to send claim back
for reprocessing (Insurance might denied claim incorrectly).
 If there is no referral then asks do they accept retro referral & what is the time period for retro
referral.
 If they accept and we have time period left for retro referral;
 First Party A/c - Ask insurance representative for PCP name & contact number. Call PCP office &
request for retro referral. After collecting retro referral, call insurance & provide the referral &
request them to send claim back for reprocessing.
 Third Party A/c - Ask insurance representative for PCP name & contact number. Request client to
call PCP office for retro referral & resubmit claim to insurance for processing with retro referral.
 If there is no referral and insurance do not provide retro referral;
 First Party A/c – Request medical notes from client and appeal to insurance to show necessity for
the procedure. If insurance denied with appeal, bill balance to patient.
 Third Party A/c – Request client to appeal claim with medical notes. If insurance denied with
appeal, request to bill balance to patient.
___________________________________________________________________________________
_______

Missing / No Authorization

 Authorization require for Surgery Code, Major Procedure, Few HMO policies and Insurance
Medical Group.
 Ask representative is there any authorization on file. If it’s there then, request them to send claim
back for reprocessing (Insurance might denied claim incorrectly).
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  If there is no authorization then asks do they accept retro authorization & what is the time period
for retro authorization.
 If they accept and we have time period left for retro authorization;
 First Party A/c – Call the insurance authorization department & request for retro authorization.
After collecting retro authorization, call insurance & provide the authorization and request them to
send claim back for reprocessing.
 Third Party A/c - Request client to call insurance authorization department and resubmit claim to
insurance for processing with retro authorization.
 If there is no authorization and insurance do not provide retro authorization;
 First Party A/c – Request medical notes from client and appeal to insurance to show necessity for
the procedure. If insurance denied with appeal, adjust the balance.
 Third Party A/c – Request client to appeal claim with medical notes. If insurance denied with
appeal, request to adjust the balance.
___________________________________________________________________________________
_______

___________________________________________________________________________________
_______

Pending For Pre-Existing Information From Patient / Provider

This denial means insurance requesting patient illness history prior to the coverage from
patient or from provider.
 Check whether insurance has sent questionnaire to patient or provider.
 If insurance has send more than 7 days ago (Both Scenario), Request them to resend.
 First Party A/c – (Information needed from patient) Call patient and ask to send the updated
questionnaire to Insurance to get paid. If patient do not respond then bill balance to patient.
 First Party A/c – (Information needed from provider) Request client to send the updated
questionnaire to Insurance to get paid.
 Third Party A/c – (Information needed from patient) Request client to call patient and ask to
send the updated questionnaire to Insurance to get paid. If patient do not respond then bill
balance to patient.
 Third Party A/c – (Information needed from provider) Request client to send the updated
questionnaire to Insurance to get paid.
___________________________________________________________________________________
_______

Inclusive To Another Procedure Or Services

 This denial means, insurance saying the denied procedure payment is included in another
procedure billed for same date of service.
There are five different billing scenarios for the same denial. We have to analyze claim and
take action accordingly.
 If claim billed with Office Visit Code and another procedure, check whether Modifier 25 is added
with Office Visit Code or not. If billed with Modifier25 then request insurance representative to
send claim back for reprocessing.
 If Office Visit Code not billed with Modifier 25 then, add the same & rebill only denied procedure
to insurance for processing.
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  Check the denied procedure billed with Modifier 51. If billed with Modifier 51 then, request
insurance representative to resend claim back for reprocessing.
 If denied procedure not billed with Modifier 51 then, add the same and rebill only denied
procedure to insurance for processing.
 Insurance still denying claim with Modifier 51 then, inform client to resubmit denied procedure with
Modifier 59 (If client allows then, only we can use Modifier 59 or, we have to escalate this issue to
client).
 If the denied procedure is Surgery Code and patient had surgery prior to the date of service (90
Days global period) then add Modifier 79 and rebill claim to insurance for processing.
 If the denied procedure is Office Visit Code and patient had surgery prior to the date of service
(90 Days global period) then add Modifier 24 and rebill claim to insurance for processing.
___________________________________________________________________________________
_______

___________________________________________________________________________________
_______

Expenses Incurred Prior to/ After Coverage Terminated

This denial means the services were rendered before the policy effective date / after the policy
termination.
 Ask insurance representative for policy effective date / policy termination date.
 Check on patient account if there is any other active insurance.
 If yes, then bill claim to active insurance for processing.
 If No;
 First Party A/c –Call patient for active insurance information and if patient do not respond then
bill balance to patient.
 Third Party A/c – Inform client to call patient for active insurance and if patient do not respond
then bill balance to patient.
___________________________________________________________________________________
_______

Primary Explanation Of Benefit (EOB) Needed To Process Claim

 This denial means insurance did not receive the claim with primary EOB.
 Ask Insurance representative to recheck their system for EOB and if they locate then, request to
send claim back for reprocessing (Insurance might denied claim incorrectly)
 If denied correctly then verify the claim mailing address. If address is correct then rebill all
pending claims with primary EOB.
 If claim mailing address is incorrect, ask for correct address. Update the new claim mailing
address and rebill all pending claims with primary EOB.
 Also, ask insurance do they accept claims via Fax. If yes, collect the Fax Number and fax all
pending claim with primary EOB.
___________________________________________________________________________________
_______

Primary Paid More Than Secondary Allowed Amount

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  This denial means, secondary insurance saying primary insurance has already paid more than
their allowed amount. There is nothing left to pay.
 If Patient has Medicaid as Secondary then we cannot bill to patient.
 First Party A/c – Adjust the balance as Primary Paid More than secondary allowed amount.
 Third Party A/c – Inform client to adjust the balance as Primary Paid More than secondary
allowed amount.
 If patient have commercial insurance as Secondary then we can bill balance to patient.
 First Party A/c – Bill balance to patient as Primary Paid More than secondary allowed amount.
 Third Party A/c – Inform client to Bill balance to patient as Primary Paid More than secondary
allowed amount.
___________________________________________________________________________________
_______

___________________________________________________________________________________
_______

Patient Cannot Be Identified As Our Insured / Unable To Identify Patient

 This denial means, insurance is unable to find patient in system with Name, Date of Birth or ID#.
 Ask representative to search patient in their system by Name, SSN# or DOB search.
 If representative is able to pull patient information then, collect correct patient name ID# & DOB.
Update the same on patient account & rebill claim to insurance for processing.
 If representative is unable to pull patient information with any of the above search then;
 First Party A/c – Call patient for correct Demographic and Insurance information. If patient do not
respond then, bill balance to patient.
 Third Party A/c - Inform client to call patient for correct Demographic and Insurance information or
bill balance to patient.
___________________________________________________________________________________
_______

Duplicate Claim

 It means insurance has received same claim twice.

 Check in system claim billed twice or not.
 If Yes, ask claim status to representative for first submission & take action accordingly (Paid or
Denied)
 If No, inform representative that there is only one submission. Claim might deny incorrectly.
 If denied incorrectly, request to send claim back for reprocessing.
 If representative says they denied correctly and they received another claim as well from another
provider.
 Insurance will never pay two providers for same specialty, same procedure on same date of
service.
 First Party A/c – Adjust the balance as paid to another provider.
 Third Party A/c – Inform client to adjust the balance as paid to another provider.
___________________________________________________________________________________
_______

Maximum Benefit Met

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  This denial means, patient has reached the maximum benefit for the calendar year.
 It may be in terms of Number of Visits assigned to patient or Dollar Value benefit given to patient.
 Ask representative for Number of Visits or Dollar Value allowed to patient per calendar year.
 Check patient old claims history in system, any of the above criteria does not meet then, request
insurance representative to send claim back for reprocessing (Insurance might denied claim
incorrectly)
 If Insurance denied claim correctly and patient has secondary insurance then bill claim to
secondary for payment.
 If Insurance denied claim correctly and patient do not have secondary insurance then;
 First Party A/c – Bill balance to patient as maximum benefit met for the calendar year.
 Third Party A/c – Inform client to bill balance to patient as maximum benefit met for the calendar
year.
___________________________________________________________________________________
_______

___________________________________________________________________________________
_______

Provider Is Non-Participating
This denial means, provider of service is non-contracted with insurance.
Request representative to verify provider benefit using Tax ID# and NPI# to see whether
provider is participating or not.
 If provider is participating then, request insurance representative to send claim back for
reprocessing. (Insurance might denied claim incorrectly)
 If provider is non-participating ask insurance representative whether patient have Out Of
Network benefit on plan (PPO or POS).
 If yes, request insurance representative to send claim back for reprocessing under out of
network benefit.
 If patient do not have Out Of Network benefit then;
 First Party A/c – Bill balance to patient.
 Third Party A/c – Inform client to bill balance to patient.
___________________________________________________________________________________
_______

Non-Covered Services / Procedure Not Payable

 This denial means the billed services are not payable according to insurance guidelines or
patient policy.
 Check the claims history in system whether billed procedure has paid earlier.
 If yes, then request insurance representative to send claim back for reprocessing. (Insurance
might denied claim incorrectly)
 If it’s not payable according to patient policy then;
 First Party A/c – Bill balance to patient
 Third party A/c – Inform client to bill balance to patient.
 If it’s not payable according to Insurance guidelines then;
 First Party A/c – Adjust the balance as non-covered services.
 Third party A/c – Inform client adjust the balance as non-covered services.

Page 35 of 44
___________________________________________________________________________________
_______

Routine Visits Are Not-Covered Under Patient Plan

This denial means, the diagnosis code reported on claim is routine in nature, and is not payable
by the payer.
 Routine Dx series will vary according to specialty.
 Verify the Dx on claim is routine according to specialty or not.
 If No, request insurance representative to send claim back for reprocessing (Insurance might
denied claim incorrectly)
 If Yes then:
 First Party A/c – Bill balance to patient as routine services are not covered under patient plan.
 Third Party A/c – Inform client to bill balance to patient as routine services are not covered under
patient plan.
___________________________________________________________________________________
_______

___________________________________________________________________________________
_______

Mutually Exclusive Procedure


This denial Means, there are two procedures billed on same day & one procedure cannot be
billable with another.
 One procedure is having mutual relation with other procedure.
 Insurance will only pay any of the one procedure.
 Insurance will not pay denied procedure with any Modifier or Appeal.
 Cross check in system from virtual billing book to see the claim denied correctly or not.
 If denied incorrectly, request insurance representative to send claim back for reprocessing
(Insurance might denied claim incorrectly)
 If denied correctly then;
 First Party A/c – Adjust the balance as mutually exclusive procedure.
 Third Party A/c – Inform client to adjust the balance as mutually exclusive procedure.
___________________________________________________________________________________
_______

Date Of Death Precedes The Date Of Service

This denial Means, patient died before or on date of service.

Ask insurance representative for patient Date of Death.
If patient died after DOS then, request insurance representative to send claim back for
reprocessing (Insurance might denied claim incorrectly)
 If patient Date Of Death is prior or on DOS then;
 First Party A/c – Adjust the balance as patient deceased.
 Third Party A/c - Inform client to adjust the balance as patient deceased.
Acts in US Medical Billing
Healthcare Quality Improvement Act of 1986 (HCQIA)
The Healthcare Quality Improvement Act (HCQIA) provides immunity for medical professionals and institutions during
conduct assessments. [1] The law originated partially due to a Supreme Court ruling involving abuse of the physician peer
review process. To date, HCQIA continues to evolve as the act arises in courtrooms and justices deliver new rulings.

Page 36 of 44
Legislators enacted the law to protect medical professionals from peer review-related lawsuits and to encourage physicians to
file official complaints after encountering unprofessional and dangerous peer conduct.

Medicare

The Medicare program provides insurance coverage for almost 50-million American citizens. [2] In 1945, President Harry
Truman rallied Congress for funding to insure all United States citizens. Twenty years later, president John F. Kennedy finally
succeeded in providing coverage for U.S. senior citizens. Today, the Congressional Budget Office forecasts that the program
will survive indefinitely thanks to sweeping spending reforms.

Medicaid

President Johnson’s 1965 legislation also included a provision to provide insurance for low-income individuals. [3] Today,
Medicaid provides coverage for over 70-million American citizens. In 2014, the program reimbursed hospitals for almost 50-
percent of all medical expenses.

Medicaid covers various recipients, such as uninsured expectant mothers, temporarily unemployed workers and disabled
individuals. Recently, new legislation has lowered the nation’s uninsured rate to under 9-percent, representing the highest
coverage rate in U.S. history.

Children’s Health Insurance Program (CHIP)

Along with the Medicaid, the Children’s Health Insurance Program (CHIP) has created a strong foundation for delivering
health coverage to children living in low-income households. The program originated with the Children’s Health Insurance
Authorization Act of 2009 (CHIPRA) and has successfully provided services to many previously disqualified clients. The
program has an extensive history of providing insurance to underprivileged children and receives funding from respective
states and the federal government. Today, the Affordable Care Act (ACA) makes this service accessible to the largest
number of low-income children in the country’s history.

Hospital Readmissions Reduction Program (HRRP)

The Hospital Readmissions Reduction Program (HRRP), an Affordable Care Act initiative, requires the Centers for Medicare
and Medicaid Services (CMS) to reduce payouts to care facilities that experience excessive patient readmissions. [4] The
program launched in late 2012 and defines readmissions as ‘repeat patient admissions among participating CMS hospitals in
a 30-day period; allowing exceptions for specific conditions, such as heart failure and pneumonia, as well as factors such as
poor health and multiple illnesses.’

Health Insurance Portability and Accountability Act (HIPAA) of 1996

The Health Insurance Portability and Accountability Act (HIPAA) protects America workers by allowing them to carry health
insurance policies from job to job. The program also permits workers to apply to a select group of health insurance plans to
replace lost coverage and adjust for family changes such as marriages, births and adoptions.

HIPAA bars insurers from discriminating against policy applicants due to health problems. In some instances, if an insurance
company denies a worker’s application, the individual may apply for coverage outside of the normal enrolment period.
Additionally, the act preserves state laws that protect workers’ insurance rights.

Patient Safety and Quality Improvement Act (PSQIA) of 2005

The Patient Safety and Quality Improvement Act (PSQIA) protects health care workers who report unsafe conditions. [6]
Legislators created the law to encourage the reporting of medical errors, while maintaining patients’ confidentially rights. To
ensure patient privacy, the HHS levies fines for confidentially breaches. The law also authorizes the Agency for Healthcare
Research and Quality (AHRQ) to publish a list of patient safety organizations (PSOs) that record and analyse patient safety
data. The Office for Civil Rights (OCR) enforces the law among national health care facilities.

Affordable Care Act of 2010

In March 2010, president Barak Obama sanctioned the Affordable Care Act (ACA), a somewhat modified version of the all-
inclusive coverage imagined by presidents since the early 1900s. [7] The act requires most U.S. citizens to apply for health
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insurance coverage, levying a penalty for individuals who fail to secure insurance but making exceptions for a few protected
groups. Under the law, enterprises that employ more than 200 workers must provide health insurance coverage. The act also
established the American Health Benefits Exchange, where citizens can review and compare insurance plans.

The Affordable Care Act offers health care professionals the opportunity to participate in shaping the delivery of patient
services. The medical field can benefit from input that helps deliver better services to the growing patient population while
reducing care expenses. As a current or future decision maker in the health care field, care providers must reflect on how to
create these results at their respective workplaces.

1. HIPAA

Originally enacted to protect health insurance coverage for workers who lost or changed jobs, the Health Insurance Portability
and Accountability Act of 1996 is now most-associated with the privacy of patient healthcare information.

Under HIPAA, the Department of Health and Human Services (HHS) establishes boundaries on the use and release of health
records. It also outlines safeguards to protect patients’ information and establishes civil and criminal penalties for violations.

The law applies not only to hospitals and medical practices, but also to chiropractors, dentists, nursing homes, pharmacies,
and psychologists. In addition, the law governs the activity of business associates such as third-party administrators,
pharmacy benefit managers for health plans, billing and transcription companies, and professionals performing legal,
accounting, or administrative work.

The law’s provisions are far-reaching

“All healthcare entities and organizations that use, store, maintain or transmit patient health information are expected to be in
complete compliance with the regulations of the HIPAA law,” according to information presented by Datica, a digital health
platform. “When completely adhered to, HIPAA regulations not only ensure privacy, reduce fraudulent activity and improve
data systems but are estimated to save providers billions of dollars annually. By knowing of and preventing security risks that
could result in major compliance costs, organizations are able to focus on growing their profits instead of fearing these
potential audit fines.”

HIPAA applies to verbal, written, and electronic patient records — and the use of electronic health records (EHR) is
increasing. With more medical providers using EHRs, data breaches have increased. Some 351 breaches of more than 500
or more records, for a total exposure of more than 13 million patient records, had been reported as of Dec. 27, 2018,
according to the HIPAA Journal. Stolen data is frequently used for identity theft and fraud.

However, as both technology and hacking attempts evolved, Congress instituted additional regulations — and stronger
penalties — to address EHR and cloud-based medical records issues, which led to the HITECH Act.

2. The HITECH Act

The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law in February 2009 to
promote the “adoption and meaningful use of health information technology,” according to the HHS website. It mandates
audits of healthcare providers to determine whether they are compliant with HIPAA’s privacy and security rules.

The HITECH Act can be considered the enforcement wing of HIPAA. Because healthcare records, unlike credit cards, can’t
be canceled, changed, or reset in the event of a breach, healthcare providers have increasingly become the target of
hackers.

The act provides financial incentives for providers to offset the initial costs of switching to EHRs — as well as tougher data
security requirements and penalties for both healthcare organizations and their business associates.

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Under the regulations, patients must be notified of any unauthorized access or use of their information. Protected health
information (PHI) can only be shared by secured methods. Using traditional, unsecured email — a common way to share PHI
electronically — can put an organization’s HIPAA compliance in jeopardy.

The cost of non-compliance can be high, with organizations facing potential fines of up to $1.5 million per calendar year for
each violation. They can also incur losses related to notifying patients affected by a breach, through investigations, audits,
and other legal issues.

Although no one could have predicted the COVID-19 pandemic, HIPAA and HITECH have proven themselves as being
“ahead of the curve” in safeguarding a patient’s right to privacy. As social distancing protocols continue to reduce the number
of face-to-face meetings in 2020, the increased flow of electronic information provides a seemingly ripe opportunity for
malefactors to intercept sensitive data.

However, due to the foresight of both initiatives, patients now have additional peace of mind that was enacted years — even
decades — before the pandemic began.

Healthcare Administrators looking to secure their infrastructure further should assess security compliance of their practice or
organization, make sure proper electronic PHI procedures are in place, and update their HIPAA privacy and security policies.

The federal government also concerns itself with compensation for physicians and healthcare providers.

3. MACRA

The Medicare Access & CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 addresses payment for
doctors as well as cost controls for Medicare Part B.

Part of an overall shift to value-based reimbursement, MACRA moves away from the Sustainable Growth Rate (SGR)
payment formula and toward a treatment model based on quality of care and use of EHRs by the medical practice or facility.

4. Medical Necessity

Medical necessity is one of the most important aspects of contemporary healthcare administration, even though it has no
regulatory definition at the federal level or in most states.

The concept of medical necessity states that if a treatment is not medically necessary, the payer — generally an insurance
company, but also Medicare or Medicaid — won’t cover the cost.

According to medical biller and coder resource MB-Guide, “Understanding medical necessity and how to document it is an
important part of medical billing, because it is why an insurance company actually pays for a claim. If it’s not documented, it
never happened.”

Not all procedures are medically necessary. A practice administrator needs to understand the coverage policies for services
to help avoid denied claims.

5. Chain of Custody

A “Chain of Custody” form, also known as a CCF or CoC, refers to “a document or paper trail showing seizure, custody,
control, transfer, analysis, and disposition of physical and electronic evidence of a human specimen test,” according to the
American Alliance Drug Testing website, which details Department of Transportation (DOT) drug testing procedures.

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The CCF is considered a legal document and can be invalidated if there’s any evidence of tampering.

Labs that perform DNA or paternity testing follow similar documentation procedures and legal requirements. In-home curiosity
DNA tests, such as those available from 23andMe or similar companies, may be prohibited in some states because no chain
of custody can be established.

The intricacies of today’s healthcare regulations require managers and administrators to be familiar with a diverse set of rules
governing their profession.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a health insurance program that allows eligible
employees and their dependents the continued benefits of health insurance coverage when an employee loses their job or
experiences a reduction of work hours. Below, we'll explore the basic details of COBRA, how it works, its eligibility criteria,
pros and cons, and other features.

KEY TAKEAWAYS

 COBRA is an acronym for the Consolidated Omnibus Budget Reconciliation Act, which provides eligible employees
and their dependents the option of continued health insurance coverage when an employee loses their job or
experiences a reduction of work hours.
 Employers with 20 or more full-time-equivalent employees are usually mandated to offer COBRA coverage.
 Health insurance coverage from COBRA extends for a limited period of 18 or 36 months, depending upon
applicable scenarios.
 The cost of COBRA coverage is usually high because the newly unemployed individual pays the entire cost of the
insurance (employers usually pay a significant portion of healthcare premiums for employees).
 If you have lost your health insurance due to job loss during the 2020 economic crisis, you qualify for a "special
enrollment" period on the federal exchange, which gives you 60 days to enroll. This may be a way to find a cheaper
health insurance option than COBRA.
 The American Rescue Plan Act (ARPA) of 2021 provides 100% COBRA premium coverage for qualified individuals
from April 1, 2021, through September 30, 2021.

What Is COBRA Health Insurance?

Large employers in the U.S., those with 50 or more full-time workers, are required to provide health insurance to their
qualifying employees by paying a part of insurance premiums.1 If an employee becomes ineligible to receive an employer's
health insurance benefits—which can happen for a variety of reasons (such as getting laid off or falling below a minimum
threshold number of hours worked per week)—the employer may stop paying its share of the employee's
insurance premiums. In that case, COBRA allows an employee and their dependents to retain the same insurance coverage
for a limited period of time, provided they are willing to pay for it on their own.

Under COBRA, former employees, spouses, former spouses, and dependent children must be offered the option of
continued health insurance coverage at group rates, which otherwise would be terminated. While these individuals are likely
to pay more for health insurance coverage through COBRA than they did as employees (because the employer will no
longer pay a portion of the premium costs), COBRA coverage might be less expensive than an individual insurance plan
would be.2

It's important to note that COBRA is a health insurance coverage program and plans may cover costs toward prescription
drugs, dental treatments, and vision care. It does not include life insurance and disability insurance.

As part of the American Rescue Plan Act of 2021, the federal government paid COBRA insurance premiums for individuals
(and their covered relatives) that lost their job as a result of the 2020 economic crisis from April 1 through Sept. 30, 2021.3

Qualifying for COBRA Health Insurance

There are different sets of criteria for different employees and other individuals who may be eligible for COBRA coverage. In
addition to meeting these criteria, eligible employees can typically only receive COBRA coverage following particular
qualifying events, as discussed below.

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Employers with 20 or more full-time-equivalent employees are usually mandated to offer COBRA coverage. The working
hours of part-time employees can be clubbed together to create a full-time-equivalent employee, which decides the overall
COBRA applicability for the employer. COBRA applies to plans offered by private-sector employers and those sponsored by
the majority of local and state governments. Federal employees are covered by a law similar to COBRA.

Additionally, many states have local laws similar to COBRA. These typically apply to health insurers of employers having
fewer than 20 employees and can be called mini-COBRA plans.4

A COBRA-eligible employee must be enrolled in a company-sponsored group health insurance plan on the day before
the qualifying event occurs. The insurance plan must be effective on more than 50% of the employer's typical business days
in the previous calendar year.5

The employer must continue to offer its existing employees a health plan for the departing employee to qualify for COBRA.
In case of the employer going out of business or the employer no longer offering insurance to existing employees (for
instance, if the number of employees drops below 20), the departing employee may no longer be eligible for COBRA
coverage.6

The qualifying event must result in a loss of the employee's health insurance. The type of qualifying event determines the
list of qualified beneficiaries, and conditions vary for each type of beneficiary.

Employees
Employees qualify for COBRA coverage in the event of the following:6

 Voluntary or involuntary job loss , such as the 2020 economic crisis (except in cases of gross misconduct)
 A decrease in the number of hours of employment resulting in loss of employer insurance coverage

Spouses
In addition to the two qualifying events for employees (above), their spouses can qualify for COBRA coverage on their own if
the following conditions are met:6

 The covered employee becomes entitled to Medicare

 Divorce or legal separation from the covered employee
 Death of the covered employee

The employee or beneficiaries must notify the plan in the event of divorce, legal separation, or a child's loss of dependent
status.

Dependent Children
Qualifying events for dependent children are generally the same as for the spouse with one addition:

 Loss of dependent child status, as per the plan rules

The employer must notify the plan within 30 days of the qualifying event that is applicable to the employee. The employee or
beneficiaries must notify the plan if the qualifying event is divorce, legal separation, or a child's loss of dependent status.6

COBRA Benefits and Available Coverage

For qualifying candidates, COBRA rules provide for the offering of coverage that is identical to that which the employer
offers to its current employees. Any change in the plan benefits for active employees will also apply to qualified
beneficiaries. All qualifying COBRA beneficiaries must be allowed to make the same choices as non-COBRA beneficiaries.
Essentially, the insurance coverage for current employees/beneficiaries remains exactly the same for ex-
employees/beneficiaries under COBRA. You must be given at least 60 days in which to choose whether or not to elect
continuation coverage. Even if you waive coverage, you can change your mind if it is within the 60-day election period.

From the date of the qualifying event, COBRA coverage extends for a limited period of 18 or 36 months, depending upon
the applicable scenarios.7 One can qualify to extend the 18-month maximum period of continuation coverage if any one of
the qualified beneficiaries in the family is disabled and meets certain requirements, or if a second qualifying event occurs—
potentially including the death of a covered employee, the legal separation of a covered employee and spouse, a covered
employee becoming entitled to Medicare or a loss of dependent child status under the plan.

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Cost of COBRA Health Insurance

The term "group rate" may be incorrectly perceived as a discount offer, but in reality, it may turn out to be comparatively
expensive. During the employment term, the employer often pays a significant portion of the actual health insurance
premium (for example, an employer may pay 80% of premium costs), while the employee pays the remainder. After
employment, the individual is required to pay the entire premium, and at times it may be topped up with an extra 2%
toward administrative charges. Costs may not exceed 102% of the cost for the plan for employees who haven't experienced
a qualifying event.8

Therefore, despite the group rates being available for the COBRA continued plan in the post-employment period, the cost to
the ex-employee may increase significantly when compared to prior insurance costs. In essence, the cost remains the same
but has to be borne completely by the individual with no contribution from the employer.

COBRA may still be less expensive than other individual health coverage plans. It is important to compare it to coverage the
former employee might be eligible for under the Affordable Care Act, especially if they qualify for a subsidy. The employer's
human resources department can provide precise details of the cost.

Those who lost health insurance due to a job loss during the 2020 economic crisis, qualified for a "special enrollment" period
on the federal exchanges, which gave them 60 days to sign up. That may have been a way to find a cheaper insurance
option than COBRA.9

Early Termination of COBRA Health Insurance

COBRA coverage can end prematurely in the following cases:10

 Failure to pay premiums on time

 Employer ceasing to maintain any group health plan
 A qualified beneficiary gaining coverage under another group health plan (for instance, with a new employer),
becoming eligible for Medicare benefits, or engaging in misconduct (such as fraud)

Pros and Cons of COBRA Health Insurance

An individual who opts for COBRA coverage is able to continue with the same physician, health plan, and medical network
providers. COBRA beneficiaries also retain existing coverage for preexisting conditions and any regular prescription drugs.
The plan cost may be lower than other standard plans, and it is better than remaining uninsured as it offers protection
against high medical bills to be paid for in case of any sickness.

Nonetheless, it's important to keep in mind the downsides of COBRA. Some of the most prominent of these include the high
cost of insurance when it is borne entirely by the individual, the limited period of coverage under COBRA, and the continued
dependency on the employer. If the employer opts to discontinue the coverage, an ex-employee or related beneficiary will
no longer have access to COBRA.

If the employer changes the health insurance plan, a COBRA beneficiary will have to accept the changes even if the
changed plan doesn't offer the best fit for the individual’s needs. A new plan may change the coverage period and number
of available services, for example, and it may increase or lower deductibles and co-payments.

For these reasons, individuals eligible for COBRA coverage should weigh the pros and cons of COBRA against other
available individual plans to select the best possible fit.

A potential COBRA beneficiary also can explore, for example, whether they may qualify for a public assistance program
such as Medicaid or other state or local programs. However, such plans may be limited to low-income groups and may not
offer the best care and services compared to other plans.

Healthy individuals can explore the option of a low-cost healthcare discount plan. But these plans don't count as insurance
coverage, which can make it difficult to get health insurance in the future since signing up for one of these plans means that
insurance coverage is considered to have been interrupted.

Managing a High COBRA Premium

If you're considering COBRA coverage but you're concerned about the differences between the cost of insurance coverage
through this program and the cost of insurance with the support of an employer, there are a number of important
considerations to keep in mind.
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When you lose your job, you generally lose your flexible spending account (FSA). If a job loss is threatened, you are allowed
to spend your entire year's contribution to the FSA before you become unemployed. If you were going to contribute $1,200
for the year but it's only January, for example, and you've only had $100 withheld from your paycheck for your FSA, you can
still spend all of the $1,200 that you were planning to contribute—say, by seeing all of your doctors and filling all of your
prescriptions immediately.

Upon choosing COBRA, you can change your plan during the employer's annual open enrollment period and opt for a less
expensive plan like a preferred provider organization (PPO), or health maintenance organization (HMO).

If available, a refundable tax credit called the Health Coverage Tax Credit (HCTC) can be utilized by qualifying individuals to
pay up to 72.5% of qualified health insurance premiums, including COBRA continuation coverage.1 1 The HCTC program
was due to expire on Dec. 31, 2020, but the Internal Revenue Service (IRS) has extended the program through Dec. 31,
2021.12

Tax deductions might also help reduce the burden of higher premiums. While filing the annual tax returns, you are allowed
to deduct COBRA premiums and other medical expenses exceeding 7.5% of your adjusted gross income (AGI) on your
federal tax return (but you must itemize your deductions on Schedule A).1 3

You can achieve additional savings by reducing other healthcare expenses, such as switching to generic drugs or buying
larger supplies at a discount, and visiting a low-cost community or retail clinic for basic healthcare services.

Finally, you can utilize the funds of your health savings account (HSA) to pay COBRA premiums as well as medical
expenses, which could significantly reduce the sting of losing your health insurance benefits.

It's important to note that making timely payments on COBRA premiums is essential to maintaining coverage for the
duration of your eligibility. The initial premium payment is due within 45 days of the date of your COBRA election, and failure
to make that payment could lead to the loss of your COBRA rights. Payment is typically designed to cover a period that is
retroactive, going back to the date of the loss of coverage and the qualifying event that established eligibility.

If you do not make your COBRA payments on time but you do within the grace period for that period of coverage, there is
the possibility that your coverage will be canceled until payment is received, at which point coverage will be reinstated.

You can use your health savings account (HSA) to pay COBRA premiums as well as medical expenses, which could
significantly reduce the sting of losing benefits.

Government Jurisdiction Over COBRA

Several agencies of the federal government are responsible for administering COBRA coverage. Currently, the Departments
of Labor and Treasury maintain jurisdiction over private-sector group health plans, while the Department of Health and
Human Services is responsible for public-sector health plans. However, these agencies are not necessarily heavily involved
in the process of applying for COBRA coverage or related aspects of the continued coverage program.

The Labor Department's regulatory responsibility includes the disclosure and notification of COBRA requirements as
stipulated by law. And the Center for Medicare and Medicaid Services provides information about COBRA provisions for
public-sector employees.

The American Recovery and Reinvestment Act of 2009 signed into law by President Biden on March 11, 2021, contained a
provision that provided a 100% subsidy of COBRA premiums beginning April 1, 2021, and ending Sept. 30, 2021.
Employers recoup the premiums through Medicare tax credits.1415

The American Rescue Plan Act of 2021, signed into law by President Biden on March 11, 2021, contains a provision that
provides a 100% subsidy of COBRA premiums beginning April 1, 2021, and ending September 30, 2021. Employers recoup
the premiums through Medicare tax credits.3

You are eligible for the COBRA premium subsidy if you lost coverage due to a reduction in hours or involuntary termination
of employment. Your employer must treat “assistance-eligible individuals” who have COBRA coverage during the six-month
subsidy period as having paid their premiums in full. If, however, you are eligible for other group health plan coverage or
Medicare, you will lose eligibility for the COBRA subsidy. You are required to self-report your eligibility for other coverage to
the COBRA plan and will face a tax penalty if you do not.

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Applying for COBRA Health Insurance

In order to begin COBRA coverage, an individual must confirm that they are eligible for assistance according to the
requirements listed above. Typically, an eligible individual will receive a letter from either an employer or a health insurer
outlining COBRA benefits. Some individuals find this notification difficult to understand because it includes a large amount of
required legal information and language. If you have any difficulty determining whether you are eligible for COBRA or how to
begin coverage through this program, contact either the insurer or your former employer's HR department.

For individuals either not eligible for COBRA or those searching for alternatives, there are other options, such as a spouse's
health insurance plan.

For individuals either not eligible for COBRA or those searching for alternatives, there are other options. In some cases, a
spouse's health insurance plan may be a possibility. Or you might explore your options on the federal health insurance
marketplace or a state insurance marketplace. Loss of a job will open up a special enrollment period.16

As indicated above, Medicaid programs and other short-term policies designed for those experiencing a gap in health
coverage may also be available to you. Health insurance professionals typically discourage individuals from electing to go
uninsured entirely, as the possibility of severe downsides is high—especially during an uncertain time. Fortunately,
individuals eligible for COBRA coverage have at least 60 days to elect to participate in the program.

The Bottom Line

COBRA is a convenient option for retaining health insurance if you lose your employer-sponsored benefits, and sometimes
it is also the best option. However, the cost is often high and the plan is not always the best one to fit an individual's or a
family's needs.

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