MEDICAL BILLING FAQ’S
Does Paramount Professional Services (PPS) submit claims electronically?
Yes. We enter patient charges and file claims electronically whenever possible, and file paper claims only when necessary.
Does PPS receive feedback reports from insurance companies?
Yes. If issues are identified, we will correct and resubmit urgently.
What is the waiting time for claim resubmittal due to lack of response?
If we have not received payment, notice of denial, or any other response within 30 days of the last billing date, we will resubmit the claim. Should claim information be incomplete, your office will be notified immediately. Once claim information has been amended by your office, we will resubmit immediately.
What if a claim is underpaid?
If a claim is underpaid, according to your negotiated contract, we will contact the insurance company directly to correct the reimbursement amount.
How are patients notified of remaining balances?
Statements are sent to patients by mail once an outstanding balance is determined.
Are unpaid accounts sent to collections?
You retain full decision-making power regarding whether accounts are or are not sent to collections. We follow state guidelines regarding collection policies.
How are insurance and patient payments reconciled?
We post all payments that are received by your office. Checks are sent directly to your office, and your office staff will send copies of EOB’s or checks to us so we can post the payments to our billing system.
Do clients have access to regular financial reports?
Yes. We provide monthly financial reports. You have a wide range of reports to choose from. Based on your initial preferences, those reports will be sent to you monthly. If you need additional reports, your Account Executive can address those needs.
MEDICAL CODING FAQ’S
How can outsourcing my coding needs benefit my medical practice?
There are so many reasons to take advantage of our medical coding services. Here are just a few of them:
- Improved cash flow
- Improved office operations, with reduction in expenses. Our services help to reduce burnout, staffing shortages, and turnover from stressful reimbursement issues. By eliminating these challenges, your staff will be happier, more stable, productive and committed.
- Reduction in office space requirements when billing and coding are no longer performed by your staff.
Should I be concerned if I work in a specialty not currently serviced by PPS?
Yes. We provide accurate and up-to-date medical coding support for any specialty.
Is the PPS coding service HIPAA compliant?
Yes. PPS strives to provide technological and professional safeguards for protected patient information. Our entire staff undergoes HIPAA training yearly.
PATIENT INFO FAQ’S
What can I do if I don’t agree with my insurance company?
If you have a claim that is denied, it is usually worth fighting your denial. Sometimes, your insurer will give in and pay your claim to avoid the cost of handling an appeal. Sometimes, your protests will uncover a mistake the insurer has made.
Start by reviewing your paperwork file. Then, call your health plan’s customer service phone number. Often, mistaken denials can be cleared up at this level. Be sure to take notes on all phone conversations, including the date and time of the call, the names of people you talk to and what was discussed.
The more information you have, the more likely you are to win your claims denial appeal. Keep a paper trail of the following items:
- A copy of your health insurance policy
- Copies of denial letters from your health plan
- Copies of any correspondence between you and your health plan
- Detailed notes of conversations with your health plan
For a consumer guide to handling disputes with your employer or private health plan, check the Kaiser Family Foundation consumer guide.
INSURANCE OPTIONS
Private Insurance
The most common types of insurance are “managed care” programs like PPOs, HMOs, or a combination of the two. These are private insurance plans that provide a network of doctors, hospitals and health care providers to chose from. When employers provide health insurance, it is usually a PPO or an HMO. It’s important to know the difference between them.
- Preferred Provider Organization (PPO). PPOs are generally more expensive than HMOs because they are more flexible. PPOs offer a wide range of options for care, including a large network and the ability to go out-of-network without a referral from your primary care specialist. With PPOs, your copayments will be higher than an HMO and your deductible will usually also be higher. Also, there tends to be more paperwork and a more complex billing process with PPOs, since there are more moving parts than with an HMO. PPOs are good for those who prioritize flexibility of options and don’t mind paying more for the freedom.
- Health Maintenance Organization (HMO). HMOs are less expensive and more centralized. HMOs offer fewer options for care, have a smaller network and require permission to seek care outside of the network. Copayments and deductibles are generally lower than PPOs and you won’t usually have to pay coinsurance. Most costs for care are covered under your plan, but your options will be fewer. Generally, you will have one primary care physician and you will need a referral for a specialist. If you do seek care outside the network, you may be liable for the full cost. HMOs are good for people who want to pay less for health insurance, prefer to have more certainty about costs, and would rather have one primary care physician or hospital than a large network of options.
- Point-of-Service Plans. POS plans are a combination of PPOs and HMOs. Generally structured like an HMO with a primary care provider, small network and lower costs, a POS plan is less strict about seeing doctors outside the network. You may have to pay coinsurance or some part of the deductible, and you will need a referral, but it is a good option for people who primarily want an HMO with the flexibility to go out of network with less hassle if they need to.
Government Funded
Medicaid covers low-income adults, families and children with limited resources. The Federal Government sets baseline rules for Medicaid, but qualifications and benefits vary between states. Medicare is established as a compliment to Medicaid and specifically covers low-income elderly adults aged 65 and over. Certain disabilities are also covered. There are two parts to Medicare, Part A, which generally covers hospital stays and Part B, which generally covers physician services.
Consumer Driven Plans
PPOs, HMOs, Medicare and Medicaid are the most common types of plans you’ll hear about, but there are many other specialized types of plans, and some of these are worth a brief mention. Consumer-driven plans have been getting attention lately as a new option for health insurance that supposedly puts the consumer back in control of their money. These are essentially health insurance savings accounts that offer the ability to put aside pre-tax dollars toward medical payments. The benefit of this is the “saving for a rainy day” mentality because funds are already available for medical expenses. Also, the funds can be used for either paying for non-plan services or for paying premiums on a managed care plan. Consumer-driven plans can work in conjunction with PPOs or HMOs, or independently. With consumer-driven plans, the deductible is inherently high. There are three types of consumer-driven plans.
- Health Savings Account (HSA). This type must be paired with a high-deductible health plan. This is a personal health account, funded personally by pre-tax funds, and the money rolls over into the next year if it is not used.
- Health Reimbursement Arrangement (HRA). These are generally paired with a high-deductible health plan, but not always. HRAs are employer-funded, so the employer puts away a certain amount of money for the employee’s health expenses, determined by the employer, and the employer can decide whether to roll over funds each year. HRA accounts cannot be transferred to a new employer.
- Flexible Spending Accounts (FSA). This is an agreement between the employee and employer in which the employee sets aside healthcare funds from their paycheck to cover expenses, but unused savings do not carry over into the next year. FSAs can be combined with any other type of managed health plan.
INSURANCE TERMINOLOGY
Beneficiary
The beneficiary is enrolled in a health insurance plan and receives benefits through these policies.
Claim
A claim is an application for benefits provided by your health plan. You must file a claim before funds will be reimbursed to your medical provider. A claim may be denied based on the carrier’s assessment of the circumstance.
COBRA
COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985, federal legislation that allows you to continue to purchase health insurance for up to 18 months if you lose your job, or your employer.
Coinsurance
Coinsurance refers to money then an individual is required to pay for services, after a deductible has been paid. In some health care plans, co-insurance is called “copayment”. Coinsurance is often specified by a percentage. Example, the employee pays 20% toward the charges for a service and the employer or insurance company pays 80 percent.
Coordination of Benefits
This means that if you have two different insurance plans, one personally and one from your employer, you will not get double benefits. The two companies will communicate to split the costs.
Copayment / Co-Pay
Copayment is a predetermined amount that an individual pays for health care services, in addition to what the insurance covers. For example, some health plans require a $10 copayment for each office visit.
Deductible
The deductible is the amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.
Dependent
A dependent is a person (or persons) relying on the policy holder for support. That can include a spouse and/or children.
Effective Date
The effective date is the date your insurance coverage began.
Exclusion
An exclusion is a provision within a health insurance policy that eliminates coverage for certain acts, property, types of damage or locations.
Explanation of Benefits
An explanation of benefits is the insurance company’s written explanation regarding a claim, showing what they paid and what the patient must pay.
In-Network
In-Network refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
Lifetime Maximum Benefit
This is the maximum amount a health plan will pay in benefits to an insured individual during that individual’s lifetime.
Out-of-Pocket
These are all the expenses that you would be required to pay, including exclusions, co-pays and premiums. An out-of-pocket maximum is the most amount of money the insured would hypothetically have to pay on an annual basis.
Outpatient
A patient who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures that will not be paid for unless they are performed on an outpatient basis.
Pre-existing Condition
A pre-existing condition is a medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.
Premium
This is simply the amount of money you pay your insurance company each month for coverage. Some employers cover the monthly premium.
Primary Care Provider
A health care provider who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as the manager of an individual’s medical care, referring the individual to more specialized physicians for specialist care.
Reasonable and Customary Fees
The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference.
