Medical Billing

I strongly believe that developing a PMS product is more about domain knowledge and business logic than just technology. I would like to share information about PMS through my blog. Over the past 10 years, I have collected numerous articles, books, and documents from various sources, which are now sitting on my desk. From this collection, I will try to educate others in a simple and easy-to-understand way, using examples when necessary

Chapter 1: Medical Billing Workflow
1. Medical Billing Use Case

Chapter 2: Medical Billing Process
1. What is Medical Billing Process?
2. Different Format of Medical Form.
3. Patient Insurance

4. Primary, Secondary and Tertiary Insurance Policies
5. Claim Life Cycle – Provider
6. Claim Life Cycle – Payer     
7. Electronic Claim Transmission        
8. Medical Billing Clearinghouse          
9. Medical Billing Process in detail            
10. Healthcare Coding system.           
11. Maintaining Patient Insurance in the software.             
12. What are the Billing Entities?
13 What is Pre Authorization? 
14  What is Assignment of Benefits - CMS 1500 Box 27

         
         
Chapter 3: EDI Transactions

1. What is an EDI?
2. EDI Transactions
3. Understanding EDI Structure (Beginner)
4. Understanding EDI Structure (Detail )
5. EDI Instruction
6. How to Read and Understand EDI File ?              
7. ASC X12 270/271: Eligibility, Coverage, or Benefit Inquiry 
8. Rejection Followup Using Claim Acknowledgement EDI 277CA
9. Difference between 277CA and 277      
10. Difference Between 837 Institutional and 837 Professional        
11. EDI 5010 Documentation 837 Health care claim: Professional      
12. EDI 270 - 5010 Health Care Eligibility/Benefit Inquiry          
13. Claim Forward to other Insurance
14. Difference between claims and encounters EDI 837 transactions
15. Understanding EDI 835 Health Care Claim Payment/Advice Transaction
16. X12 EDI Examples with Payer Claim Number
17. Map claim information between EDI 837 and EDI 837
18. Understanding EDI 999 functional Acknowledgement – Example 1
19. EDI 837 Professional Loops

 

Chapter 4: Payment
1. EOB – Explanation of Benefits
2. Understanding EOB - Explanation of Benefits
3. Understanding EDI 835 Electronic Remittance Advice
4. What is Copay, Co-Insurance, and Deductible in Insurance Payment Posting?
5. Types of Reimbursement
6. How to process Copay, Co-Insurance, and Deductible Amount in Insurance Payment Posting?

Chapter 5: Claim Submission after Primary Insurance
1. How to submit the claims after primary insurance?

Chapter 7: Claim Processing by the insurance company
1. Claims adjudication and Payment process.?

 

New to Health care Domain? Here are some documents which can help you to understand the basics. I am trying to refer to the official link(where I downloaded the document) and as well as a link to my server(sometimes, official links are broken).

1. Introduction_to_Health_Care_in_USA (or you can click here to download)
2. Medicare Incentive Program Beginners guide MU Stage 1 ( or you can click here to download)

All about Prescription

•  An Introduction to ePrescription
•  How ePrescribing works
•  Paper Prescription workflow
•  Electronic Prescription workflow
•  Refill Paper Prescription workflow
•  Refill Electronic Prescription workflow

Flow charts

• Medical Billing Overview
• Rooming Overview
• Medical Billing Flow chart
• EMR Test Visit Flow chart
• EMR Patient Examination Flow chart
• EMR Office visit Flow chart
• Medical Claim Life Cycle
• Claim Adjudication and Payment Flow chart
• EMR Office Visit
• Billing Flow chart

Medical Billing blogs

• Blog on Medical Billing – Revenue Cycle Management
• Medical Billing and Coding
• Medical billing CPT modifiers
• CMS 1500 claim and UB 04 form
• Medicare Fee Schedule, Payment and Reimbursement
• Insurance claim denial and appeal

Patient Demographics

Patient browse (search) is the key element for any EMR / PMS Software. In my past 15 years experience, i involved more than 5 times in design/development (using VB6, VB.NET) / test the Patient demographics search and patient demographics page.

Here is the excellent UI which shows how to design patient search window
Patient Search window
or you can see the screen shot here

MU Certification Smoking Status

For the MU Measure Test Procedure for §170.302 (g) Smoking Status , make sure your software shows both the Smoking status recodes and Smoking status. Because certification bodies will ask to show the code also in the drop down.

MU Certification

For the measure, Test Procedure for §170.302 (h) Incorporate Laboratory Test Results, we could not able to find or get the HL7 File for the data sets. So by looking the data on each data sets, we created the HL7 File which given here for new people

Data Set 1

Data set 2

Data set 3

We completed our MU Certification in Nov 2011 itself, but this year only i got time to share / transfer our knowledge/expereince to  others. In the upcoming post, i will share some of my experience in the certification

Individual and Group NPI

Here is the very good article which explains with simple examples when and where to use Individual and Group NPI.
http://www.iridiumsuite.com/npi-and-billing

Sample EOB

EDI 5010 Documentation – 837 Institutional - Loop 2300 Prior Authorization or Referral Number

2300 Prior Authorization or Referral Number

All My Healthcare Domain stuffs

Looking for best Practice Management software? Please email at vbsenthilinnet@gmail.com

1. Medical Billing concepts
2. Medical Billing Terminology    
3. Health care Introduction documents    
4. EMR Appointment Features    
5. EMR SOAP Note    
6. EMR History of Present Illness    
7. EMR Use cases    
8. EMR Test visit (Lab) workflow    
9. Most commonly Used Lab Test Panels    
10. EMR Most Commonly Used Vital Signs
11. Physician Quality Reporting System – PQRS

 

 

Healthcare Technical
1 EDI 5010 Documentation 837 Health care claim: Professional with Sample Files
2 EDI 5010 Documentation 837 Health care claim: Institutional with sample Files
3 EDI 5010 Documentation 835 Health Care Claim Payment/Advice with sample Files and Parsing Tool
4. EDI 5010 Documentation 270 Health Care Eligibility/Benefit Inquiry
5. EDI 5010 Documentation 271 Health Care Eligibility Benefit Response
6. SQL Server Stored Procedure for EDI 837 P 5010 Version
7. MYSQL Stored Procedure for EDI 837 P 5010 Version
8. Apply Insurance Payment (EOB Posting) Use cases.
9. Difference Between 837 Institutional and 837 Professional
10. Sample HL7 Files
11. HL7 Parsing
12. My Own HL7 Parser in java
13. MSH Message Header Segment
14. OBX Observation/result Segment

15. JSON to EDI 270 Eligibility and Benefit Inquiry

EDI RESTful Web Service API

Many Healthcare software development company needs Subject Matter Expert to complete their Medical Billing Component. In order to develop the Medical Billing Application, X12 EDI plays a major role. For example, from the Medical Billing software, they need to send the bill (claim) to the Insurance via Clearing House and the format should be X12 EDI 837. So i decided to provide a Latest Spring Boot Restful web services API Calls for all the major transactions that are needed in the Medical Billing Application. Here is the List of transactions available and please connect with me to use these API Service calls.

1. JSON to EDI 270 Eligibility and Benefit Inquiry

2. Parse EDI 271 Message to Human Readable Text       
3. JSON to EDI 837 Professional Claims     
4. Parse EDI 837p Message into JSON

5. Parse EDI 835 Message into JSON

6. JSON to cms 1500 Form

 

Meaningful use Public Health Surveillance

Not too much information on the measure http://healthcare.nist.gov/docs/170.302.l_PublicHealthSurveillance_v1.2.pdf . Any one knows what exactly have to do in the EMR Workflow ?

About Me

LinkedIn Profile : https://www.linkedin.com/in/senthil-muthiah-16693857/

Email : vbsenthilinnet@gmail.com 

Location: Bengaluru (Bangalore), India.

Skills  : US Medical Billing, US Health care, Revenue Cycle Management,
Practice Management System, EDI Transactions such as EDI 837I, EDI837P, EDI270, EDI271, EDI835, ETC and EMR, HL7, etc. Also E-Prescription certification via Sure scripts, MU Stage 1 certification,etc

 

 

• Strong knowledge in Medical Billing (aka) Practice Management systems and published self-learning Chapters. You can check here
• Developed own EDI 835 Parser. Please check here
• Solid knowledge in Java EE and still hands on writing Complex business logic.
• Solid knowledge in ZKOSS RIA Framework and has been awarded from their team as one of the contributors. You can check here.
• Good Knowledge in the Latest MVVM Design pattern and created several examples to help developers. You can check here.
• As an independent developer, recently completed the Independent Practice Management software (PMS), you can see some screens in the following link
  Link 1 , Link 2, Link 3
• Recently completed Meaningful stage 1 Certification for the current product. Helped the developers to understand the requirements for MU Stage 1.
• Involved in creating complete documentation for EDI 5010. Please check here
• Strong knowledge in Crystal reports and created numerous of Reports for Practice management application
• Conducted interviews with key business users to collect requirement and business process information.
• Interacting with the developers on resolving the reported bugs and various technical issues.
• Gathered Business Requirements and wrote Business Requirements documents (BRD) by working with the client's IT staff, project managers.
• Received numerous letters of recommendation, and appreciation from customers, and management.
• Conducted various meeting with Billing End users and come up with an Exclusive Tool called MedAZ Billing Tool, which takes care most part of their Follow-up activities. Actively involved in database design, user interface design, coding and implementation activities in that.
• Provided HIPAA integration and applied ANSI ASC X12 standards for 837 (P, I, D), 270/271, 276/277, 278, and 835 transactions
• Developed HL7 interfaces for Orders (ORMs) and Results (ORUs)
• Played Billing Revenue cycle Collection manager for some time and understood the complete billing process which helps to build an independent system called Billing Tool.

 

Summary

A technology-driven professional with over 16 years of experience including nearly 9 years in Software Development and Business Analysis. Thorough understanding of the SDLC with proficiency in mapping Business Requirements, Technical Documentation, Application Design, Development, Integration, Testing, and Troubleshooting for Information Systems Management. Adept in business process analysis and design, and application-based process reengineering.

Well-versed with US Healthcare Domain – Electronic Medical Record (EMR) & Medical Billing. Exposure in design, creation, testing and documentation of new and amended programs from supplied specifications in accordance with agreed standards. Deftness in monitoring delivery of high-quality customer experience. Strong communication, interpersonal, analytical & team-building skills with proficiency at grasping new concepts quickly and utilizing the same in a productive manner.

Well versed with Health care certification such as CCHIT, Meaningful use Stage 1, Sure scripts e-prescription, and HL7 Both inward and outward lab modules.

Core Competencies

Project Management	Software Development	Business Analysis
Requirement Gathering	Technical Support	Troubleshooting
Client Servicing	Software Testing	Gap Analysis
MU Stage I Certification	CCHIT Certification	E-Prescription Certification

IT Skills

Visual Basic 6.0, VB.NET 2005

Microsoft SQL server 2000/2005/2008

Crystal Report 8.5, 11.5

VBA (Word and Excel macros), Windows NT Service, Web service in VB.NET

Java 1.6

Hibernate 4.x

Spring Security 3.x

Maven 3

MySQL Server 5.x

Jasper Reports 4.x

Dynamic Reports 3.x

Dynamic Jasper 4.x

MyBatis 3

Zkoss Framework 6.x

Angular 9

Spring Boot

and Many more…………

and whatever current and future Technology……

Knowledge Purview

• Sound knowledge in ZKOSS RIA Framework and has been awarded from their team as one of the contributor
• Possess good knowledge in the Latest MVVM Design pattern and created several examples to help developers
• Well versed with Crystal reports and created numerous of Reports for Practice management application
• Proficient in the following Modules:
  • HPI, ROS, and EXAM Templates
  • Patient Encounter or SOAP
  • Screen-based permission user security
  • Sure scripts E-Prescription Certification
  • Lab inward and outward Modules
  • Encounter – Current Medication and Prescription
  • Billing – Charges and Payments
  • EDI 4010 and 5010
  • Billing Reports

Employment Details
Aug’10 – June 2013  e-Cosmos Solutions India Pvt., Bangalore as Senior Business Analyst/Product Owner
Highlights

• Involved in creating complete documentation for EDI 5010
• Involved in Meaningful Use stage 1 Certification.
• Involved in UI Mockup for the web-based product.
• Successfully completed the Independent Practice Management software (PMS)

Jan'05 - Aug'10: Koni Ameri Tech Services India Pvt. Ltd., Chennai

Highlights

• Conducted interviews with key business users to collect requirement and business process information
• Coordinated with the developers on resolving the reported bugs and various technical issues
• Gathered business requirements and wrote Business Requirements Document (BRD) by working with the client IT staff and Project Managers
• Obtained numerous letters of recommendation, and appreciation from customers and management.
• Organized various meetings with Billing End users and came up with an Exclusive Tool called MedAZ Billing Tool, which takes care most part of their Follow-up activities
• Actively involved in database design, user interface design, coding, and implementation activities
• Provided HIPAA integration and applied ANSI ASC X12 standards for 837 (P, I, D), 270/271, 276/277, 278, & 835 transactions
• Developed HL7 interfaces for Orders (ORMs) and Results (ORUs)
• Managed responsibilities of Billing Revenue cycle Collection Manager for some time and understood the complete billing process which helps to build an independent system called Billing Tool
• Functioned as a Subject Matter Expert in US Health care outpatient domain.

Actively involved in:

• CCHIT 2008 Certification
• Superscript E-Prescription Certification
• Integrating Lab services from the quest, Lab Corp, etc.

Growth Path:

1. Jan'05 - Apr'05 Senior Programmer
2. Apr'05 - Apr'06 Programmer Analyst
3. Apr'06 - Apr'08 Senior Business Analyst
4. Apr'08 - Aug'10 Chief Technical Officer

Highlights

• Organized various meetings with Billing End users and came up with an Exclusive Tool called MedAZ Billing Tool which takes care of most part of their Follow-up activities
• Actively involved in database design, user interface design, coding, and implementation activities
• Successfully completed the migration of patient demographics, procedure rates, locations, referring physicians from Lytec/Medisoft/Medical Manager, etc. database to Medaz database

Previous Experience (Non Healthcare Domain Experience)

1. Mar'02 - Dec'04: Mice Computer Center, Madurai as Senior Programmer
2. Sep'00 - Feb'02: Soft Solutions Pvt. Ltd., Chennai as Programmer
3. Dec'99 - Aug'00: Laconic Software India Pvt. Ltd., Dindigul as Programmer
4. Oct'96 - Nov'99: Lakhotia Computer Center Dindigul as Senior Faculty

 

Client Testimonials

 

 

 

 

 

 

My Quick Reference

MySQL Reference

Update	Update From within the same table using some condition
Update	SQL Update query with group by clause
Stored Procedure	How to pass list of values to Stored Procedure.
Query	MYSQL Query for Aging Report