How Does Medical Billing Help With Accounting?

Posted by EditorChoice
Thursday, 26 July 2007

Medical Billing. This is probably not the first time you've heard of this word and you pretty much have a basic idea what the phrase connotes. However, one thing you should know is that most people have the wrong idea of what is medical billing in reality.

Often, what is medical billing is equated with what is medical transcription or what is medical coding when in fact, the three are as separate and as distinct from each other as night and day. While its true that all three of them are somehow related and sometimes even their responsibilities overlap, it still doesn't change the fact that medical coding deals strictly with codes and medical transcription is strictly on transcribing doctors notes.

So, what is medical billing then?

Some people say it is the doctors key to getting paid for services rendered. Others say that it is a process of submitting claims to insurance companies. But these descriptions are vague. What is it really?

Perhaps, the question what is medical billing is better answered with this definition of the term:

Medical billing is practice management. It involves front office skills, with emphasis on billing and accounting, insurance claims processing, and making decisions concerning the financial aspects of a practice.

What is medical billing compared to medical coding and medical transcription?

Compared to medical coding and medical transcription, medical billing is wider in scope and broader in its range of responsibilities. Front office also means acting as an executive secretary to the practice, dealing in clerical work such as patient scheduling, clearing appointments, documenting patient visits, recording diagnostic and treatment procedures, and organizing medical records using a software program.

What is medical billing and what are its responsibilities?

The job of the billing professional starts with the office visit where you will handle everything from scheduling of the appointment to making sure that the patient makes it to his appointment. After the doctor sees the patient, depending on the services provided and the examination, he will then create and update the patients medical record.

The billing professional then organizes these records according to a system earlier adopted by the practice. This record contains a summary of treatment and demographic information related to the patient. The medical billing specialist will have to organize these records according to their contents to provide for easier access in case of another visit or some such circumstance and to create the billing record which is the document submitted to either a clearinghouse or an insurance company.

Article Source: 1ArticleWorld.com

Doctor’s fraud totals $3 million, prosecutors say

By Scott MacKay

Journal Staff Writer - The Providence Journal

PROVIDENCE — Federal prosecutors are seeking $3 million from Dr. Tarek W. Wehbe, an internist with the Renaissance Medical Group in Providence, who the federal government accuses of fraudulently billing Medicare, Medicaid and private insurers for services he did not perform.

Wehbe, who had his license suspended last week by Rhode Island Health Director Dr. David R. Gifford, is accused of billing for services he didn’t perform, inflating the type of treatment he provided and billing for days consisting of more than 24 hours.

The complaint filed in U.S. District Court in Providence asserts that Wehbe billed for visits and treatments that, if performed properly, would have taken more than 24 hours in a single day. For example, Wehbe billed for 87 patient visits on March 7, 2006, according to the complaint. According to federal standards, the time needed to see that many patients would have been more than 30 hours.

On other days, the complaint alleges, Wehbe billed for 28, 27 and 23.6 hours of visits in a single day.

Federal prosecutors also say that Wehbe fraudulently billed for infusion of the drug Remicade, which is used to treat Crohn’s disease and rheumatoid arthritis, and for treatments with drugs such as Paclitaxel and Gemzar, which are used to treat cancer.

According to the affidavit, between November 2001 and December 2006, suppliers delivered 22,890 units of Remicade to the Renaissance Medical Group, which Wehbe owns. He billed insurers for 39,239 units, or about 16,000 more than he received. The complaint states that from 2002 to 2006, Medicaid, Medicare and private insurers overpaid Wehbe $2.99 million, of which $1.8 million went for infusion drug treatments and $1.1 million for fraudulent office visits and treatments.

Prosecutors are seeking forfeiture of Wehbe’s property and bank accounts. The affidavit states that Wehbe has an account at Citizens Bank and owns real estate at 1630 Mineral Spring Ave., North Providence; 566 East Shore Rd., Jamestown; 6 Pine Tree Lane, Lincoln, 15 Dennell Drive, Lincoln; and 78 Farnum Pike, Smithfield.

Along with the U.S. Attorney’s office, other agencies involved in the investigation include the U.S. Department of Health and Human Services, the Internal Revenue Service, the U.S. Food and Drug Administration and the Rhode Island attorney general’s Medicare fraud control and patient abuse unit.

Wehbe, 43, has been under investigation by state and federal agencies for alleged health-care fraud and medical negligence since a raid at his office in December 2006. When the state suspended Wehbe’s license on April 7, Gifford, state health director, used his power to pull a doctor’s license without a hearing if a physician is deemed to be an immediate danger to the public.

That suspension was prompted by the discovery that Wehbe’s records of purchases of chemotherapy drugs did not match the amount he billed insurance companies. “In reviewing the records, it doesn’t appear that he could have given what he billed for,” said Dr. Robert S. Crausman, chief administrative officer for the state Board of Medical Licensure. “That could be just billing fraud but it leaves open the possibility that patients didn’t get what they should have gotten.”

Most of the affected cancer patients left Wehbe’s practice in December 2006 after he agreed to stop offering infusion therapy at his office after the investigation started, Crausman said. At the time, investigators were concerned about his treatment of patients who had rheumatoid arthritis, hepatitis C and fibromyalgia. When the cancer treatment issue came to light, the medical board considered the matter more serious and recommended that Gifford immediately pull Wehbe’s license, according to Crausman.

The state attorney general’s office is following up to determine if there was abuse of patients, said spokesman Michael Healey.

smackay@projo.com

Balanced Billing Destroys Capitalist Economy - Opinion

By: Alex Wawro

Posted: 4/9/08

If you have health insurance you ought to know what "balance billing" is. Balance billing and the ongoing attempts to outlaw it directly determine how much you pay for medical services.

Typically, if you have medical insurance (say, Kaiser Permanente), your provider will pay any medical fees above your standard co-payment. If Kaiser, however, only pays a standard allotment of $500 for a service a physician would normally charge $750 for (say, an emergency cardiac bypass), the doctor or hospital might send the patient a bill for the missing $250.

What this means for the average consumer is that not only do they have to pay their co-payment, they may receive a second bill for the remaining amount the insurance chose not to pay. Governor Arnold Schwarzenegger supports a bill that would outlaw balance billing.

The less money you have to pay the better, right?

Wrong. The legislation is blatantly unjust; worse, it undermines the foundation of free enterprise that our economy is built upon.

Think about it - when you sign up with an HMO like Kaiser, you agree to pay a standard fee monthly in exchange for a guarantee of financial aid if you need serious medical care.

In return, Kaiser receives monthly income and negotiates flat rates for services with a pool of physicians; those physicians give up the right to charge their own price in exchange for guaranteed business from Kaiser customers.

But if you, as a Kaiser customer, are brought to the ER for emergency surgery, there are no guarantees that the surgeon working is a Kaiser-approved doctor. If that surgeon saves your life, should he or she be forced to accept whatever percentage of the standard rate Kaiser chooses to pay him or her for the service? He does not receive the benefits of being a member of the Kaiser family; why should he be forced to abide by their restrictions?

Essentially, passing this bill destroys the basis of our capitalist economy in favor of a more socialist system in which the government regulates our freedom to spend and charge what we think is fair. By eliminating the practice of balance billing, Schwarzenegger forces all doctors to accept whatever healthcare providers think is fair payment.

Even worse, it makes the entire system of licensed physicians meaningless. A doctor who agrees to accept Kaiser's rates does so in exchange for receiving more business from the company. In essence, what he loses in individual sales he more than makes up for in volume.

If all physicians are limited to collecting only what Kaiser chooses to pay, why bother contracting with doctors in the first place?

Kaiser can pay a doctor whatever they believe they can get away with, and the physician has no choice but to take what he is given.

By removing a practitioner's ability to charge what he thinks is adequate for his services the government is sullying the principles on which this country was founded.

Though this legislation seems to benefit the consumer, in the end only the corporation wins.

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© Copyright 2008 Weekly Hornet

‘BPO is here to stay’

- An Article in The Hindu byD.Murali

The general perception is that the US slowdown will hit the software and BPO (business process outsourcing) industry. “I have a different view,” avers S. Shivakumar, CEO of iSource IT Enabled Services.

“US corporates can afford to hold on to and defer decisions on software projects. But BPO work ought to continue because it is an essential service,” he explains. “In fact, it will gather further momentum as the squeeze tightens on cost. More corporates will start thinking of outsourcing their administrative support services,” adds Shivakumar, during the course of a recent lunch-hour interaction with eWorld.

iSource is into services such as document management and accounts receivable management for media, market research and healthcare verticals. “Though we began by signing up customers in the US for search engine optimisation business — to help them generate leads and expand business presence — we decided to use our skills in order to build our own BPO business,” recounts Shivakumar.

At a time when the BPO industry is facing challenges such as rupee appreciation, unsustainable salary levels, high attrition rates, etc, any positive words offer solace.

“Innovation and experiments hold the key,” Shivakumar says. “We at iSource have decided to stick to our core strengths such as presales consulting, intensive online marketing, process migration from US to India, vendor management and quality control and sub-contract the rest to strategic delivery associates away from the company.”

“We get 90 per cent of the work done in the Tier-II and tier-III cities of India, the Philippines and Kenya. The fall in dollar value has made us look at the Philippines. In fact, besides beating the loss due to dollar slide, we are at gain as the rates in the Philippines are 25 per cent less compared with India,” he says. Excerpts from the interview:

On how it all began…

It was not easy in the beginning. Especially for a person like me who did not have a business background. We had a tough time finding the start-up capital. But with our being in the Web solutions market from the early stages, our expertise in online marketing and related opportunities came in handy.

What has been the impact of rupee appreciation?

The recent dollar turmoil made us innovate to stay competitive. We have ventured into near shore. We have made strategic investments in the Philippines and Kenya and managed to cut cost by 30 per cent. We also leveraged strength from our near-shore facilities.

On attrition.

As we do only the core jobs in-house, our headcount is kept low, which helps us in tackling attrition.

Among call-centre employees, most of the dropouts are women; and metros are becoming a nightmare for those commuting to office. Hence we have come up with a home-based working option, which will benefit women, in particular. What are the skill-sets you expect from women who opt for what you offer?

Good English and listening and comprehension skills. Initially, they will be expected to train themselves from home for about two months. They are advised to visit the office once a week for guidance. They would need a computer with broadband connection.

Within six months of getting into the job, people who put in eight hours of work can earn a minimum of Rs 15,000 a month.

What are the hurdles you faced as an entrepreneur?

Typically the same hurdles faced by any other small business in India. Let’s face it: the financial environment is not in favour of entrepreneurs, in spite of all the talk. When it comes to funding, entrepreneurs are still faced with collaterals that are required in the form of assets, the mandatory three-year audited financial statements, high interest rates, etc. Even companies that receive 100 per cent of earnings through foreign inward remittance are denied overdraft and other credit facilities by banks.

What growth areas are you working on?

We are looking to scale up presence in the US by opening more offices and adding more staff.

In India, we are looking to expand our medical billing business and set up offices in tier-two and tier-three cities such as Madurai and down South. We are also looking for strategic partners, who are looking to diversify into BPO.

Do you see a bubble in the BPO industry?

BPO is here to stay. Compared to software and dotcom businesses, BPO is critical for the day-to-day functioning of US businesses. For example, medical transcription is a regular task that needs to be done on a daily basis; not so with software development, which can even be postponed.

In my opinion, it will take another five years for the saturation point to be reached in the BPO business. After that there will be a price war, which only the fittest will survive.

Is there room for more entrepreneurs to hop on to the BPO bandwagon?

Despite big players ruling the roost, there is still room for small players in the BPO industry, provided the funding options are improved.

Venture capitalists, who mostly look at newer technologies, steer clear of run-of-the-mill BPO businesses.

Significant milestones?

A major point in our growth story was when we incorporated our company in California 18 months ago. It helps us compete with local American companies. We have served big and small clients, including the World Bank, Microsoft, CNBC, Harvard University and Nasdaq.

BPO workforce, journalists getting insomniac

Santanu Saraswati

Kolkata, May 18, 2007

Chandrika Chhetri is still fighting against depression at her Namchi residence, a small town in Sikkim. After completing her honours from a reputed south Kolkata college, Chandrika took up a tele-caller's job with a BPO company at Sector V.

Chandrika has to answer every question her company's client in Sydney, Melbourne and Toronto used to make over telephone. Sometimes, she has to hear all abusive language her clients used to throw from the other side of the telephone. "We didn't have any fixed work schedule. Sometimes, I have to reach my office by 4 in the morning, sometimes at 8 in the night. Just after a month, I started having fragmented sleeps. It was really taking toll on my health. To make myself awake, I started smoking and drinking at least 20 cups of coffee from the canteen. It was really a horrendous experience I had during my six months of job with that company," Chandrika said.

Chandrika had to undergo treatment under a well-known psychiatrist. She, still, has to visit his chamber once a month.

Anamitra Chakraborty has not slept for months properly. After every half-an-hour, his sleep breaks that has compelled him becoming an irregular employee of a BPO company operating at Sector V. "I used to drink 15-20 cups of black coffee at night just to make myself awake at the night. The company, I am serving, is having most of its client base in North American countries, and there is a time difference of more than 12 hours. So I have to work everyday from 7 pm to 7 am. But finally it landed me with the habit of taking sleeping peels regularly. First, I started with minimum doses, and after few months with 10-15mg of alprazolam. My employer served me show-cause notice and I had nothing to say except submitting my medical prescription. The doctor advised me three months complete medication," said Anamitra.

Anamitra is not the precedent. Some have lost their job as their competency in solving the clients' problem gradually witnessed a downward trend. Some, under doctor's advice, change their trade, just to go back to the normal life.

Piyush Goswami is now working with a multinational bank as a junior executive. Piyush was compelled to lose few years of experience of working with a software BPO having office at Infinity Building career after his doctor advised him to go back to his normal daily schedule for getting cured from acute insomnia. "I lost my sleep and my marriage was on the verge of breaking. Thanks to one of my friend who made me visiting the doctor," said Piyush.

City is having sleepless nights. At least for the past five years the city has witnessed a tremendous rise in psychogenic and physiological disorder caused due sleeping disarray and fragmented sleep. The worst hit of this disease are the business process outsource workforce, the healthcare employees, the medical practitioners and even the journalists who have either shifting work schedule or prolonged and continuous night shifts.

City doctors termed the disease as mainly -"BPO-genic". A recent survey on city's highly skilled workforce revealed that more than 80 per cent of them are suffering from insomnia, a major cause of depression, obesity, cardiovascular diseases, diabetes, decrease efficiency, acute abdominal pains and irregular periods, caused due to late-hours of watching television, attending late-night calls of the patients and shifting work schedules. Doctors, though blaming the changing life style pattern of the city, failed to find any solution other than changing jobs from BPO sector or changing profession.

"Depression caused due to acute insomnia has become a common phenomenon among the city's highly skilled workforce, especially working in the business process outsourcing companies. In the past five years, there has been 82 per cent rise in psychogenic and physiological disorder among people working in healthcare, BPO, multinational companies, electronic and print media. And 45 per cent of this are patients having perennial sleeping disorder, and the rest suffering from depression caused due to situational insomnia," said Dr Shiladitya Ray.

Ray is of opinion that fragmented sleep may even give rise to diseases like trigeminal neuralgia, burning skin, decrease efficiency and irregular period among women. Psychotherapist, Sunita Kumar, observed that there has been a steady rise in the number of her patients at Apollo Clinics, suffering from insomnia and depression. "When we start questioning our patients, in most of the cases, it is found that irregular sleeping hours or continuous nightshifts is what has made the patient vulnerable and feeling isolation. Except few hours of counselling and prescribing medicines, we don't have any other solution for these patients. And if the patient doesn't change profession and go back to normal life, chances of relapsing the disease is almost 200 per cent," said Kumar.

Not only depression or insomnia, Kumar observed that fragmented sleeps or sleeping disorder has given rise to high level of toxic anxiety and loss of appetite.

Experts recommend that adults get between seven and eight hours of sleep each night to maintain good health and optimum performance. Those who think they might have a sleep disorder are urged to discuss their problem with their primary care physician, who will issue a referral to a sleep specialist.

The study also finds that fragmented sleep profiles, akin to individuals suffering from middle of the night insomnia, healthcare workers on call, and parents caring for infants, medical practitioners and even journalists, alter natural systems that regulate and control pain, and can lead to spontaneous painful symptoms, said Dr Tapan Basu. "Our research shows that disrupted sleep, marked by multiple prolonged awakenings, impairs natural pain control mechanisms that are thought to play a key role in the development, maintenance, and exacerbation of chronic pain," said Basu, a pain-manager with Belle Vue Clinic.

Consultant psychiatrist, Dr Rima Mukherjee, observed that there has been a steady 10 per cent rise in the number of such patients at her clinics in West Bank Hospital and Arabinda Seva Kendra in the past one year. Mukherjee, even blames rise in accidents on city roads because of fragmented sleeps. "People are becoming susceptible to chronic psychomatic disorder and dependable on sleeping pills and alcohol. Because of fragmented sleeps, BPO and such-types of workforce are gradually losing efficiency and concentration," Mukherjee said.

Doctors suggesting immediate visit to clinics if fragmented sleeps persists for more than a week. "Otherwise, sleeping disorders will take its toll on city's health slowly.

According to Parikshit Bhaduri, head of US-based software development company, Connectiva Systems, there are cases, where sleeping disorder has finally taken toll on the efficiency of employees. "I found two of my very efficient colleagues doing mistakes, which were unlikely of them. When I started enquiring their details, it was found that both of them got the habit of playing on the computers, chatting with their friends in other parts of the world throughout the night. Finally I made them compelled of leaving their laptops in the office at the time of leaving for home. It worked wonders," Bhaduri said.

Psychoanalysts like Nandita Mukherjee, however, differ with the doctors regarding curability of this disease. Nandita suggests the best way to get cure is the willingness of the people suffering from such diseases. "Apart from counselling I always advice my patients to start yoga and reduce the amount of coffee or tea intake. Drinking tea or coffee, especially at night, causes immense harm on sleep. High intake of coffee or tea, even gives rise to loss of appetite apart from fragmented sleep. Counselling does help, but people suffering from depression out of sleeplessness could benefit from practising yoga. But I don't think, change of profession is really possible in our country where getting a fresh job is really very hard," Nandita said.

She even warns the students, who have the habit of studying at night and sleeping in the day. "Our body never allows change of schedule so easily. All these types of diseases are result of this. So it is always better to lead normal lifestyle what our climate and body permit," she added.

DATA OWNERSHIP ISSUES FOR THE PHYSICIAN PRACTICE AND A MEDICAL BILLING SERVICE

Article Date: April 4, 2008

Medical billing services assist physician practices in billing, coding, accounts receivables and management activities. By outsourcing to a medical billing service, a physician practice may realize increased profitability by decreasing the administrative time and expense involved in the billing process. The relationship between the physician practice and a billing service is an important and complex one. The issues are not limited to the billing service’s effectiveness in collecting payments. Both the physician practice and the billing service will benefit from a clear agreement, appropriately documented, as to all aspects of their relationship, including matters relating to data ownership of medical records and termination of the relationship.

Information technology systems are making it easier to rapidly transmit medical records and associated claims data while also reconfiguring and manipulating the data to exchange. To protect patient’s privacy and security, the American Medical Association (AMA) and the Healthcare Billing Management Association (HBMA) encourage physician practices and medical billing services to consider discussing, agreeing upon and including provisions in their contracts regarding software and proprietary information, claims data-ownership with respect to both original and copies of physician practice records and termination procedures. Physician practices are encouraged to consider the value the relationship will bring to the practice before entering into an agreement.

Typically, the physician practice will provide a medical billing service with a variety of records required for various billing, coding, accounts receivable, and management activities. A medical billing service may incorporate the records into proprietary forms, templates and other tools to prepare reports for the physician practice. This document will list topics for physician practices to consider addressing with prospective medical billing services prior to entering into an agreement.

Definition of Physician Practice Records

Typically, three categories of records belong to the physician practice: (1) patient records, claims, Explanation of Benefits (EOB)/Remittance Advice (RA) and other documents containing patient information, (2) managed care contracts, fee schedules and other proprietary information of the physician practice itself, and (3) final reports, such as accounts receivable (A/R) registers, prepared by the billing service for the physician practice.

Definition of Medical Billing Service Records

Typically, three categories of records belong to the billing service: (1) internal notes and work papers prepared by its employees, such as records of conversations with third party payers relevant to documentation needed for appeals, (2) papers relating to the billing service’s software and other proprietary or licensed tools, and (3) other proprietary information of the billing service, such as the forms and templates used to prepare reports furnished to the physician practice. The billing service may also have proprietary or confidential information regarding its operations.

Transfer of Documents and Electronic Records When Relationship Terminates

Prior to entering into an agreement, the medical billing service and the physician practice should agree on how to handle any termination of the relationship. Questions to consider include:

• What materials should be returned by the billing service to the physician practice or a successor billing service, subject to any transition agreement, for the practice or successor billing service to: (1) enter patient and charge data into its computer system, or (2) seek to collect pending billings on health plan claims for the physician practice.

• Who has custody of the documents relating to health care claims filed, which generally fall into three categories: (1) source documents, usually in the form of copies of visit or operative notes, (2) payer generated data, such as EOBs, and (3) reports that the billing service generates on billing and management activities for its clients. Occasionally, when discussing these questions, both the physician practice and billing service should realize that a billing service may have a legitimate need to retain copies of or at least a right of access to any records—even documents owned by the physician practice, as discussed above, in order to document their services, particularly if the billing service codes physician claims.

• What should the format and media for the return of physician practices records be?

• When and how will electronic records be returned to the physician practice?

(1) What information will be provided in file layout?

(2) What file codes and programming will be given?

(3) Which patient account data on the billing service’s computer system or software will be returned to the physician practice or sent to a successor billing service?

• Who will own documents that do not contain protected health information, such as the coding notes, and other work products of the billing service? Will it be the original or copies?

• Who keeps original records and who pays for any copies?

• Who pays the cost of locating or transferring hard copy or electronic records to the physician practice or to a successor billing service?

• Under what circumstance will the physician practice (or a successor billing service) have access to billing and claim denial notes and records made by the billing service as it provided services to the physician practice?

Record Retention and Access – Points to consider and discuss

At a certain point in time, retained records cease to be of any value, typically upon the lapse of the longest applicable statute of limitations for a third party payer audit or legal actions as to which the records would be relevant. In the case of patient records in the custody of a billing service, the patient records will be copies only, with the originals of the patient’s records at the physician practice or facility at which the underlying care was rendered. Some of the considerations in this section apply principally to original records.

• When the applicable time frame for retention of records in the custody of the billing service expires, will the records be destroyed or returned to the physician practice?

  • What are the state and federal laws pertaining to the period of time records are to be retained?

  • To the extent that the billing service is a business associate of the physician practice, a written HIPAA business associate agreement should be in place documenting among other things how protected health information (either in paper or electronic forms) must be either destroyed or returned to the physician upon termination of the agreement with the billing service. This language can also provide for other equally secure methods of protected health information management upon termination. Additionally, physician practices should ensure that the underlying agreement with their billing services provides for safeguards to the confidentiality, integrity and availability of the protected health information disclosed to the billing service and any other confidential information. These provisions should comply with any state law that is more stringent than HIPAA, and be consistent with guidance from the physician’s professional liability carrier.

• Due to the cost of storage of voluminous paper records, a billing service may scan original paper documents and store them electronically.

  • Will electronic copies of paper records be accepted as the original document?

  • Does the state the physician practices in accept a scanned medical record or other business record as an original as long as the accuracy of the scanned document can be reasonably substantiated?

  • Will the original paper records be destroyed after such records are scanned?

  • If, for some reason, electronic scanning is not permitted due to cost or availability, will the paper records be stored on the billing service’s premises or, especially after the termination of the agreement, in an offsite storage facility?

  • Will there be any costs charged to the physician practice for storage of paper records by the billing service during or after the termination of the agreement?

• Selection of offsite facilities. A storage facility off the premises of the billing service needs to be secure both for the integrity and availability of the stored records and for compliance with HIPAA and state medical records laws. Ultimately, this is the physician practice’s responsibility, although the selection may be delegated to the billing service.

  • Who will pay the cost of storage at offsite facilities during the term of the relationship?

  • After termination, will the physician practice be responsible for the costs of storage or scanning of records retained on behalf of the physician practice (as opposed to for the billing service’s own purposes)?

Audit and Litigation Assistance and Record Searches

Certain records searches and data assembly may be time consuming if the search requires manual review of stored records. This may be the case where, for example, a records search is conducted by date of service rather than by patient name. Physician practices should expect a reasonable level of support from their billing services during the term of the relationship as “part of the service”, but may also anticipate incurring additional costs for assistance which goes beyond that level.

• During the term of the relationship, the billing service and the practice need to determine if there is a component included in the basic service for searching records and otherwise assembling information for litigation or third party payer audits.

• For more extensive work, discussions should include the fee the billing company will charge for personnel and reimbursement for associated costs.

• For services during and after the termination of the relationship, discussions should include the fee and other costs that is the responsibility of the physician practice, such as if the billing service will be reimbursed for copies of records it provides to the physician practice.

For more information on medical billing services, as well as further questions that should be asked before contracting with a medical billing service, AMA members can visit the Private Sector Advocacy (PSA) Website at http://www.ama-assn.org/go/psatools and download the complimentary flyer “What is a medical billing service?”

Prepared by the American Medical Association, Practice Management Center, along with the Healthcare Billing and Management Association, December 2007.

Questions or concerns about practice management issues? AMA members and their practice staff can email the AMA Practice Management Center at practicemanagementcenter@ama-assn.org for assistance.

Contact the AMA-PSA unit:

• Call (800) 262-3211 and ask for AMA-PSA.

• Fax information to (312) 464-5541

• Visit www.ama-assn.org/go/psa to access the AMA-PSA Web site.

Contact HBMA:

• Call (877) 640-4262 and ask for HBMA’s Billing Resource Center

• E-mail requests to info@hbma.org

• Visit www.hbma.org

This educational flyer was developed through a cooperative effort between the Healthcare Billing and Management Association and the American Medical Association. © Copyright 2007 American Medical Association. All rights reserved.

Big Sentence for Medicare Fraudster

April 03, 2008 02:59 PM ET | Luke Mullins

Rita Campos Ramirez, a 60-year-old Miami resident, received a 10-year prison sentence for her role in a multimillion-dollar Medicare fraud scheme. The $170 million scheme is the program's largestindividual case of fraud ever. The sentence was announced Wednesday.

As part of her punishment, Ramirez will also have to hand over her three homes and a car. Plus, she was ordered to pay $105 million in restitution to the federal government.

"The sentence in this case dispels the myth that white-collar-crime defendants get off lightly," FBI Special Agent in Charge Jonathan Solomon said in a press release. "It reinforces the message that healthcare fraud—stealing from U.S. taxpayers—is a serious crime."

Details of the crime:

Campos pleaded guilty on Aug. 28, 2007, to one count of conspiracy to commit health care fraud and one count of submitting false claims to Medicare. As part of her plea, Campos admitted that between October 2002 and April 2006 she owned and operated R&I Medical Billing Inc., a medical billing company that specialized in submitting bills to the Medicare program on behalf of HIV infusion clinics. Campos admitted that she knowingly submitted approximately $170 million in fraudulent medical bills to Medicare on behalf of 75 HIV infusion clinics in Miami-Dade County that were part of the scheme. Infusion clinics serve HIV patients by providing prescribed medications intravenously.

The Medicare program paid approximately $105 million of the $170 million in fraudulent bills submitted by Campos, with Campos personally receiving $5 million for her role in the fraud.

Full press release is here.

‘Inpatient hospital coding, an emerging BPO vertical’

- An Article in The Hindu byD.Murali

Chennai: Coding, as commonly understood, refers to programming and writing a lot of lines of software. However, in the healthcare BPO (business process outsourcing) industry, ‘coding’ refers to the conversion of paperwork, such as patient-charts created by doctors and hospitals, for reimbursement purposes.

“What is currently emerging as a BPO vertical is inpatient hospital coding,” says Mr Gopi Natarajan, CEO of Omega Healthcare India Pvt Ltd. “As an offshored industry, India has been mainly doing outpatient coding for US hospitals and medical professionals. Now, the dearth of qualified resources in the US makes the offshoring of inpatient hospital coding a necessity.”

In terms of jobs that can be offshored, only about 6 per cent of the US healthcare BPO industry has been offshored, informs Mr Natarajan, speaking to Business Line. “With 1,400 employees, Omega has about 16 per cent of the market in terms of offshored healthcare BPO jobs.” The Bangalore-based company provides medical coding, billing, accounts receivable management, claims processing, and healthcare revenue management.

What does inpatient hospital coding involve? And how is it different from the outpatient work? Explains Mr Natarajan, “Inpatient hospital coding is more about the procedures that are done within the hospital, such as the use of beds, surgical equipment, and specialty care. These services are of much higher value in terms of dollars, compared to the outpatient category.”

Omega is working with its clients in the US to make a foray into inpatient hospital coding in the forthcoming fiscal. “We see this new vertical as a shift up the value chain,” says Mr Natarajan.

Offshoring: Where's the Value?

4/4/2008 --

New research shows that customers perceive little value in outsourcing.

ANN ARBOR, Mich.—U.S. companies that outsource business functions overseas may save money in labor costs but they also pay a price for unhappy customers, say University of Michigan researchers.

Firms are increasingly offshoring front-office functions such as customer service call centers and back-office functions like information technology to manage their operations and achieve strategic objectives, says M.S. Krishnan, professor of business information technology at Michigan's Ross School of Business.

"However, neither front- nor back-office offshoring are associated with an increase in perceived value," he said. "This suggests that firms may be reducing their costs by offshoring, but are either not passing on these savings to customers or not re-investing these savings to create a perceptible increase in value for customers."

Krishnan and colleagues Claes Fornell of the Ross School and Jonathan Whitaker of the University of Richmond examined 154 North American firms and business units that engaged in offshoring from 1998 to 2005. They used Fornell's American Customer Satisfaction Index to measure customer satisfaction and gleaned more than 50,000 news reports for information on the offshoring activities of companies.

The researchers found that front-office offshoring (sales and customer service call centers) results in lower customer satisfaction and a decrease in each of its primary determinants---perceived value, perceived quality and customer expectations.

Previous research has shown that nearly nine in 10 American customers have experienced some kind of problem when contacting overseas call centers, including lack of responsiveness, reliability and other variables of service quality.

"With the cultural, language, distance and time-zone differences inherent in offshore services, one or more of the (service quality variables) may not translate properly in the offshore service setting," said Fornell, professor of marketing at Michigan's Ross School of Business.

However, when it comes to offshoring back-office functions (those that support front-office functions, such as IT, human resources, finance and accounting, and research and development), customer expectations and perceived quality improves---despite a drop in perceived value.

Overall, the researchers suggest three primary implications of their study:

—Firms must carefully consider which functions are suitable for offshoring.

—Companies must ensure that their vendors overseas are properly equipped to provide high-quality service to customers.

—In addition to using offshoring as an opportunity to save on internal costs, firms must also use it as an opportunity to create additional value for customers.

The researchers say that offshoring activities of American companies can be successful if they manage the process properly.

"Companies often have a knee-jerk reaction," Krishnan said. "Why are we spending so much money? Let's cut costs and go to India or the Philippines or someplace. Most companies have a myopic view to blindly go out and outsource.

"But it's the process that matters. It's not about exporting jobs. It's about importing competitiveness."

For more information, contact:
Bernie DeGroat, (734) 936-1015 or 647-1847, bernied@umich.edu