Unraveling The Complexities Of Pediatric Diagnosis For Insurance Billing

Billing for children's healthcare services can be a complex process, with multiple bills from different providers and insurance companies to navigate. It is important to understand the billing and insurance process to ensure that families receive the necessary financial support and that healthcare providers are fairly compensated for their services. When seeking healthcare for children, it is common to receive separate bills from the hospital and the doctors involved in the child's care, such as the attending doctor, surgeon, radiologist, and pathologist. These bills may include charges for lab tests, supplies, and facility fees. Understanding insurance coverage and billing procedures is crucial to avoid unexpected financial burdens on families.

Understanding the billing lingo

When it comes to billing for medical services, there is a lot of jargon to get your head around. Here is a guide to help you understand the billing lingo:

Invoices, Bills, and Statements

An invoice, bill, or statement is a printed summary of your medical bill. It will include details such as the amount billed, the services provided, and the date of service. You may receive multiple bills for your child's hospital visit, as you will often be billed separately for professional services such as doctors' fees.

Insurance Coverage

It is important to understand what your insurance plan covers and what your out-of-pocket expenses will be. Check with your insurance company to see what type of services are covered and if there are any exclusions or limitations. Your insurance plan may also have a deductible, which is the amount you must pay before your insurance company starts paying.

Co-payments and Co-insurance

A co-payment, or co-pay, is a fixed fee that you pay at the time of service. The amount may vary depending on the type of service and the provider. Co-insurance, on the other hand, is the percentage of the total bill that you are responsible for paying. For example, if your insurance company pays 70% of the allowed amount, you will be responsible for paying the remaining 30%.

Authorization and Certification Numbers

Before receiving certain treatments or services, your insurance plan may require pre-authorization or pre-certification. This means that they have approved the treatment and agreed to cover the costs. You will usually be provided with an authorization or certification number, which you can include on your bill to ensure smooth processing.

Explanation of Benefits (EOB)

After your insurance company processes a claim, they will send you an Explanation of Benefits (EOB). This statement will outline the amount billed, the allowed amount, the amount paid to the provider, and any co-payments, deductibles, or coinsurance that you are responsible for.

Diagnosis and Procedure Codes

When billing insurance companies, healthcare providers use standardized coding systems such as ICD-10 (International Classification of Diseases, 10th edition) and CPT (Current Procedural Terminology) codes. These codes help communicate the diagnosis and the type of service provided, ensuring efficient billing and tracking.

Out-of-Network Providers

If you receive treatment from a doctor or hospital that is not part of your insurance plan's network of providers, they are considered out-of-network. Out-of-network providers may have higher costs for patients, as the insurance company may not cover the full amount of the bill.

Knowing the diagnosis codes

Diagnosis codes are used in medical billing and coding by healthcare providers to document a patient's disease or condition using a standard classification system. The International Classification of Diseases (ICD) is a system of medical diagnostic or medical insurance codes developed by the World Health Organization (WHO). The latest version of the ICD is the ICD-10, which consists of 7 alpha or numeric digits and allows for 155,000 different codes.

The ICD-10 codes consist of up to seven characters that classify medical diagnoses in a specific way. The first three characters—a letter and two numbers—classify the disease or health condition. The next three numbers describe the cause of the disease, how severe it is, or where in the body it is located (including whether it is on the left side, right side, or both). Each ICD-10 code starts with a capital letter from A to Z, which broadly categorizes the nature of the diagnosis. For example, codes starting with the letter "A" refer to infectious and parasitic diseases, while codes starting with "F" refer to mental and behavioral disorders.

The ICD-10 codes are used in billing, treatments, and statistics collection. Having the correct diagnosis code is important to ensure that standardized treatment for a medical issue is delivered and that medical expenses are reimbursed. When a healthcare provider submits a bill to an insurance company for reimbursement, each service is described by a common procedural technology (CPT) code, which is matched to an ICD code. If the two codes don't align correctly, the insurance company may deny payment.

In addition to the ICD-10 codes, there are also CPT codes and HCPCS codes. CPT codes, or Current Procedural Terminology codes, indicate the type of service provided related to a given diagnosis. CPT codes consist of five-digit numeric codes for professional and outpatient facility billing. HCPCS codes, or Healthcare Common Procedure Coding System codes, are used for equipment, supplies, or non-physician services that are not covered by a CPT code.

To bill insurance, healthcare providers must learn the billing lingo, including diagnosis and procedure codes. They must also obtain their National Provider Identification (NPI) number, which is required when interacting with insurance companies. Additionally, they need to fill out the CAQH, which collects and maintains all the information needed for credentialing by insurance companies.

Filling out the CAQH form

• Familiarise yourself with the type of information required in the profile and the steps to complete it. The CAQH form is extensive and will require various personal and professional details, as well as information about your education, training, work history, and practice location.
• Gather all the necessary materials, including your transcripts, training site information, licensure information, and malpractice insurance policy. You will also need identification numbers, such as your National Provider Identification (NPI) number, and the physical addresses of the universities you attended.
• Create an account on the CAQH website. Provide the necessary personal information, verify your email address, and set a password.
• Complete all the required sections of the application, including personal details, professional information, and practice affiliations. The CAQH website has helpful features like drop-down selections and required fixes to guide you through the process.
• Upload any supporting documents, such as copies of medical licenses, malpractice insurance, and identification numbers.
• Review and submit your completed application. The CAQH form typically takes around 1.5 to 2 hours to complete.
• Remember to periodically update your CAQH profile with any changes to your information. You will also need to re-attest your CAQH every quarter to ensure that your information remains current and accurate.

By following these steps, you will be able to successfully fill out the CAQH form, which is an essential step in the process of diagnosing children for insurance billing.

Getting credentialled

Step 1: Research Insurance Companies

First, research which insurance companies offer coverage in your area. Consider the type of healthcare you provide and the geographic area you serve. There may be certain plans that work well with the services you offer or more general plans for expanded practice. Major national carriers include Aetna, Blue Cross/Blue Shield, Cigna, Humana, and United Healthcare, but there may also be common regional insurance carriers to consider.

Step 2: Obtain Necessary Credentials

Before applying, ensure you have the necessary credentials. This includes your National Provider Identifier (NPI) number, malpractice insurance, and any other licenses or certifications required by your state's medical board.

Step 3: Complete the CAQH Application

The Council for Affordable Quality Healthcare (CAQH) offers a universal provider credentialing program, allowing healthcare providers to easily apply for credentials with multiple insurance plans. By obtaining a CAQH provider identifier, you streamline your application process and gain access to multiple health plan contracts. Create an account on the CAQH website, providing personal details, contact information, practice and specialty information, professional qualifications, and certifications. Once this step is complete, submit any required documentation, such as a copy of your state license.

Step 4: Contact Desired Insurance Companies

After completing the CAQH application, contact each insurance company with which you want to be in-network. Review the contract and fee schedule, ensuring you understand the requirements and that they align with your business/practice needs.

Step 5: Submit Credentialing Application

Submit your credentialing application to each desired insurance company. This may include completing additional forms and providing detailed information about your professional background, practice information, and relevant documents.

Step 6: Follow Up

Once you've submitted your applications, follow up with the insurance companies to confirm receipt. The insurer will then review your credentials, comparing them against their standards or requirements.

Step 7: Contracting

If approved, you will enter the contracting phase, where you and the insurance company finalize a contract specifying the in-network services you will provide, the reimbursement rates, and how you will receive reimbursement.

Step 8: Stay Informed

Even after becoming credentialled, it's important to stay informed of any updates or changes in guidelines, regulations, reimbursement rates, or policies from insurers. This will help ensure you continue to meet all requirements when interacting with payers.

Learning the rules of billing insurance

Billing insurance for diagnosing children can be a complex process, and it's important to follow certain rules to ensure accuracy and compliance. Here are some key guidelines to keep in mind:

• Understanding Insurance Coverage: Before billing insurance, it's essential to verify the patient's insurance coverage. Contact the insurance company to confirm their benefits, eligibility, and specific plan details. This step helps determine what services are covered and to what extent.
• Diagnosis Coding: When submitting claims, use standardized diagnosis codes such as ICD-10 (International Classification of Diseases, 10th Edition) to describe the patient's condition. These codes are essential for insurance reimbursement and must be accurate and supported by clinical documentation.
• Procedure Coding: In addition to diagnosis codes, you'll need to use procedure codes such as CPT (Current Procedural Terminology) codes. These codes describe the services provided, such as psychotherapy sessions or diagnostic tests. CPT codes are linked to the length of service and are crucial for billing the appropriate amount.
• Billing Forms and Submission: Familiarize yourself with the required billing forms, such as the CMS-1500 (Centers for Medicare and Medicaid Services) form. This form includes sections for diagnosis and procedure codes, patient information, service dates, and insurance details. Most billing is now done electronically through secure systems.
• Insurance Payment and Adjustments: After submitting a claim, the insurance company will process it and determine the allowed amount, taking into account the patient's coverage and any applicable deductibles, co-insurance, or co-payments. You will receive an Explanation of Benefits (EOB) outlining the payment details.
• Patient Billing and Collections: If there is a remaining balance after insurance payment, you can bill the patient for their portion. It is important to communicate this clearly to the patient and offer payment options or plans. Be mindful of any financial assistance or hardship programs that may be available.
• Compliance and Fraud Prevention: It is crucial to adhere to insurance company guidelines and regulations to avoid insurance fraud. This includes charging the same fees for all patients, not waiving co-pays or other patient responsibilities, and justifying that your services are medically necessary.
• Record-Keeping and Audits: Maintain thorough and accurate records, including treatment notes, billing information, and patient consent forms. Insurance companies may request audits of your records, so ensure that your documentation is organized and readily accessible.
• Billing Timelines and Follow-up: Stay on top of billing timelines to ensure prompt reimbursement. Follow up on any unpaid or denied claims, and be prepared to provide additional information or appeal decisions if necessary.
• Billing Software and Support: Consider using billing software or hiring a billing professional, especially if you work with multiple insurance plans. These resources can streamline the billing process, reduce administrative burdens, and help you navigate the complexities of insurance billing.

Remember, each insurance company may have its own unique processes and requirements, so it's important to familiarize yourself with their specific guidelines. Staying organized, accurate, and compliant will help ensure a smoother billing process and better patient experiences.

Frequently asked questions