Healthcare system in the United States is very complex. Before the patient decides to see a specialist, the first question that needs to be answered is if he/she has health insurance. There’s a huge variety of group health insurance plans offered through employers, but the system also includes Medicare, Medicaid, the Veterans Health Administration system, and individual plans offered through the insurance markets set up by the Affordable Care Act. The kind of insurance that your patient has can directly influence how much your patient pays for healthcare and what doctors or specialists he/she is permitted to see. This is why health insurance providers are a lot more complicated than any other type of insurance. Over time it gets more complicated as new laws, regulations, court cases and differing opinions start to add complexity.

To ensure that a client's insurance provider will pay up all the required medication and treatment, doctors and other medical professionals require prior authorization to their clients. Under some medical and prescription drug plans, treatments and medications may need approval from the health insurance provider before you provide care.

Prior authorization is usually required if your client needs a complex treatment or prescription. Coverage will not happen without it. One reason why health insurance providers require this type of document before proceeding with different medical procedures is that a less expensive treatment option may be sufficient rather than simply defaulting to the most expensive option. To make sure that reimbursement will not be denied and that you will receive proper compensation, this document must be secured prior to giving your client the required procedure.
 
How to Get Prior Authorization?

If you’re in-network to your patient’s insurance coverage, then you have to prepare the necessary documents for your patient. Prior-authorization procedures are different from every insurance provider.

Submission of Prior Authorization Request
 
You submit your pre-authorization request by mail or fax. Many authorization companies provide Prior Authorization Request Form (both offline and online) to submit written pre-authorization. Every insurance company has its own requirements for pre-authorization requests. However, you should include the following information in all types of requests.

• Demographic information of the patient (name, date of birth, insurance ID number and more)
• Provider information (both referring and servicing provider)
  • Tax ID number
  • National Provider Identifier (NPI) number
  • Address where services are being provided
  • Phone and fax number
• Requested service/procedure along with specific CPT/HCPCS codes
• Diagnosis (corresponding ICD code and description)
• Location where the service will be performed
  • Tax ID number
  • NPI number
  • Address
  • Phone and fax number
• Length of stay requested in case of inpatient requests

 
How Long Do Prior Authorizations Take?

• A prior authorization can take days to process. However, being proactive and maintaining a very detailed communication log can help to reduce the amount of time a prior authorization takes.
• Also, keeping some sort of alert/calendar so that you know when the first request was sent and following a very strict follow-up schedule will help you avoid the dreaded delay that is typically caused by prior authorizations. Below are a few tips to reduce the time spent processing prior authorizations:

1. Start the process early.
2. Know the key dates for when your information needs to be submitted.
3. Send a follow-up fax or phone call if the requested authorization has not been returned within 5 business days.
4. Don’t hesitate to ask if you need a short-term process.
5. Have your patient be involved in the process to expedite the approval.

The process of obtaining and maintaining prior authorizations is vital to the success of any medical practice. Overall, the prior authorization process impacts almost every aspect of the revenue cycle and operations of your medical practice.
 
HOW TO REQUEST A GAP EXCEPTION/ PRIOR AUTHORIZATION FOR OUT OF NETWORK CARE How to request a gap exception/ prior authorization for out of network ... (n.d.). Retrieved August 6, 2022, from https://favoredmedicalbilling.com/forms/GAP_Request_Guide_for_Midwives_and_Birth_Centers.pdf
 
References

Lower burden with outsource prior authorization: Drcatalyst. English. (n.d.). Retrieved August 6, 2022, from https://www.drcatalyst.com/importance-of-prior-authorization

Prior authorization. Santa Clara Family Health Plan. (n.d.). Retrieved August 6, 2022, from https://www.scfhp.com/for-providers/provider-resources/prior-authorization/

Clements, J. (2022, July 14). What is prior authorization? when is it needed and not? Outsource Strategies International. Retrieved August 6, 2022, from https://www.outsourcestrategies.com/blog/what-is-prior-authorization-when-is-it-needed-and-not/ 

 Each profession has its own jargon. The language used specifically in a communicative context and may not be well understood outside that context. Language that is understood by the people within specific areas of expertise. Medical codes are the universal language of understanding between payers and providers and hence used for communication and billing purposes. The financial criticality for both payers and providers mean that providers have to be compliant and accurate in coding for medical treatment provided.

To enter into the medical field, specifically midwifery, one must have enough knowledge and understanding with medical codes. Codes and descriptions that play a vital role in the billing procedures of all medical services rendered. Having the proper medical coding ensures that insurers have all the diagnostic codes required for appropriate payment. In this article,  we will have a closer understanding in dealing with CPT codes, diagnostic codes and service locations.

What is CPT Code?

The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. Administrative management purposes, such as claims processing and developing guidelines for medical care review, also use CPT codes.

The CPT terminology is the most widely accepted medical nomenclature used across the country to report medical, surgical, radiology, laboratory, anesthesiology, genomic sequencing, evaluation and management (E/M) services under public and private health insurance programs. All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have a common understanding across the clinical health care paradigm.

What is Diagnostic Code?

In healthcare, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes. Both diagnosis and intervention codes are assigned by a health professional trained in medical classification such as a clinical coder.

As the knowledge of health and medical advances arise, the diagnostic codes are generally revised and updated to match the most up to date current body of knowledge in the field of health. The codes may be quite frequently revised as new knowledge is attained.

What are Service Locations?

A service location is where services are rendered to a patient. This can be a hospital, the provider's office, or a nursing home, for example. In medical billing, service location is presented through the place of service (POS) dodes. Place of service codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.

Here’s the complete Place of Service (POS) Codes lists

CPT Codes, diagnostic codes and service locations are three different coding classifications used in diverse areas. Healthcare is highly regulated, therefore understanding these three factors are very important. Although it may seem overwhelming with the number of codes you might need to use, the terminologies you might encounter every once in a while, when you have a basic understanding of them, you’ll have the foundation you need to start billing insurance in your private practice. Now you’ll have the opportunity to open up care to more clients, grow your practice and your impact. 
 
References

Hazelwood, A (2005). ICD-9-CM Diagnostic Coding and Reimbursement for Physician Services 2006 Edition (PDF). United States of America: American Health Information Management Association. p. 2. Archived from the original (PDF) on 2013-07-18. Retrieved 2013-05-27.
M, M. (2021, December 3). Revisiting the basics: Understanding medical coding. Medical Billing Wholesalers. Retrieved August 5, 2022, from https://www.medicalbillingwholesalers.com/the-revenue-cycle-blog/revisiting-the-basics-understanding-medical-coding#:~:text=Medical%20Codes%20are%20the%20universal,Coding%20for%20medical%20treatment%20provided.

Place of service codes. CMS. (n.d.). Retrieved August 5, 2022, from https://www.cms.gov/Medicare/Coding/place-of-service-codes 

In this hastily developing healthcare setting around the US, employers need trained professionals to help them manage the inevitability of changes, maintain compliance, and preserve profitability. Billing is a complicated matter that only trained and skilled people can do. Its importance is often overlooked most especially in the healthcare industry as professionals in this field tend to focus on giving proper care and services to the patients that is why administrative tasks like this are not their priority. This happens most likely to midwives and other birth professionals. Some individual practice owners don’t have enough time to crawl out keeping track of all the records, collecting payments, managing cash flows. Hence, a medical biller is the one that can save the day.

A medical biller is a trained professional who submits bills to patients and/or health insurance companies and follows up to make sure the healthcare provider receives payment for the services. When the medical biller receives a claim for the healthcare services, it’s represented by a code, and it’s the medical biller who translates it into a claim. It’s the medical biller’s responsibility to follow up on the bill until the provider has the final reimbursement.
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Like any other profession, Medical Billers are compensated well. As they perform crucial tasks, they are paid more. On average, medical coders (certified and non-certified) make $54,797 annually. Medical billers and coders without certification earn approximately $47,200 per year while certified coding and billing specialists make an average annual salary of $60,097 — 27% more than their non-certified colleagues.
 
The Medical Coding and Billing Salary Survey demonstrates once again that certification pays. The average salary for professional coders with two credentials rises to $64,712. Billing and coding specialists with three or more credentials earn approximately $69,942 per year.
 
In addition to competitive salaries and standard employment benefits, many employers also offer paid professional association dues and paid continuing education. Full or partial coverage of continuing education is particularly valuable, given the correlation between salary and medical coding credentials. Other variables that weigh into the salary equation include experience, specialty/medical field, employer type, and location.
 
The price you pay for a biller varies greatly from hourly rate, commission, scope of work specific charges, or salaried.  When determining if the price is fair for the services, determine the return on investment that cost if bringing in to your practice.  If this biller is really good and brings you in far more money for a quicker reimbursement time, paying them more makes a lot of sense to do.  Hiring the experts and the national bests will costs you more, but get you far better results in the end.
 
References

Aapc. (2022, February 9). Medical coding salary survey. AAPC. Retrieved August 5, 2022, from https://www.aapc.com/resources/research/medical-coding-salary-survey/
Pettigrew. (2021, May 7). The growing importance and value of medical billing services. PETTIGREW. Retrieved August 5, 2022, from https://www.pettigrewmedical.com/the-growing-importance-and-value-of-medical-billing-services/

What is a medical biller? The Best Health Degrees. (2022, April 25). Retrieved August 6, 2022, from https://www.besthealthdegrees.com/faq/what-is-a-medical-biller/ 

Medical billing is a series of complicated matters that requires enormous amounts of effort and understanding to perform. It contains different codes and descriptions that are intended to determine and facilitate payment and collection to keep your practice operational.

If you're aiming to dig into medical billing, whether you want to add it onto your skills or if you decide to hire an expert in medical billing, it is important to understand the nature of the job in different types of facilities. In the medical and midwifery world, codes work differently. Countless codes that need to be updated from time to time. There are ICD Codes, CPT Codes, HCPCS Codes, DRG Codes, Modifiers, etc. Each code has different usage and transcriptions that are used and designed within specific diagnostics. In this article, we will be discussing how professional fee and facility CPT codes differ from each other.

Professional and facility coding describe two very diverse aspects of the healthcare industry. Simply speaking, professional fee coding is the billing for the physicians and the experts. The facility coding is billing for the facility and the equipment. Professional codes primarily capture the complexity and intensity of provider care provided during a visit, facility codes detail the volume and intensity of hospital or health system resources used to deliver patient care, such as the use of medical equipment, medication, and nursing staff.
 
What is a Professional Fee Code?

Professional fee, refers to coding and billing the physician side of a patient encounter. Professional fee coding covers the work performed by the provider and the reimbursement they will receive for the medical services performed.

In general, midwives and midwife-led birth centers offer standard pregnancy care packages. This package covers the professional fee, all prenatal visits, labor and delivery care in a birth center, at home, or in a hospital, birth kits, newborn care and assessment, postnatal visits at two and six weeks postpartum, and phone consultations. On average, a midwife's basic maternity care package ranges from $3,000 to $6,000 for normal low-risk pregnancies. This can vary depending on the location or state where your practice is located. The basic package cost usually comprises prenatal visits, labor and delivery care, and postnatal visits.

To know more about midwifery reimbursement rates, here is a sample professional fee for CNMs and CMS MEDICAID FEE-FOR-SERVICE REIMBURSEMENT RATES FOR CNMs and CMs as of September 2013

What is the Facility Fee Code?

A facility fee is a charge that you may have to pay when you see a physician or a midwife at a clinic that is not owned by that physician or midwife. Facility fees are charged in addition to any other charges for the visit. Facility fees are often charged at clinics that are owned by hospitals to cover the costs of maintaining that facility
 
Hospitals, hospital-based facilities (such as outpatient clinics owned by a hospital), and various other medical facilities often charge a facility fee as well as the provider's professional fees. CMS regulations do not establish a general definition of “facility fee,” but CMS sets reimbursement rates for these fees subject to various requirements set forth below. The facility fee covers overhead costs, such as equipment, space, and support staff. This fee is sometimes referred to as the technical component of the bill.

Under the CMS “provider-based status” rules, Medicare will reimburse for facility fees at a hospital-based facility (such a group practice owned by the hospital) meeting certain requirements but not at providers' offices not affiliated with a hospital. A facility or practice has provider-based status and thus can bill for facility fees it if has a relationship with the main provider (i.e., the hospital) concerning a range of issues, such as licensure, clinical and financial integration with the hospital, public awareness, and billing practices. The regulations specify payment recovery procedures if a hospital inappropriately treats a facility as provider-based.

Facility Claim

A single facility claim is submitted for all services provided to the patient on that date.
●        Condition code is submitted in the claim header, letting the payer know that the evaluation and management (E/M) codes are distinct, potentially reimbursable services, and not duplicates.
●        The occurrence code and occurrence date at the header level indicates some of the services were related to an accident, which lets the payer know other medical coverage may apply for the services on the claim.
●        Revenue codes indicate the facility department or area
●        HCPCS Level II/CPT® codes
●        Diagnosis codes appear at the header level, not tied to a particular line

In order to bill the facility fees, the hospital or facility like a birth center should already have criteria for the codes they use. The Centers for Medicare and Medicaid Services does not specify these criteria, but expects them to form a bell-shaped curve. If the hospital has not established these guidelines, they could use and modify the suggestions published by the American College of Emergency Physicians, available at https://www.acep.org/administration/reimbursement/ed-facility-level-coding-guidelines/
Also visit https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/Facility-Billing.pdf

Your practice will rely mainly on your cash flow. Professional fees and facility fees are the top two revenue streams of your business. Your clients must pay you with your expertise same with the facility you have been using to provide quality of service. As a practice owner, if you happen to create a unique system that collects these two types of fees and utilize it methodically, then you are on the right track and that is for sure.

References

Renee Dustman. (2015, February 1). Compare and contrast physician and outpatient facility coding. AAPC Knowledge Center. Retrieved August 6, 2022, from https://www.aapc.com/blog/29346-compare-and-contrast-physician-and-outpatient-facility-coding/

James Orlando, A. A. (n.d.). Facility fees and Accountable Care Organizations. Retrieved August 6, 2022, from https://www.cga.ct.gov/2014/rpt/2014-R-0238.htm
Understanding facility fees - the Alliance. (n.d.). Retrieved August 6, 2022, from https://the-alliance.org/wp-content/uploads/2021/05/TheAlliance_FacilityFees2021_EE_UnderstadningFees_6152021.pdf

One of the most common mistakes in medical billing is the failure of accurate verification of insurance claims. Insurance verification is the topmost significant step in the medical billing and coding process. Before you provide midwifery care to your clients, you have to verify if the patient’s healthcare benefits will cover up all the medical procedures needed. Presently, the healthcare industry continues to shift into many complex settings that require closer attention in validating insurance coverage, patient benefits, deductibles and copayments.
 
Every successful billing merely depends on the success of eligibility verification. In a brief summary, health insurance verification is the process of checking a patient’s active coverage with the insurance company. It also verifies the eligibility of a patient's insurance claims. Checking your patient's insurance benefits BEFORE the patient is seen should be a fundamental part of your practice's administrative process. Otherwise, you run the risk of claims being denied and left unpaid. You don't always have the right to appeal or bill your patient which is why it is so important to know the patient's insurance benefits before treatment begins.

When checking benefits, be sure to ask the right questions.
        1. What is the patient's financial responsibility?                                                

• Informing the patient of any co-pays, deductibles or coinsurance upfront will guarantee a better patient experience. Not only will the patient know what is expected from them financially, your front desk staff will also feel more confident when asking for payment at time of service.  This decreases the chance of a nagging patient balance and can reduce the number of patient statements that you need to send each month.
  
• Routinely checking benefits can also reduce the amount of refunds to the patient or insurance company due to over-payments.

        2. Does this patient have visit limits?

• Not all insurance plans offer unlimited visits to specialty healthcare services such as physical, occupational, and speech therapy.  This is why it is essential to ask this question when you call to check the patient's benefits. If the patient has a visit cap, what is the limit? How many visits have they already used for the year? These might seem like small details but they will play a huge role in reducing denials due to exceeding benefit maximums.
  

​          3. "Is this a plan year or calendar year?"

• Finding out if your patient's insurance plan operates under a calendar or plan year will benefit both the patient and your bottom line. This information lets the patient know when their benefits reset giving them a better understanding of their financial responsibilities.  And, having your front desk track and re-verify when benefits renew assures that there are benefits in place at time of service.  Keeping everyone informed and benefits up to date reduces frustration for all involved. 

          4. "Is a referral or authorization required?"

• Referral and authorization denials are two of the most common denial reasons. Finding out whether or not a referral or authorization is required BEFORE the patient is seen will have a huge impact on the number of denials your office receives. 
• It is important to note that denials due to "no auth" cannot be billed to the patient because it is not the patient's responsibility to obtain the authorization.  However, denials due to "no referral" can be billed to the patient because it is their responsibility to obtain a referral before receiving treatment. 

 
If your administrative process does not include checking patient benefits before the patient is seen, your revenue cycle management is hindered from the start. Accurate insurance verification ensures a higher number of clean claims which speeds up approval and results in a faster billing cycle. Inadequate verification of eligibility and plan-specific benefits puts healthcare organizations at risk for claim rejections, denials, and bad debt. Always pay attention to the documents submitted and be scrupulous in receiving the data needed for your service reimbursement.
 
Reference
Ramsey, D. (n.d.). The 5 most important questions to ask when checking benefits. Account Matters Blog. Retrieved August 5, 2022, from https://blog.accountmattersma.com/5-important-questions-to-ask-when-checking-benefits