Importance of Getting All the Information from Clients Before Billing Midwives Insurance Claims
Billing plays a significant role in your practice’s revenue. When you have your patient, you either bill them out personally or through their health insurance coverage. Getting cash from clients may be easier but what if they will use their insurance? Not all insurance claims get approved, there are times that patients get rejected and as the healthcare provider, it will greatly affect you and your practice. Study shows that insurance claims can also be denied or rejected for a variety of reasons. Many of these denials are due to human error. 75% of claims were incorrectly coded. To avoid this to happen, you must get all the information needed and verify it first hand before submitting claims.
Insurance claim data entry is very challenging. It is common for insurance claim documents to be copied, shared, and reviewed by multiple departments depending on the type of claim. Multiple employees cannot work on the same claim simultaneously if they have to deal with physical documents. These steps can cause errors or omissions in claim management software by manually entering data from different documents in a claim. This could lead to chaos, delay payments, mishandling the claim, and/or create delays in payment.
It is vital to have a healthy revenue cycle to support the expensive work of every midwife. However, it can be difficult to ensure that your practice receives payment for the services it rendered. This can be especially difficult because midwives often get reimbursed by third party payers after the patient has left. There is also a delay between rendering services and receiving payment. Below are the reasons why it is important to get all the information from clients with billing insurance claims out:
Having your midwifery business is worthwhile, hence deciding how to get paid what you are worth is challenging. It can be difficult to decide how much you should charge for your midwifery service since midwives just started to be recognized with the value they put in the healthcare industry. You could be priced out of the market if you charge too much. If you charge too much, you might be earning nothing. As a midwife, you must charge a reasonable amount of money that can help you survive your practice in the long run. To help you decide, here are some ways you can use to determine your pricing point for your midwifery business.
1. Do not be a discount queen Although it might seem tempting to offer sales to get new business, if you discount certain things without asking why, you could lose money.
2. Take into consideration all costs This is an important step in pricing your services. Calculating your cost of sales (COS) is essential. You should make a list of all the steps involved in creating or delivering your midwifery services. This includes your time and the cost of outsourcing or hiring help.
3. Calculate Your Overhead Percentage
You must also include costs related to staying in business. I think overhead costs are like a roof above your head. Freshbooks offers a detailed guide which explains everything. These costs include utilities, taxes, office equipment, and office rent. Direct costs refer to the costs associated with each project, such as gas, filing fees and your time. These are the overhead costs listed above. Divide the indirect costs by direct costs to calculate your overhead percentage. Then multiply 100 by 100.
4. Avoid Low Balling Your Prices at First Although it might seem tempting to offer low rates to attract customers and undercut the competition, don't. It will be harder to raise your prices later if you do. Customers might be price sensitive and you could lose customers if your prices are raised to a livable level. Instead, determine the price you would like them to be at the beginning.
5. Fee for Value Consider the value of your services when pricing your services. A professional midwife who has had experience delivering babies will charge a mom more than someone who doesn't. It is important to invest in your education and training. Be valuable to your customers.
6. Don't confuse Rate and Price It's simple to do but don't let your personal rate get in the way of the price you charge. You don't want to charge $100 an hour if you want your hourly rate to be $100. Also, you need to factor in overhead and COS. You might earn less than $75 an hour if you take these into account. If you would like your hourly rate to be $100, then calculate the costs first, and include your rate within those costs. You should then charge $125 and not $100.
7. Take into consideration the market demand You can make changes to your midwifery service if there isn’t much demand. Printing paper flyers is not a popular service in today's market. Consider offering social media graphic design as an alternative if this is your business or skill.
8. Find Ways to Increase Sales Upselling is a great way to increase your income. Do not include additional fees in your base price. These extras should be kept secret and offered to clients as valuable options. You may add ancillary services to your midwifery practice such as ultrasound and other test that will be helpful to the customers
9. Invest in the business to increase rates Find ways to invest in your business to increase your rate of return. You might be more productive with a new technology. Continuing education can give you more authority, knowledge and confidence. Clients will pay more if you offer faster turnarounds and other value.
10. Identify Your Ideal Customer When setting your prices, keep in mind your ideal customer. If you offer discounts and set extremely low rates, you will attract this type of customer. Midwifery services are quite expensive if you don’t have insurance coverage in the US. It is important to determine that your customers have the ability to pay for your services rather than expecting to get discounts in every service that you offer.
11. Create a written fee agreement Make sure everyone signs the fee agreement after you have established your fees. Make sure you are clear and answer every question upfront. This will prevent any confusion or arguments later. Pricing is the first step to establish your business, and you must remember that the first step is always the hardest. Yet, if you realize the value of the midwifery service you can offer to your community, along the way things will go smoothly as how you perceived your practice to be. Have patience and you will get there.
Inks, S. (2020, May 23). How to price your services and get paid what you deserve. SMI Financial Coaching. Retrieved November 28, 2022, from https://smifinancialcoaching.com/how-to-price-your-services/
The New Year is a new opportunity to start fresh. We use a very important concept called "self-efficacy" when we make New Year's Resolutions. This means that we can set goals and follow through on them, giving us a sense of control over my life. New year, new business opportunities, new chances to grow. People in the business industry use this opportunity to create new habits that will help them in their business. Habits to maintain up to the end of the year.
In midwifery, particularly in billing for your practice, it is important to measure the habits you have, improve the old habits that helped your practice, and remove those habits that made your billing procedures difficult. It is possible to resolve and improve your medical billing process by setting aside some time. In a matter of days, this can make a huge difference in your bottom line. We recommend that you take the time to read these seven tips and find cash where it is missing. What are the best ways you can improve your billing for your midwifery practice?
1. Collect patient contact information and insurance details prior to their appointment
It will save both you and your client a lot of time by collecting the necessary information before your clients visit the clinic. This will also allow you to plan the end of your day. Your receptionist/front desk staff should be able to collect the most current and complete information from patients calling your office to schedule an appointment. Patients can also choose to send or mail their information. This information should be available on your patient portal and online appointment tool. Staff will be able to verify the patient's insurance information and follow-up with them throughout treatment and collection.
2 Check your client's eligibility for insurance and calculate any outstanding balances
Verify coverage with payers before or during service. These steps will allow you to identify any changes in patient collections, determine what percentage of the treatment will be covered and who is responsible for payment.
3. Adopt a payment policy that places patient responsibility at check in
Patients should be required to pay copays at check-in. This is the best way to collect patient balances. Create a policy for medical offices to ensure that patients are aware of the requirement. Include a patient responsibility agreement for patients to sign in your check-in paperwork. This policy provides clear guidelines to your staff and patients regarding collection. You can also use your patient message solution for automated appointment reminders that communicate what is due at the time you are providing service.
4. Transparency in your billing and collection processes
Patients should be aware of your terms and conditions for medical billing and collection. They won't be surprised if a bill arrives and they don't know what to do. Transparency in billing can help reduce the stress for both your staff and your patients. You can also help your patients by keeping all their current information on file, so that claims are correctly submitted and not denied.
5. Accept multiple payment methods
You can increase your chances of getting balances collected at check-in by offering multiple payment options, such as cash, credit/debit cards, and checks. A convenient and simple-to-use online payment system can be included in your patient portal. This will facilitate patient payments.
6. Provide payment plans and keep track of them
Establish payment plans to help with larger balances. Train staff how to explain and track these options. Your practice will increase its collections by offering flexible payment options. Patients will feel more secure knowing that they can afford the treatment they require.
7. Monitor unpaid accounts
To maximize collections, persistence is the key. Create a plan to contact patients who have not paid on time and a protocol for staff. Your staff should be able to request payment in full, discuss payment options and offer a plan of payment if necessary. You should track accounts at all stages of your revenue cycle. Also, pay attention to unpaid accounts. These accounts can often lead to problems or unresolved billing. A tracking system should be in place to track every account's status. It can tag any status as unpaid, pending or paid. You can also manage tricky accounts by keeping a list of problem accounts that you check on regularly.
8. Learn how to bill Medicare or Medicaid and how to train your staff regularly
Every week brings new medical billing issues. It is important to keep your staff trained and current on how to bill Medicare, Medicaid, and your insurance partners. It will save you time and money on corrections and resubmissions. It is easy to improve your medical billing process by hiring professionals to visit your practice and learn about your accounts receivables and then implement a better billing strategy. The most trivial part of having a new year’s resolution is it may only happen for three months after the new year itself. Many people fail because they lack consistency and motivation to push through. Remember, when you start something, always make sure to finish it.
6 tips to improve collections and cash flow at your medical practice. Greenway Health. (2020, June 22). Retrieved November 28, 2022, from https://www.greenwayhealth.com/knowledge-center/greenway-blog/6-tips-improve-collections-and-cash-flow-your-medical-practice
Marketing, P. (2021, April 26). 4 ways to improve your medical billing process - frost-Arnett. Frost. Retrieved November 23, 2022, from https://www.frost-arnett.com/4-ways-to-improve-your-medical-billing-process/
Regulation Changes for Billing in 2023
Regulatory compliance helps you protect your business's resources and reputation. Building trust with prospects, customers, and vendors takes time. A large part of that depends on your ethical conduct. Compliance is the foundation upon which your company's reputation can be built. For those who work in the midwifery industry, the sheer number of regulations that regulate maternity care can be overwhelming. Nearly every aspect of this is monitored by one or more regulatory bodies. Some midwives feel they spend more time following rules than actually performing the work.
Billing is a complicated part of your midwifery practice because its system is designed to allow for payment by insurance companies or government programs like Medicare and Medicaid. These payers require that bills be submitted using specific diagnosis, treatment, and supply codes. Otherwise, the bills will not get paid. That is why you need to be aware of any changes in billing regulations, regardless of whether you bill for your own practice or hire someone. New billing regulations have been published since the end of the year. These are the new billing regulations that every customer and biller must know about for 2023.
The existing 2021 guidelines implemented by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) allow healthcare providers to document E/M visits based on medical decision-making (MDM) or total time. This was a major departure from the previous guidelines that required them to address three elements in the patient’s progress notes: patient history, physical exam and medical decision making for code selection). The new E/M guidelines for 2023 build on the flexibilities of the 2021 office/outpatient E/M coding and documentation rules.
2023 E/M Code Updates Reduce Documentation Burden
The goal of the updated guidelines for coding and documenting E/M services is to make coding and documenting E/M services easier for medical practices and other facilities.
The final CY 2023 PFS conversion factor is $33.06, a 4.48 percent decrease from CY 2022 and slightly higher than proposed. This decline is due to a statutorily required budget neutrality adjustment, an expiring temporary adjustment to mitigate the impact of previous coding changes and a zero percent update factor.
CMS finalized several significant payment policy changes, including revaluing remaining evaluation and management codes, continuing its four-year phase-in of clinical labor pricing updates, and delaying changes to redefine the substantive portion of a split/shared visit by time only until 2024.
CMS issues 2023 Medicare physician fee schedule final rule: Insights. Holland & Knight. (n.d.). Retrieved November 28, 2022, from https://www.hklaw.com/en/insights/publications/2022/11/cms-issues-2023-medicare-physician-fee-schedule-final-rule
What are the latest medical billing and coding changes in 2022? Outsource Strategies International. (2022, November 7). Retrieved November 28, 2022, from https://www.outsourcestrategies.com/blog/what-are-latest-medical-billing-and-coding-changes-in-2022/
A private midwifery practice 's success is not determined only by the quality of patients care, but it also includes your financial stability. However, they often have little or no experience in handling the financial aspects of a business. But finances are something that cannot be ignored. Many practices have fallen prey to financial ruin. One reason is that health care professionals often write off patient debts out of compassion. It is important to understand that deductibles may be deemed insurance fraud if they are not written off.
Private midwifery practices are no different. Every midwife depends on stable revenue sources. In the past, there was no such thing as a steady revenue source. Revenue from your midwifery practice mostly relies on cash flow and insurance reimbursements. This revenue responsibility shifts more towards consumers. Midwives choose to write off more 75% patient balances. This can have a severe impact on practice income. You can increase your practice's revenue by making sure your balances are clear of any overdue bills and by not writing off any deductibles or out-of-pocket expenses.
How can your practice address patient balance collection issues?
Importance of timely collection of patient balances on practice financials. Practolytics. (2022, January 27). Retrieved November 29, 2022, from https://practolytics.com/blog/importance-of-timely-collection-of-patient-balances/
s a midwifery practice owner, you must decide whether or not you'll accept insurance for healthcare or if you would like that your service be cash-based which means that the client pays on their own and at a predetermined fee for each appointment. There are advantages and disadvantages to accepting both forms of payment therefore your final decision will depend on the goals you have to achieve for the practice. There is no law which says that if you start with healthcare insurance, it is not possible to switch to cash-based services later on. date.
Most hospital-based midwifery services accept insurance. Nearly half of birth center practice accepts insurance. A smaller percentage of home birth clinics provide insurance processing. Families usually have to provide an insurance coverage with an itemized bills of service for reimbursement directly if out of network benefits are available.
Insurance plans with fewer benefits do not have out-of-network benefits, and being part of the network typically requires some type of malpractice insurance. Smaller midwifery practices may not be able to manage the monthly payments needed for that protection. The more extensive your practice or is expected to become more likely that to be insured and billing for services be essential to ensure that your business is profitable.
The choice between cash payment and billing insurance policies has numerous pros and cons every midwife should consider. Billing insurance plans do not just ensure that midwives receive the right amount of money, it also leaves a variety of benefits to the healthcare industry.
Functions of Healthcare Insurance and why Midwives Should opt to Billing Insurance Plans
In 2017, the average insurance premium for US families with employer-sponsored health insurance cost $18 764, an increase of 3% over the previous year. What this mean value hides, however, is the enormous variance in the amount of health care received by different people in the United States.
That variance is reflected in huge disparities in health care spending. In 2016, the top 5% of US health spenders accounted for 50% of total spending, or about $50 000 per person. The bottom half of the population, based on health expenditures, accounted for only 3% of total health spending, or $276 per person in 2016. People in both groups buy health insurance, but the benefits they gain from doing so are different.
In addition to helping people stay healthy and improving their health when they get sick, our system of health insurance serves at least several functions to enable everyone to benefit from being insured. These functions, however, are not always compatible.
Some of the benefits of outsourced medical billing include:
There is no certain reason for you to choose between choosing cash payments or billing insurance policies for your practice than knowing what you truly need. You need to look at your specific mission, goals, area, and services wanting to provide to the community. Typically, care is a hybrid between insurance reimbursement and cash discount prepayment models of payment. It will give families choices that can fit a family that doesn’t have good and poor health insurance coverage.
Midwiferybusinessconsultation. (2020, December 11). Cash versus billing insurance for midwifery care? MIDWIFERY BUSINESS CONSULTATION. Retrieved September 30, 2022, from https://midwiferybusinessconsultation.com/cash-versus-billing-insurance-for-midwifery-care-2/
Hoffman, A. (2022, March 8). 6 proactive medical billing tips to maximize revenue: HAP. Healthcare Administrative Partners. Retrieved September 30, 2022, from https://www.hapusa.com/6-proactive-medical-billing-tips
Pranammya Dey, B. S. (2019, April 2). The 6 functions of health insurance. JAMA. Retrieved September 30, 2022, from https://jamanetwork.com/journals/jama/fullarticle/2729357
When we talk about matters pertaining to your client’s insurance, you have probably heard the terms “in-network” and “out-of-network” care thrown around quite a bit by different healthcare provider including midwives. But what do these terms actually mean, and more importantly what do they mean for you as a midwife? How will these affect your practice and you be able to apply these terms to your midwifery practice?
What does in-network mean?
In-network refers to a midwives that has direct contract with the health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, clients pay a lower cost-sharing when they receive services from an in-network midwife.
What does out-of-network mean?
Out-of-network refers to midwives who does not have a contract with the health insurance plan. If a client use an out-of-network provider, health care services could cost more since midwives don’t have a pre-negotiated rate with the client’s health plan. Or, depending on the health plan, the health care services may not be covered at all.
Depending on the coverage the client have purchased, the plan has established deals with a wide range of midwives and other specialists. These are the health care providers that the insurance company considers in your client’s “network.” The insurer has identified a group of providers who are “in-network” and has contracted with these providers on the client’s behalf to get services at “discounted” rates. The primary advantage of using an in-network provider is that your client receive this negotiated or discounted rate for your services, and the insurance provider generally picks up a larger portion of the bill than with an out-of-network provider.
This means that as a midwife, once you’re in an agreement with the insurance company to accept your client’s plans and contracted rate as payment for your full services. This contracted rate that was negotiated by your client and its insurance company includes both the insurer’s share of the cost, and the part that your client will be responsible for paying. The part that your client’s responsibility for paying may be in the form of a co-payment, co-insurance or deductible depending on their negotiation.
Simply speaking, as a midwife, when you accepts your client’s health insurance plan we say you’re in network. You will also be called as “participating providers”. When you don’t take your client’s plan, we say you’re out of network. The two main differences between them are cost and whether the plan helps you receive enough value for the care you provide as out-of-network provider.
Healthcare is an important aspect aspects of our daily lives. As a healthcare provider, we are expected to give the best services to our clients and in order for our practice to keep on growing we must receive proper compensation out of that service. Remind your clients that they can avoid unexpected medical bills by knowing how their plan works. Certain choices they make can affect what they'll pay out-of-pocket. Know the difference between in-network and out-of-network care to help them save on health care expenses.
Outreach & Education. CMS.gov Centers for Medicare & Medicaid Services Health Insurance. (n.d.). Retrieved May 13, 2022, from https://marketplace.cms.gov/outreach-and-education
Accurate diagnosis can have a significant impact on the midwifery practice's claim for billing. It is evident to us that coding and billing are among the most crucial elements in every midwifery clinic. The accuracy within each of them is essential to ensure the safety of patients, quick payments and effective operations.
Historically speaking midwives, other health care providers and payers were on the same page' with regard to fee-for-service reimbursements. Midwives performed a task and the they earned the payment. Simple and straightforward. However, with reforms in healthcare is the requirement for health care professionals to be precise and thorough in the diagnosis codes they use. The shift to pay-for-performance (P4P) programs, originally initiated by the CMS, but increasingly adopted by private payers, demands this accuracy. Along with offering incentives to Midwives for providing quality care, there are now penalties for midwives and other health care professionals who may not be offering patient care of acceptable quality. With this reform, accurate diagnosis became a top priority in order for midwives to claim bills accurately, here’s the reasons why.
Accuracy Was Always an Issue
While accurately recording diagnosis codes has always been important, until P4P programs, many payers accepted marginally thorough supporting information to approve claims and pay providers. The new emphasis on claims clarity often proves to be challenging for midwives and billing staff, particularly for those providers not in the habit of submitting fully documented reimbursement claims.
In the past, claims with faulty diagnosis codes typically were denied. Yet, some insufficiently explained claim submissions slipped through and were approved. If payer claim reviewers were hurried into claim examinations, it was always possible that some submissions that could have had payers ‘scratching their heads’ were approved.
However, most of the diagnosis coding rules have changed. Accuracy, always a factor, has become the primary component of claims approval. Along with approved/rejected decisions, medical providers now face quality care issues, requiring further justification and explanation to eliminate payer confusion.
Proper Diagnosis Critical for Payment
Some midwives and billing personnel seem forgetful that Medicare Advantage plans pay, in part, as a function of the number and severity of sickness in the total population of patients. CMS calculates variable per month payments based on the levels of the ‘sick’ population. Some private payers are endorsing this approach, demanding that physician diagnosis coding ‘fits’ the matrix.
While some midwives during the fee-for-service era always went the extra mile to fully explain their diagnostic coding and process, many other providers, often because of billing staff time constraints, neglected to thoroughly document their diagnosis procedures. However, providers now risk facing claim denials with P4P programs if payer review staff is unsure that the doctor performed diagnostic services that were necessary to design a treatment plan.
Accurate and thorough coding for chronic conditions is another prime area of payer scrutiny. ICD-9 guidelines require providers to use these codes ‘as often as applicable’ when treating chronic conditions. P4P quality care evaluation depends on proper use of these codes. The penalty consequences of taking coding ‘shortcuts’ can result in lower income for the midwife.
These are some of the reasons that using accurate diagnosis codes are critical for maximum claim approvals and CMS decisions that physician care qualifies as meeting quality guidelines. The strong focus on procedural diagnostic coding accuracy is here—possibly affecting your compliance and income levels.
Accurate diagnosis coding, backed up by thorough documentation regarding the necessity of diagnostic procedures, is no longer a payer ‘luxury.’ Accuracy and clarity are now a necessity for all physicians. Achieving this result typically demands some combination of the following actions.
Midwives and other healthcare practices using these tips should remain in HIPAA, CMS and P4P compliance, maintain or increase revenue and create evidence of delivering quality care to all patients. Properly using diagnosis codes and supporting your diagnostic procedures with valid documentation will achieve these results.
Diagnosis coding has taken center stage in medical billing. Coronis. (n.d.). Retrieved September 29, 2022, from https://www.coronishealth.com/blog/diagnosis-coding-has-taken-center-stage-in-medical-billing/
Ways To Prevent Insurance Fraud
Insurance fraud is any act made to deceive an insurance procedure. It occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that is due. It is also a deliberate deception perpetrated against or by an insurance company or agent for the purpose of financial gain. Fraud may be committed at different points by applicants, policyholders, third-party claimants, or professionals who provide services to claimants. Insurance agents and company employees may also commit insurance fraud. Common frauds include “padding,” or inflating claims; misrepresenting facts on an insurance application; submitting claims for injuries or damage that never occurred; and staging accidents.
People who commit insurance fraud include:
Inside the healthcare industry lies good opportunity for insurance fraud as well. Insurance fraud causes tens of billions of dollars in losses each year. It can raise health insurance premiums, expose you to unnecessary medical procedures, and increase taxes. If you’re in the healthcare industry, you must learn to identify what are the common types of healthcare and insurance fraud.
Common types of healthcare and insurance fraud:
1. Fraud Committed by Medical Providers
How to Prevent Insurance Fraud?
The Affordable Care Act of 2010 included fraud-fighting efforts, such as allowing the U.S. Department of Health and Human Services (HHS) to exclude providers who lie on their applications from enrolling in Medicare and Medicaid and the Improper Payments Elimination and Recovery Act, which requires agencies to conduct recovery audits for programs every three years and develop corrective action plans for preventing future fraud and waste.
Other efforts included:
Additionally, in 2012, HHS and the Department of Justice formed the National Fraud Prevention Partnership to combat health care fraud. The group also consists of private and public groups such as health care companies and their organizations, the National Association of Insurance Commissioners, the National Insurance Crime Bureau and the National Health Care Anti-Fraud Association. The groups will share information on claims from Medicare, Medicaid. and private insurance to be administered by a third-
Fraudulent acts have no escape with the law. Whether you’re a healthcare provider trying to slip away money from your clients, or a client who doesn’t one to compensate the services provided to you. Either way, one must be vigilant enough to take part in protecting his/her right and preventing these things to happen. Keep all your records intact and avoid providing your information to anyone asking for it. Always verify, verify, verify!
Background on: Insurance fraud. III. (n.d.). Retrieved June 18, 2022, from https://www.iii.org/article/background-on-insurance-fraud
Through the years, the field of midwifery as a profession has been the subject of a variety of misconceptions that can go as far as the idea of comparing midwives to quacks. Even today, the job of a midwife can be misinterpreted as simply helping births. Often times, midwives experience misconception about the true quality of service they provide, as it is not only vital for all women and newborns to access care – it is critical that this care is of a sufficient quality to provide a safe and positive childbirth experience, and that it is provided with respect and dignity.
Midwives should be recognized for the excellent the services they provide. It's not a flimsy hoax. There are a few reasons to believe it;
Ways To Increase Awareness
Midwifery is proficient, educated, and compassionate care for childbearing women, newborn babies, and families throughout the pre-pregnancy, pregnancy, childbirth, postpartum, and the early weeks of life. Indeed, midwives are valuable sector of the society and that they need to receive the recognition they deserve.
Barker, J. (2021, February 13). Midwives do not get the recognition they deserve! Blog About Midwives & Doulas. Retrieved September 30, 2022, from https://www.fruitfulwombs.com/midwives-do-not-get-the-recognition-they-deserve/#:~:text=The%20Pros%20For%20Midwifery%3A&text=Quality%20midwifery%20care%20is%20essential,interchangeable%20with%20women%2Dcentered%20care.