Emergency Room Physician Billing Services
Physician Medical Billing Services
Emergency Room Physician Billing Services
ER is a specialty with unique challenges when it comes to practice operations, billing, coding, staffing, efficiency and cash flow. Emergency room billing challenges are many and complicated as the patients are admitted quickly with no insurance information or without proper insurance information. As per Federal law, especially the Emergency Medical Treatment and Labor Act (EMTALA) mandate that ER doctors provide emergency care regardless of the patient’s insurance status.
Critical Billing Challenges
The most challenging part of Emergency Room Physician Medical billing is getting maximum reimbursement from insurance companies which is a challenge due to the below reasons:
1.OON Billing
Many insurance plans avoid contracting with ER (Emergency Room) doctors and pay whatever benefits they want to pay which increases the out-of-pocket costs for patients and provider responsibility to collect the balance from the patient.
2. High Patient responsibility
Apart from Deductible, Coinsurance provider also needs to verify the patient’s Out-of-Pocket Limit
3. Payment agreement Proposals
Commercial insurances like UHC, Aetna, Cigna etc. try to reduce their reimbursement and also patient liability by negotiating payment agreements (prompt payment proposals) and sometimes they use third party pricing companies like Multiplan, Data iSight for the purpose. There is always a discount amount which will be a loss to the provider. The catch is that the provider gets paid lesser than the agreed amount many times, due to patient responsibility like coinsurance and deductible. The payment agreements need to be returned within a short span of time to the insurance or pricing company Provider needs to clearly verify and ascertain the patient responsibility amount before agreeing on a payment agreement or they may end up losing money.
4. Paid at in-network rate (lesser rate)
Provider need to call the carrier to reprocess the claim under out of network rate but when the insurance refuses to reprocess and make additional payment, then provider will need to have the patient call their carrier to reprocess the claim(s) out-of-network.
5. Paid to Patient
For OON providers, claims get processed to the patient, need to call the patient to inform that they will be receiving or should have a received a check/payment from the insurance which is supposed to come to the provider. Also request the patient to endorse the check to the provider.
6. Coding the correct level of Service
The health plan’s claims processing system will use a coding algorithm strategy to automatically adjudicate emergency department claims based on the applicable ED claim category in accordance with the diagnosis code appearing on the claim. If the diagnosis code classification falls into a categorization indicating a lower level of complexity or severity, the claim will be paid at the Level 3 emergency department reimbursement level.
7. Prudent Layperson rule
The Prudent Layperson Standard requires health insurance companies to cover visits based on the patient’s symptoms, not the final diagnosis. This means if a patient has chest pain, but turns out to have a non-urgent medical condition, such as a hiatal hernia, the insurance company must still cover the visit. EMTALA mandates the evaluation and stabilization of all patients who present to the emergency department, and the prudent layperson standard gives patients the protection to seek emergency care and provides hospitals and emergency physicians the assurance of payment for those services.
e-care’s revenue cycle management solutions for ER physicians provide excellent coding and billing services from our experience of many years in Emergency Room physician billing which are compliant services with all the federal and state regulations. We understand all the nuances of Emergency Room billing and maximize the reimbursement of the physicians using efficient billing methodologies.