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Medical Billing Diagram

In medicine, coding and billing utilize diagnosis codes, known as International Classification of Diseases (ICD) codes, and procedure codes, known as Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. ICD codes are gathered from patient symptoms documented during a medical visit and are used to demonstrate medical necessity for the corresponding procedure codes performed during the visit. An important point to note as it pertains to QSA Optimization is that different types of providers bill and are reimbursed at different Medicare rates. In other words, the same exact procedure can cost different amounts depending on where a patient chooses to have the procedure performed. Medical billing can get complicated, but let's look at the process in general and then explore some different reimbursement models that exist.

The Medical Billing Process

In general, this is what happens from the time a patient provides his or her insurance information for a medical visit to when the claim is fully closed by the provider's office.

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How Your Health Insurance Affects Billing

Insurers have slight variations in their billing rules; however, CMS sets the general rules that most insurance plans abide by. Here we'll look into a couple of the more significant regulations and how your choice of insurance carrier can affect medical billing.

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Medicare Reimbursement

Understanding Medicare reimbursement is extremely useful because, in general, reimbursement from private insurers is based in large part on the applicable Medicare reimbursement rates, so Medicare cost comparisons generally translate to private insurers as well. Medicare typically reimburses on a fee-for-service basis utilizing one of two methods: Fee Schedules or Prospective Payment Systems.

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Other Reimbursement Models

In addition to fee-for-service, which continues to be the dominant reimbursement model in the United States, other methods exist and new models are emerging as the healthcare industry attempts to deal with sky-rocketing medical costs. Here we'll look at capitated reimbursement models and accountable care organizations.

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Medical Billing Resources

Links and other resources to refer to for more information on medical billing.

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