V BILLINGS V BILLINGS

https://www.youtube.com/watch?v=m175PzSmpe8



Claim denied for missing/invalid REFERRAL :(BLOCK 23)

RENDERING PROVIDER:

A provider who provides actual service.

REFERRING PROVIDER/Primary Care Physician/ Family Doctor:

A provider who provides initial service.

² Questions to probe with Payer Rep:

²Claim received date?

²Claim denied date?

²Check system for referral is available or not if found give that to rep and reprocess

²Check claim image if referral# found in Block#23 give that to rep for reprocess

²If referral# not found in anyway, ask rep what is PCP (primary care physician) name and PCP phone# and get the corrected claim address and time filing limit

²Claim# and Call reference#

²Thank you.

²

***Note:

PPO & EPO plan doesn't require a referral, if the patient plan is PPO & EPO ask the rep to reprocess.

https://www.youtube.com/watch?v=nKY3LAITtvs&list=PL5RwhjoJ5VJNVVzWNpzi7NDalFv01pW7K&index=3

REFERRAL_MOCK_CALL|US PAYER REP & AR CALLER |MEDICAL BILLING TRAINING



Claim denied for missing/invalid REFERRAL :(BLOCK 23)

RENDERING PROVIDER:

A provider who provides actual service.



REFERRING PROVIDER/Primary Care Physician/ Family Doctor:

A provider who provides initial service.

² Questions to probe with Payer Rep:

²Claim received date?

²Claim denied date?

²Check system for referral is available or not if found give that to rep and reprocess

²Check claim image if referral# found in Block#23 give that to rep for reprocess

²If referral# not found in anyway, ask rep what is PCP (primary care physician) name and PCP phone# and get the corrected claim address and time filing limit

²Claim# and Call reference#

²Thank you.

²

***Note:

PPO & EPO plan doesn't require a referral, if the patient plan is PPO & EPO ask the rep to reprocess.

https://www.youtube.com/watch?v=NYXI_sRfX9o

HMO: Health maintenance organization: Budget-friendly plan.

It is one of the cheapest types of health insurance. It has low premiums and the deductible and fixed copay for doctor visits.

HMO is an individual plan.

In this policy, a PCP (Primary Care Physician) will be allocated.

HMO requires referral# from PCP when patient referred to get treated by a Specialist.

It covers only In-Network benefits, Out of network benefits not available.



POS: Point-of-Service: Hybrid of HMO and PPO

POS is one of the cheapest types of health insurance. It has low premiums and the deductible and fixed copay for doctor visits.

POS is an individual plan.

PCP (Primary Care Physician) will be allocated in POS,

Requires referral from PCP when patient referred to a Specialist.

Both In-Network benefits and Out of network benefits available.



PPO: Preferred Provider Organization: A high premium plan but fewer patient responsibilities.

PPO is one of the costliest types of health insurance. It has higher premiums than HMO and POS plan type. Copay and Coinsurance for in-network doctors are low.

PPO is a group policy.

PCP (Primary Care Physician) and Referral not needed.

A patient can directly meet Specialist

Both In-Network benefits and Out of network benefits available.



EPO: Exclusive Provider Organization: Lower monthly premiums but a higher deductible

If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan.

EPO is a group plan

PCP (Primary Care Physician) and Referral not needed.

A patient can directly meet Specialist

It covers only In-Network benefits. Out of network benefits not available.

https://www.youtube.com/watch?v=TyulTmrC5bY&t=381s



The wait is over, after many struggles, office works, and personal issues, I spent much time on this, yes our ebook for AR CALLER MEDICAL BILLING has been completed. I have launched it on amazon kindle for rs 350. You can read it for free if you have kindle account if not you have to purchase it for rs 350.00, but for our subscriber, I can send thru WhatsApp for just rs 200 so anybody wants it just pay Rs.200.00 thru google pay, phone pay or pay by UPI ID. 

Once paid take a screenshot and send that to my WhatsApp and I will send you the copy once I verified it.  

Google pay, phone pay = 9080556859  

UPI ID : = 9080556859@kotak 

Paytm: 9080556859@paytm  

Bank details: 

Kotak Mahindra 

Name Vijayakumar Munusamy 

Bank account# 5445416980 

IFSC: KKBK0000471 

MICR# 600485009 

Branch Madippakkam



Insurance payment to provider methods: Fee-for-service,  Capitation, Salary

Fee-for-service is a system of health insurance payment in which a doctor or other health care provider is paid a fee for each particular service rendered. The more services he does the more revenue. Financial risk-free tradition payment method.  

Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. When the provider signs a capitation agreement, a list of specific services that must be provided to patients is included in the contract.

youtube: https://www.youtube.com/watch?v=IE-joQ4dUb8



Centers for Medicare & Medicaid Services:

The Centers for Medicare & Medicaid Services (CMS) is the agency within the U.S. Department of Health and Human Services (HHS) that administers the nation's major healthcare programs.

1.PATIENT(Insurer/subscriber/dependent/policyholder)

The person who gets medical services from the provider.

Other names Insurer/subscriber/dependent/policy holder



2.PROVIDER(Doctors, physicians, surgeons, technicians, hospitals, clinics, laboratories)

The individual or an organization that provides medical services to the patient

Other names Doctors, physicians, surgeons, technicians, hospitals, clinics, laboratories



3.PAYER(Insurance company)

The individual or an organization that process the claim and pays the provider for 

the medical services are given to the patient.