What New Physicians Need to Know about Billing Insurance

By Emily O'Brien
MedPage Today

As a new physician, there’s a lot to keep track of. Add billing and coding for insurance claims on top of seeing patients, managing the practice’s workload, keeping electronic medical records up to date, and more. Fee-for-service reimbursements for healthcare are the primary way physicians receive payment for their work. For every patient seen and for each procedure performed, there is a diagnosis and CPT code that must be applied to a bill. 

Undercoding is an issue all doctors face, but it’s especially the case with newer physicians. Sometimes newer doctors want to err on the side of coding less to avoid mistakes, yet the reality is that many newer doctors over-document in the electronic health record system, easily meeting requirements for a higher level of service. Any in-office services, like an EKG or urine analysis, should be itemized.

Getting Established

When a new physician becomes part of a practice, insurance carriers need to be provided with their information. Most payers, with the exception of Medicare and Medicaid, provide an effective date for new billing to begin. Medicare pays claims retroactively from the date of the NPI application, but private payers don’t allow for retroactive billing. 

When a new physician begins practicing, it’s wise to anticipate delays. The application process should start as soon as the provider’s state licensure and DEA registration information are available. Ideally, this would occur at least two months ahead of the start date, especially for Medicare. 

Proper billing needs to be enabled for new and established patients. If a patient has already visited the practice but has seen a different physician, they are an established patient. A new patient would be one visiting the practice for the first time. 

Coding 101

New physicians need to know that evaluation and management (E/M) codes are the core of many practices. Physicians, nurse practitioners, and physician assistants can reduce stress and maximize payment by understanding how to properly document and code for services. While most patient visits require an E/M code, they may also need more codes added to properly bill for their visit. 

Each code will have a specific time range, so physicians should indicate the total time spent during the visit.

Good Faith Estimates – No Surprises Act

Good faith estimates have risen from the No Surprises Act, which passed in December 2021. It aims to protect patients from the financial impact of surprise medical billing, which restricts surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, or air ambulance services from out-of-network providers. 

Starting in January 2022, providers were required to begin offering good faith estimates to any uninsured or self-pay patient detailing costs of items or services. A patient is allowed to dispute to the Department of Health and Human Services for any bill that is $400 or more above the estimate.

In 2023, estimates will look slightly different, including information from any co-providers or facilities. The estimate will include any fees related to a surgery or procedure, prescription drug charges, or devices. 

A survey from The Medical Group Management Association (MGMA) shows us that physicians complying with good faith estimates of care reported an increased feeling of burden. Prior authorization tops the list of frustrations, but the good faith estimates are not far behind. MGMA reported 82 percent of practices say the estimated requirement increased administrative burden, and 74 percent don’t have the technical infrastructure ready to comply with the new 2023 requirements. 

The more a physician understands correct coding and billing practices for insurance plans, the better off the physician-patient relationships will be. Here’s why: If a patient understands upfront what their health insurance plan will and won’t cover for what’s billed during a visit, they will ultimately be happier and more comfortable paying their medical bills. Physicians who can’t adequately explain how their services are billed can have a negative impact on a patient’s visit. Patients want transparency and to know what they will be responsible for.