Best Practice Guidelines: Healthcare Practice Management

8. Billing

Responsible Roles

Do billing and switching whilst treating the patient, or provide clear, readable and correct descriptions or ICD10 codes to the Billing Expert to avoid rejections. Timely communication and billing will ensure that patients don’t leave the practice after switch rejections due to for example insufficient funds. Keep record of procedures and all medicine and materials.

Design and check the process to get files and/or billing notes from the Practitioner to the Billing Expert and check that all billing is daily up to date.


The Billing Expert needs to have advanced knowledge of the speciality’s billing codes and rules to ensure accurate and optimal billing. Ensure all medical aid billing is switched / sent to the medical aids and make sure all corrections are done. All billing must be done on a daily basis to ensure correct figures and healthy cash flow. Private patient billing must preferably be done before the patient leaves the practice so that the need for debt collection is limited.


Check that all billing and corrections were done and all medical aid claims and corrections were submitted. Ensure that all outstanding invoices are sent as soon as possible to patients.
  Go through all the stock that was billed and check that it is correct and everything that was taken has been billed. Ensure all stock that was used on patients and is not going to be charged, that the items are marked as non-chargeable and have been indicated that the items were used on the patient or on the patient’s account or as a non-chargeable account. Check that the correct item, strength and pack size were used with the billing. Confirm that the cost of sales has been calculated and are correct. Ensure there are stock to be billed and all supplier invoices are up to date.

Ensure that billing was done correctly and balances with the Audit Trail. Ensure that VAT calculations are correct.


Purpose of Billing

Billing is equal to Income (money). Billing is the only way to generate income for the procedures that were done or stock that was used or sold. Billing ensures that timely, accurate and complete accounts are submitted to medical aids or issued to private patients.


Optimisation of turnover in your practice

Turnover = Invoices - Credit notes.

There are some keys to making sure that you optimise your turnover in your practice. They are as follows:

KEY 1:

Ensure that ALL visits of patients have been billed.

  1. If you make use of the Desktop App diary, you can print the "Print days list invoices" at the end of the day. This report will help you to check if all visits were actually billed (remember there has to be at least one invoice per visit).
  2. If you make use of the Web App diary, check at the end of every day that all the bookings’ invoice icons are green. This indicates that invoices were completed and posted.
  3. If you bill from a list you must use the episode screen in the Desktop App to capture the template numbers of invoices received from the client so that you ensure that all documents are billed. In the Web App you must use the diary as a worklist (stack view) and ensure all the worklist items’ invoice icons are green.
  4. If you bill from an integrated system, eg pathologists use integrations between GoodX and pathology systems, you should check that all items billed in the integrated system are also billed in GoodX.

KEY 2:

Understand the price structure and contracts of the medical aids. You can optimise your billing by using the correct price lists and contracts. Understand a PMB ICD10 in order to optimise emergency cases that entitle you to bill higher fees. Ensure that all rules that are applicable to your speciality are adhered to. SAMA provides billing courses to teach the rules per speciality.

KEY 3:

Make sure that you bill all the relevant codes that are allowed for a procedure to optimise your invoice (sometimes there are multiple codes per procedure). Ensure the correct modifiers are used in the correct order.

KEY 4:

Make sure that you import the relevant data from the medical aid to ensure accuracy when you switch. Validations are important at each visit. The benefit check assists the practice in making sure there are enough funds available (only available from a few medical aids).

KEY 5:

Follow up immediately on rejected claims to correct and resend claims. Draw all relevant reports to make sure that all claims have been successfully processed. The 4 R’s are important to apply: Reverse, Redo, Resend and Resolve.


Critical Steps of Billing

Understand your Medical Codes & Rules

Medical practitioners do not only have to diagnose and treat their patients, but they also have to spend large amounts of time managing the financial information related to the dispensing of medical supplies, use of equipment and calculating the rates for different medical procedures. The range of medical procedures and routines that take place in the medical industry are extensive and the result is that the billing process can become quite complicated if you do not have an understanding of how codes and modifiers are used when issuing invoices.

What are codes and why do they exist?

Medical codes are essentially used to describe and categorise the types of services rendered or medicines used to treat patients and to calculate their invoices. When claims are submitted to medical aids, the codes and descriptions are used as references to validate fees and payments. Most codes consist of a code, description and an amount that is allowed to be charged for the different specialities.

What are modifiers?

Modifiers are codes that are used by certain medical practitioners in conjunction with their normal codes to modify or change the rate at which they charge patients during a consultation or procedures. For example, a practitioner may perform more than one procedure during a consultation and use a modifier to adjust the second procedure’s amount. GoodX has built-in functionality to help you configure and manage these modifiers. Incorrect use of modifiers is considered fraud or non-compliance, and can result in further audits and revenue loss.

Types of modifiers:

a. Addition modifier

A modifier that adds value, by using a percentage value or a unit value, to a procedure code. This modifier should be added to a separate line with its own value.

b. Compound modifier

Modifiers that must be posted on a separate line with its own value but must also be indicated on each procedure code's line where it is applied.

c. Information modifier

A modifier that serves to add additional information to procedure codes and has no financial value. This must be added to the same line as the procedure.

d. Reduction modifier

A modifier that reduces the value, by using a percentage value or a unit value, of a procedure code. This modifier should be added to the same line as the procedure code.

How are codes and modifiers controlled and managed?

The range of medical services that are possible in the modern world has resulted in a wide range of codes and modifiers, each with a possible range of prices and charge types. Codes are analysed and developed by the South African Medical Association (SAMA) and can be found in the SAMA book.

The codes are developed in conjunction with a range of professional bodies and given to the Medical Schemes Council for review, publication and distribution. There are two types of codes:

  1. RPL (Reference Price List)
  2. CCSA (Complete CPT for South Africa) and is only used by surgeons. 

Medical code categories:

The following medical code categories are available:

  • Consultation Services
  • Clinical Procedures
  • Materials
  • Medicines
  • Modifiers
  • Other kinds of services

Confirm Contracts with Medical Aid

  • Each Speciality can negotiate with the different medical aids to sign a specific contract with special prices on the Tariff codes. When a contract is signed only that tariffs are allowed to be charged by the practice for their patients. This is not the same as just registering at the Medical aids.
  • Ensure that all contracts signed with the medical aids, by the medical practice, are loaded in GoodX.
  • This ensures that the maximum amounts can be claimed from the medical aids, therefore, optimising the medical practice turnover.


Billing Screens in Desktop App and Web App

The billing screen will be used to indicate the consultation, procedures and any medication or materials that were done or used on the patient, and will be added to the patient account when posted. Some key points that may differ in the different apps:

Invoice Screen (Web App)

  • Generic Medication with prices are available, when the medical aid only pays for Generic medication OR when the medication comes out of the patient’s savings, generic medication can be used
  • Integration with MIMS
  • Multiple appointments - this feature can be used to link multiple appointments to one booking. For example, if a parent brings their child in for a consultation and they also consult the practitioner about a specific condition that they may have, then the practitioner needs to create an invoice for them as well as a separate one for the child.

Periodontal Chart (Web App)

  • The Periodontal Chart is a graphical tool/function for organising all the important information about the Patient's teeth and gums (Plaque, Bleeding, Furcation Lesion, Pocket depths, Mobility, Calculus, Recession) when the Doctor does the Billing after or during the Appointment.
  • Voice command is available for the billing in the Periodontal screen.
  • Treatment plans can be created to assist the practitioner
  • Different pictures for each procedure will indicate on the tooth graphics 

Multi-Invoice capturing (Desktop App)

  • New episode screen will allow the user to invoice the same patient but for different service dates.
  • Repeat code and repeat treatment will allow the user to take one code or all the codes and repeat them over multiple service dates.
  • Invoice analysis will display how the account will post as medical aid or patient liable before the invoice gets posted and indicate the price with the mark-up/ SEP rules that will be applied on the patient stock items.
  • This screen does not allow you to choose the period in which you want to work. Depending if the practice is on a month end system or a non month end system, the invoice will post in the correct period.
    • Month End: The multi-invoice capturing screen will first check the service date, if the period of the service date is open, the transaction will post in that period. If the Service date, if the period is closed the invoice will post in the first open period, so make 100% sure the month end is done.
    • NON Month End (All periods are open): The multi-invoice screen will select the same period as the chosen service date.

Simple Dental Invoice Screen (Desktop App)

  • All Dentists, Oral Hygienist, Orthodontist and some other specialities will use the Dental Invoice screen. The dental screen will allow the user to see and use the dental chart for the patient.
  • There is also an extra field to specify the applicable tooth numbers.


Confirm File Details
  • Confirm the Main Member and Dependant details is correct
  • Validations are important to ensure the correct details has been captured and the Patient is an active member on the Medical Aid
  • Make sure all information are up to date.


Load ICD10s / Codes / Modifiers / Assistants 

  • Load the correct ICD10 codes by using our advanced ICD10 search screen or add multiple codes.
  • Load the correct procedure or consultation codes.
  • Make sure the right modifiers are loaded.
  • Please ensure that your assistant doctor is preloaded in GoodX and linked to a creditor and expense account.


Estimates

  • An Estimate is a quotation that is created for a patient to give them an indication of how much a treatment or procedure will cost.
  • The quotation or estimate can be used to get authorisation from the medical aid or for private patients to have an idea of how much they will have to pay for the treatment or procedure.
  • The estimate will be saved for when the patient accepts the quotation. The quotation can be used to bill the patient, remove any lines or add some more lines. 
  • A quotation can be emailed or printed.
  • The practice must decide on how long a quotation is valid for. 


Combinations / Macros / Protocols

  • Combinations are used as a tool to capture commonly used procedures. Before the combination can be used, it needs to be set up in your system. It will reduce the time you spend on billing, reduce errors and prevents you forgetting any procedure codes
  • A combination is also known as a Macro, Basket or Protocol.
  • This is a set of stock, procedures and/or consultations that are always used for a specific treatment.
  • The combination is set up for a treatment with the necessary items and procedure codes.
  • There are 2 types of combinations:
    • Fixed combination: A Fix combination does not have variances in the combination and all the procedures or stock will always be used, with the same quantity. For example a Flu injection.
    • Choose combination: A list of possible items, procedure codes and quantity can be created and when that combinations are chosen the correct items on that list can be chosen before the combination is put on the billing screen. For example a sutures procedure. There can be 3 different sizes of sutures and the correct ones that were used can be chosen, with all the other standard items.

Send/EDI Claims

  • GoodX provides Practice Management Software and Switching which is integrated directly into GoodX Software. This means you can manage everything from GoodX Software.
  • GoodX Switch allows you to submit claims directly and real-time into all major Medical Aid Computer Systems and to receive proof of submission and delivery of claims directly into GoodX.
  • Send claim is used for the GoodX Switch to deliver the invoice to the medical aid for payment.
  • The invoice is sent to the medical aid in an electronic format with all the necessary information of the claim.
  • Most of the big Medical Aids can accept electronic claims, but there is still Medical aids that do not accept electronic claims, then the claim must be sent through with a paper claim.
  • The response must be checked immediately. 


Account Enquiries

  • The full billing and payment history of a debtor and his/or dependants can be seen on the account enquiry screen.
  • The account enquiry screen shows all outstanding amounts payable by the medical aid or debtor.
  • All debtor queries can be responded to from the account enquiry screen.
  • Statements draw their information from the account enquiry screen.


Add an Assistant (Specialists)

  • An Assistant is another treating Practitioner who assists the practitioner in treating the patient and must be paid for his time and services. 
  • The patient will have a code on the invoice to indicate that an assistant was used and that codes must also be paid.


Add an Assistant as Creditor (Specialists)

  • The assistant can be added in GoodX as a Creditor.
  • The system will automatically create an invoice for the assistant in the creditor as soon as the medical aid/patient pays the practice and the receipt is done on the patient account.
  • This process will allow the practice to ensure the correct amount is paid over to the assistant at the end of the month.


Episode Management in the Desktop App

The GoodX Episode Management option is available in the MedDebs Module. The function allows the business to do the following:

  1. The bureau can issue and book a series of numbered billing templates / template books for a medical practice, which will be logged on the system.
  2. As soon as the template books have been completed with billing codes by the medical practice and handed back to the bureau, the template book will be marked as received by the bureau.
  3. As soon as the received template book's billing is captured on the system, the template status will change to "Invoiced", which indicates that the billing instruction has been received and billed.
The result of this process is that the bureau has a full report of:
  1. the status of all templates issued to medical practices, warning the bureau of issued templates that are outstanding; and
  2. all instructions received by the bureau and if all have indeed been captured on the system.