Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age [Hardcover]

Yuval Lirov (Author), Alison Cohen (Editor), Doug Cassel (Foreword)

Book Description

ISBN-10: 0979610133 | ISBN-13: 978-0979610134 | Publication Date: January 1, 2009 | Edition: 1

Is your practice profitable and compliant? Some state-managed insurance company audits have discovered up to 30% in mishandled and wrongly denied claims. This book shows private practitioners how to automate and enable such insurance claim payment audits in real time. You' will discover how to: • Improve your cash flow and reduce audit risk using Straight-Through Processing (STP) technologies • Design and implement industrial-grade network standards for continuous billing quality improvement and compliance maintenance • Reduce operations risk and improve your balance sheet using Software as a Service (SaaS) and outsourcing Understand the rules of the modern "payer-provider conflict" and learn to apply and manage winning Internet strategies, such as the "billing network effect." Gain further insight from guest chapters by Dennis Alessi, Esq., of Mandelbaum, Salsburg, Gold, Lazris & Discenza, PC; Eric Fishman, MD, of EHR Scope; Joe Kamelgard, MD, of Billing Integration, LLC; and Erum Raza, Esq, of Fox Rothschild, LLP.

Editorial Reviews

Review

A thorough, easy-to-reference guide to improving medical billing procedures and collections that will be of value to medical practices small and large.

Mathematician, inventor and CEO Lirov brings his broad range of knowledge and experience to the subject of medical billing. The company that he heads, Vericle, brings this technology to clients, but the book avoids frequent references to the enterprise and is clearly not an advertisement. Targeted toward those who are involved at any level with medical billing--including computer programmers, medical office or billing service workers, and physicians--the book addresses the problems that practices of all sizes face: how to simplify the payment process and maximize collections from clients and insurance companies. Lirov begins with an overview of the economics of health care today, comparing billing procedures and outcomes of the past with the strategies Vericle utilizes. He then explores the administrative aspects of medical offices, such as choosing the ideal billing system, computer-aided scheduling and problem tracking. The author also addresses metrics that are useful in determining efficacy of the chosen billing system--and what an office can learn from this study. Compliance with regulations including insurance claims and HIPAA is a large task for medical offices, and Lirov invited guest authors to detail their specific procedures. These authors contributed several chapters, covering topics such as physician "Super Groups," dictation versus electronic records and integration of electronic health records. Other topics of interest include outsourcing of billing and patient retention. This well-written guide contains easily referenced chapters, section headings and lists of key points, with each chapter concisely summarized and indexed. Consequently, all office workers will be able to understand the language and terminology. Further, charts and diagrams provide examples and illustrate key points.

An excellent manual for medical offices seeking to improve billing. --Kirkus Discoveries, February 5, 2009

From the Publisher

You want to heal the sick, but you waste your time fighting insurance companies and barely making ends meet in a conflict-ridden business environment. "Insurance companies have not only cut compensation rates, they have systematically developed elaborate and arcane systems that make medical billing so complicated that individual physicians cannot hope to confront the forces arrayed against them," says Dr. Doug Cassel, MD, Board Member and Compliance VP of Vericle, Inc., a medical billing network technology company.

Carriers are reducing reimbursement levels to participating providers, and they're engaging in guerrilla warfare in the claims/reimbursement process to further forestall and reduce what they pay physicians for their services.," adds Dennis Alessi, Esq, co-chairman of the Health Care Law Department at Mandelbaum and Salsburg, PC, and a contributor of a special chapter on Super Groups, a new profitable business model for physicians.

Lirov's new book, Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age, helps both owners of healthcare clinics and managers of medical billing service companies understand the rules of the modern "payer-provider conflict" so that they can improve billing and reduce audit risk. This book systematically approaches billing from the payer-provider conflict perspective and shows how to use the "network effect" to level the playing field. The network effect is the most revolutionary characteristic of Internet technology. In short, it's when the value of a networked service to a customer increases in step with the growing number of customers, and it's used by services like Google, eBay, Skype, Amazon, and MySpace.

"Some state-managed insurance company audits have discovered up to 30% in mishandled and wrongly denied claims," says Dr. Joseph Kamelgard, MD, FACS, founder of Lighter for Life, a surgical practice, a co-founder of Billing Integration Group, and a contributor of an invited chapter on building best-of-breed integrated information technology solutions. "This book shows private practitioners how to automate and enable such insurance claim payment audits in real time."

"This follow-up to Lirov's earlier book, Practicing Profitability - Billing Network Effect, expands its scope by bringing in more information relevant to a wider range of medical specialties," says Eric Fishman, MD, who practiced orthopedic surgery for over 20 years prior to creating EHR Scope, a quarterly publication that includes the largest compendium of EMR software, and who contributed a chapter that compares dictation with point-and-click user interface for electronic medical records. "The book covers practice workflow, reporting, outsourcing, patient scheduling, EMR, SOAP notes, billing, collections, HIPAA compliance, and audit risk management."

"The best and perhaps the most common way for the federal government to 'cut government spending' and 'maintain the viability of the healthcare industry' has been through actively enforcing federal antifraud compliance laws against physicians and other healthcare providers," says Erum Raza, Esq., an associate of Fox Rothschild, LLP, and a contributor of two invited chapters about how the federal False Claims Act (FCA) can be enforced against physicians for improper coding and billing, how investigations come about, and how physicians can avoid investigation of their medical practice and/or liability under the FCA.

"This book is a service to all of those who wish to understand the billing process--and those who wish to address their own billing issues," writes Dr. Cassel in the book's foreword. "Rather than surrender to the overpowering and relentless tactics of the insurance companies, Lirov, who holds patents in artificial intelligence and computer security, has designed a solution that matches the power, sophistication, and cost advantages of the insurance companies to finally give the advantage to the physician."

Medical Billing Networks and Processes spans forty four chapters and three hundred and twelve pages, and it contains informative illustrations, tables, and an extensive index. It's aimed at practice owners, owners of billing companies, practice managers, office management consultants, and billing specialists as well as recent graduates of medical schools and chiropractic colleges.

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Product Details

• Hardcover: 312 pages
• Publisher: Affinity Billing, Inc; 1 edition (January 1, 2009)
• Language: English
• ISBN-10: 0979610133
• ISBN-13: 978-0979610134
• Product Dimensions: 9.1 x 6.2 x 1.1 inches
• Shipping Weight: 1.2 pounds (View shipping rates and policies)
• Average Customer Review: 4.6 out of 5 stars  See all reviews (7 customer reviews)
• Amazon Best Sellers Rank: #808,892 in Books (See Top 100 in Books)

More About the Author

Yuval Lirov, PhD, is the author of "Medical Billing Networks and Processes," "Practicing Profitability: Billing Network Effect" (Affinity Billing) and "Mission Critical Systems Management" (Prentice Hall), inventor of patents in artificial intelligence and computer security, and CEO of Vericle.net Distributed Practice Management and Billing Technologies. Lirov earned his doctorate in systems science and mathematics under the guidance of Professor E. Y. Rodin at Washington University in St. Louis.

Customer Reviews

Most Helpful Customer Reviews

5 of 5 people found the following review helpful:

5.0 out of 5 stars Fixing a Broken System, May 7, 2009

By 

Mark Deo - See all my reviews

This review is from: Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age (Hardcover)

Medical Billing is one of those niche targeted books that demonstrates the benefit of place like Amazon.com. This is the kind of book that you would NEVER find if not for the Internet. This book is a veritable cornucopia of information and advice on how a medical practice needs to structure itself to ensure viable billing practices. This is valuable to not only the physician but also to the patient.

The author suggests that although the managed care billing system may appear to be broken, with the right disciplines we can FIX IT ourselves in many cases. In my work with medical practices and hospitals I can't tell you how often I come across physicians that have no choice but to reduce certain patient services because they just don't have the income to invest it where they would like. In the same way I have seen improper billing procedures frustrate patients so much that they literally REDUCE the number of doctor visits just to avoid the hassle of dealing with insurance and billing companies.

What I particularly liked about Yuval's book is that it can be easily understood by medical professionals, billing and insurance company representatives but also by the common person. He starts with a clear, thorough explanation of the history of the medical billing system, the advent of managed care and then gets into the nuts and bolts of billing explaining in a very down-to-earth manner, Super bills, allowable, write-offs, charge-backs, how the clearing houses work and so on. The book is loaded with graphs, captions, bullet points and images that just aid in the understanding of what can often a rather confusing topic.

Throughout the book, the author makes reference to how the system needs to change and what new variables may be on the horizon. I found this to be helpful in guiding my medical clients toward some policies and procedures that we may want to put in place regarding the new ICD codes and CPT10 system, the new FTC Red Tag privacy issues, and new HIPA regulations. The book makes a great reference tool for planning as well.

As a consultant that spends time consulting with hospital administrators, practice managers and physicians I have to say this is probably THE MOST comprehensive, easy to understand manual on medical billing that I have ever seen. I have actually purchased several copies to give to some of my clients and I suggest other medical consultants do the same.

I STRONGLY recommend this book to all medical professionals, practice managers and medical consultants. That said, if you are a patient and really want to understand the medical billing process I will say this is the ONLY book for you.

Also check out Yuval's book on practice management as well. Thanks Dr. Lirov for helping us to all take charge in fixing what is a broken system!

3 of 3 people found the following review helpful:

5.0 out of 5 stars Excellent Resource, March 9, 2009

By 

F. Cheung (New York, NY) - See all my reviews
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Amazon Verified Purchase

This review is from: Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age (Hardcover)

I recommend this book to anyone who is new to the medical billing industry. I learned a great deal about the processing cycle, approaches to track claims and maximize management workflow. The language is easy to understand and has great examples. However, if you have this book, do not buy the Medical Billing Networks and Processes - Profitability...by the same author. Many of the chapters are exactly the same in both books; one is sufficient.

3 of 3 people found the following review helpful:

5.0 out of 5 stars Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age, February 9, 2009

By 

Gregory Ribitzky "Dr.Ribitzky" - See all my reviews
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This review is from: Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age (Hardcover)

Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age- in my opinion this "how to" book is simply a must in any medical office . Before i read it- i was providing service- but did not know how to claim my money effectively and found myself loosing tens of thousands of dollars yearly. The author, Dr. Lirov showed me the way to work less and make more money.