Practice management

A practice management system (PMS) is a part of the medical office record. It carries the financial, demographic and non-medical information about patients. This information frequently includes:

patient's name
patient's federal identification number
date of birth
telephone numbers
emergency contact person
alternate names for the patient
insurance company or entities financially responsible for payment
subscriber information for an insurance company
employer information
information to verify insurance eligibility
information to qualify for lower fees based on family size and income
provider numbers to process medical claims

Detailed description

PMSes are frequently combined with electronic medical records ("EMR"). Some of the information between PMS and EMR systems overlap such as the patient, provider and clinic names. The differences between the PMS and EMR systems are in the feature focus. The PM system features are focused on medical billing and calendaring and the EMR is focused on patients' medical record. Many proprietary software vendors offer EMR modules for PM systems. For open source software the EMR is frequently integrated with the PMS.

Medical billing with a PM system in the United States can be accomplished electronically or on paper. Most payers prefer electronic submissions, and provide faster payment when claims are submitted electronically. ANSI X12 837 provides for electronic medical billing directly to payers or to a clearing house. Paper billing is accomplished using a HCFA 1500. A clearing house provides a service of accepting claims from a variety of payers and then distributing those claims to the appropriate payer. FreeB and REMITT are GPL implementations of X12 837p 4010a and HCFA/CMS 1500 generation.

A clearing house for medical claims differs from a medical billing company. A medical billing company provides billing, collection and accounting services. Generally if a medical clinic uses a medical billing company that clinic will not need a PMS. The medical billing company handles accounts receivable and sending statements to patients. A clearing house sends a claim to the payer, but does not handle accounts receivable or collection services. In many cases a medical clinic will need a PMS to collect the information for submitting a claim to a clearing house and to manage the accounts receivable after submitting a claim. Many clearing houses offer a variety of services and there is overlap between the services from a medical billing company and a clearing house.

Electronic practice management falls under the purview of medical informatics, a combination of computation and computer science and medical record keeping. See medical informatics for some historical remarks.

HIPAA

HIPAA provides for electronic standards for submitting medical claim information to payers. These standards include:

ANSI X12 270 - Health care eligibility & benefit inquiry - Is the patient an insured of this payer?
ANSI X12 271 - Health care eligibility & benefit response (response to 271) - A yes or no response that the patient is insured.
ANSI X12 276 - Health care claims status inquiry (follows 837 submission)
ANSI X12 277 - Health care claim status response (response to 276)
ANSI X12 835 - Health care claim payment/advice (follows 837) - 837 medical claim is paid, and amount of payment and the patient's financial responsibility
ANSI X12 837 D - Health care claim submission for dental claims
ANSI X12 837 I - Health care claim submission for institutional claims
ANSI X12 837 P - Health care claim submission for professional claims

External links

HCFA/CMS 1500

Clearinghouses for Medical Billing in the United States

Commercial practice management systems

Open-source practice management systems

ClearHealth
FreeMED (see also the FreeMED wikipedia article)
GPLMedicine.org A Open Source EHR/PM comparison site
MirrorMed
OpenEMR (see also the OpenEMR wikipedia article)

Medical informatics Medicare and Medicaid (United States)