Medical Billing Basics – Claims Processing
The term “claims processing” describes the course of submitting a claim to the payer and subsequent adjudication. Understanding how this process works allows physicians and staff members to file claims properly and leads to maximum and timely reimbursement. In addition, this knowledge will allow the physician’s office to serve as a resource to patients in understanding the process. For paper claims, use the standard claim forms (CMS-1500 and the UB-92) when submitting charges, and be sure to complete the forms completely and accurately.
What to Include on Claims
- Patient Information: Before filing any claim, obtain clear, accurate information from the patient, and update the information regularly. Most offices verify the information at each visit. A uniform policy for multiple physician offices or clinics makes everyone accountable for current and correct patient data.
- Primary vs. Secondary Coverage: Households with dual incomes often have more than one insurer. Determine which is the primary and which is the secondary insurance company. For commercial plans, the subscriber’s or insured’s insurance company is always primary for the subscriber. In other words, the husband’s insurance company is primary for him and the wife’s insurance company is primary for her. However, the primary insurance company for any dependents is determined by the insureds’ birthdays, the primary insured being the individual whose birthday is first during the year. This is often referred to as the “birthday rule.” For example, if the husband’s birthday is October 14, 1960, and the wife’s birthday is March 1, 1962, the wife is primary for their dependents because her birthday is first during the year (year of birth is ignored)
Assignment of Benefits and Release of Information
Consider adding an assignment of benefits statement to the patient information form. It should state that the patient has agreed to have insurance payments sent directly to the physician and that medical information can be released to the patient’s insurance company. A signed copy of this assignment submitted with a claim helps ensure at least partial payment from most commercial insurers. Assignments also reduce collection expenses. An alternative, lifetime assignment of benefits should nearly eliminate the need to obtain a signature after each date of service; however, there are payers that require a current signature with each claim. If the office participates with Medicare, an assignment of benefits and release of billing are necessary.
- Determining Coverage: A patient’s insurance coverage should be verified before any service is rendered with the common sense exception of emergency treatment. This policy should not apply exclusively to new patients. Established patients may have changed employers, married or divorced, or no longer be covered by the same policy that was in effect during the last visit. The law requires Medicaid patients to provide current proof of eligibility for each visit.
- Preauthorization: Determining in advance the benefits and allowable provides the physician’s office with reimbursement figures before the patient’s visit. Under most circumstances, the office should be able to discuss the deductible, copayment, and balance over and above the allowable with the patient prior to providing costly surgical services.
Claims submitted with all of the information necessary for processing are referred to as “clean” and are usually paid in a timely manner. Paying careful attention to what should appear on the claim form helps produce these clean claims. Common errors include the following:
- Failure to pay attention to communications from carriers (including Medicare and Medicaid transmittals)
- An incorrect patient identification number
- Patients’ names and addresses that differ from the insurers’ records
- Physician tax identification numbers, provider numbers, or Social Security numbers that are incorrect or missing
- No or insufficient information regarding primary or secondary coverage
- Missing authorized signatures — patient and/or physician
- Dates of service that are incorrect or don’t coincide to the claims information sent by other providers (such as hospitals or nursing homes)
- Dates that lack the correct number of digits
- A fee column that is blank or not itemized and totaled
- Incomplete patient information
- Invalid CPT and ICD-10 codes, or diagnostic codes that are not linked to the correct services or procedures
- An illegible claim
We hope that this article has provided a basic idea of claims processing. If you are looking for overall billing and coding services you can refer to E2E Medical Billing Services. Our accurate and affordable billing services will eliminate billing and coding errors and will increase your practice collection. To know more about our medical billing and coding services, call us at 888-552-1290 or write to us at [email protected]