For successful claims processing and payment, it all starts
with the proper verification of insurance coverage and benefits.
Proper claims reimbursement
Follow the guide below to ensure you are gathering all the
necessary information to create a complete and accurate patient benefit
profile.
Medical billing hint
Basic information needed before
contacting the insurance company:
1.First and
last name of patient and the subscriber (if other than the patient)
2. Patient’s
date of birth
3. Policy number
as shown on the insurance card
Medical billing hint
(The insurance card is one piece of
essential information your patient should bring on their first visit. Please see this New Patient Checklist other
important documents, etc.)
4.Diagnosis or
chief complaint
5. CPT codes for
anticipated procedures
Verify medical benefits
Ask these questions to build your
patient benefit profile:
1.What are the
effective dates of the current policy?
2.Are they any
pre-existing conditions limitations?
3.What are the
benefits for the anticipated service?
a.Does a deductible
apply (see b) or only a copayment (see d)?
b.If there is a
deductible, how much is the deductible and how much is met?
c.After the
deductible, what is the co-insurance amount?
d.How much is
the copayment?
e.What is the
annual out of pocket maximum and how much is met?
f.Do the
deductible and copayments apply toward meeting the out of pocket maximum?
4.Does this
policy require any type of authorization of the anticipated service(s)? If yes, make sure to obtain the proper
contact information for that internal department or outside agency.
Verify medical benefits : If you are unaware of the entities
process for obtaining authorizations, immediately contact them by phone or
review available information on their website.
This is a huge time saver to have this information on hand before you
may actually need it.
5.Is there an
annual, lifetime or per illness/diagnosis maximum benefit? If so, how much has been met?
Medical billing terms : If some of the above terms seem
confusing, refer to the table below for helpful explanations.
Pre-existing Condition
Most often occurs with a lapse of insurance coverage. The new insurer can refuse to cover a
condition that was diagnosed before the effective date of the policy.
Deductible
Amount the subscriber is responsible to pay before insurance
will pay their portion.
Copayment
A flat rate assigned to specific procedures that the
subscriber is required to pay. Most
commonly to office visits and outpatient diagnostic procedures.
Coinsurance
The percentage of the charge that is the subscriber’s
responsibility. Refers to benefits
like”80/20”, the insurance pays 80%, the patient pays 20%.
Out of pocket Maximum
This is the total patient’s out of pocket financial
responsibility designated by the payer.
Once the subscriber has met this amount, services then become covered at
100% by the payer.
Benefit Maximum
This is the monetary payment limit set on the subscriber’s
policy. Once this maximum is reached the
payer has no more financial liability and the subscriber must pay for the
rendered services.
Iridium Suite
Practice Management software from Medical
Business Systems has an integrated insurance Real Time Eligibility function
that can do most of this work for you.
See how Iridium Suite can help you “work smarter not harder”.
Office Workflow Step 1: New Patient Check List
When scheduling a patient for their first visit to your
practice, you should advise them of what they need to bring to help ensure a
smooth registration process and to assist your physician in making that first
visit as thorough as possible.
Follow this check list as a guide:
Picture identification and current insurance card(s)
Hint: Once provided
with this information, you need to verify insurance coverage and benefits. This is the optimum time to collect
copayments from the patient.
Contact information for emergency contact and/or healthcare
surrogate
Hint: Make sure the
patient indicates the name(s) of any authorized persons on your HIPAA
notification form.
Contact information for all current healthcare providers
Hint: Please have the
patient add to the HIPAA form, the names of any physicians they would like your
physician to communicate with or share their medical records.
Copies of any applicable medical records and recent
diagnostic testing results
Hint: If you are
handed records that are the patient’s only copy, make your own copy and return
the “originals” to the patient. They may
need them for another provider. X-rays
or radiology “films” stored on computer discs, should be logged in the
patient’s record if they are left behind after the visit.
Complete list of current medications, both prescription and
over the counter.
Hint: Adding the
pharmacy name and phone/fax number into the patient chart facilitates issuing
any required prescriptions.
Observe National Women's Health Week
National Women’s Health Week is May 12-18 and is a weeklong
health observance coordinated by the HHS Office on Women's Health.
Per 2009 statistics from Center for Disease Control and
Prevention Office of Women’s Health the top three causes of death in the United
States for women are: heart disease, cancer and stroke.
Take this week to encourage all the women in your life to
make their health a priority. Have them schedule preventative medical services and
screenings such as:
Annual physical including basic lab tests Cancer screenings (mammogram, pap test, pelvic exam,
clinical breast exam, and colorectal cancer screening)
Information on women's health
CMS now covers many preventive
services and screenings under its Medicare Part b benefits for eligible
beneficiaries. For further information
see the following:
- MLN Preventive Services Educational Products for Health Professionals
- CMS Prevention website
- CMS Immunizations website
- Discuss the importance of making healthy lifestyle choices:
- Participate in regular physical activity for a minimum of 2 and ½ hours per week.
- Consume a healthy daily diet of fruits, vegetables and whole grains, with limits on foods with high calories, sugar, salt and fat.
- Eliminate tobacco use and avoid tobacco smoke exposure.
- Limit alcohol consumption to one drink per day.
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