Medical Office Workflow Step 4: Collecting Your Charges and Filing Claims

By properly registering your patient and verifying their benefits, you have laid the groundwork for correct claims reimbursement.  See these previous articles for more information:  New Patient Checklist and Proper Insurance Verification.

Office workflow step 4 

You now need to establish a reliable process for collecting charge date and filing claims.  One of the best ways to accomplish this is to utilize your Practice Schedule.  You will want to verify you have received a charge slip or “superbill” for each patient that has been marked as seen on your schedule.

Information on medical billing software

Integrating multiple systems can enhance your work environment and improve efficiency. A medical billing software that is able to directly import charge data from your EHR will eliminate the need for manual charge entry from “superbills”.

Iridium Suite

Iridium Suite Practice Management software now comes with the Connectivity Clearinghouse enabling connections to multiple EHR systems.

prevent denials

To prevent denials and receive proper reimbursement:

·Be aware of any services/procedures you provide that may conflict with others or be bundled together according to NCCI (National Correct Coding Initiative) edits.

Iridium Suite

Iridium Suite features a built-in claim scrubber that has many capabilities, so a biller can be confident that coding violations will be caught before the claim is generated.

Information on medical billing software

This article contains additional information on preventing common claim denials: http://www.iridiumsuite.com/mbs-blog/prevent-these-high-volume-claim-denials

·Stay informed of your commercial payers’ Medical Policies and government payers Coverage Guidelines.

Information on medical billing software

These two articles can provide more detailed guidelines on payer’s policies:  Reviewing Commercial Carriers Medical Policies/Clinical Guidelines and Understanding Medicare Fiscal Intermediaries.

Now that you have entered your “clean claims”, it is time to get them off to the payer.  Filing your claims can be done:

HCFA 1500 claim formvia paper on the standard HCFA-1500 claim form, or sent electronically electronic claims.

Information on medical billing software

Sending claims electronically utilizes Electronic data interchange (EDI). EDIis the structured transmission of data between organizations by electronic means.  Claims are batched in the medical billing software, and then transmitted in an electronic format directly to the payer or to a clearinghouse.

Iridium SuiteIridium Suite utilizes EDI to improve your claims processing in the following ways:

·Ability to track the Electronic Claims from receipt by the clearinghouse to the acknowledgement and acceptance by the payer.

·Electronic claims are pre-screened for certain errors with notices being sent back to the medical practice within days for quick correction and resubmittal.

·Due to their formatting, electronic claims are much more quickly processed by the payer, reducing the wait for reimbursement in some cases from weeks to days.

Medical Office Workflow Step 3: Obtaining Procedure Authorization

During your insurance verification process, you became aware that one or more of the services you will be either providing or ordering for your patient require an authorization.

For a guide on Proper Insurance Verification follow this link: http://www.iridiumsuite.com/mbs-blog/medical-office-workflow-step-2-proper-insurance-verification.

If you have no current method in place for obtaining authorizations, use the following suggestions to create your office process.

1 Gather all pertinent patient information: name, date of birth, insurance policy number and contact information for the authorizing entity.

The authorizing entity can be the insurance company, but more and more frequently payers are contracting out to third party organizations to perform this function.

2 Obtain the following data:  accurate diagnosis including the ICD9 or 10 code, copies of related medical records, the history and physical report from your physician, and the procedure(s) ordered with the appropriate CPT code(s).

Because you will need accurate medical data on your patient and in some cases actual office notes to provide to the authorizing entity, your hands may be tied in regards to the speed in which the authorization can be obtained.  For this reason, it is always helpful when possible to schedule the services enough into the future as to allow for processing time.

3  Now that you have the basics you are ready to begin the authorization process.  Follow the guidelines indicated by the authorizing entity to complete your authorization request.  This can vary from phoned in requests, to online or faxed submissions.  Make sure to complete any forms as accurately and thoroughly as possible.

 It is helpful to compile a file on authorization processes for each authorizing entity you encounter.  This allows you to have the information readily available again and again.

 

4 Now you wait.  With online submissions, you may have your authorization within seconds or minutes.  Other authorizing entities may take 24-48 business hours as their standard turn around.  You may even on occasion experience a week or more time between the request and the response.

 If you fail to get a response in the time specified by the entity, do not wait idly by.  Call or email as follow up.  You may discover the request was incomplete so you are able to provide the additional needed information.   Unfortunately, sometimes it is just floundering around on someone’s desk and you have to make sure it is brought to their attention.

Now that you understand the terminology, you can begin to post your remittance:

As you match on the service date and procedure, you will enter the appropriate indicated amounts for payments, contractual write off amounts, and patient responsibility.  The patient responsibilities, such as co-pays, co-insurance and deductibles, are allocated to the next responsible financial party; this may be the patient or another insurance company.

Medical billing hint

Once you have completed entering the data for the service line, the remaining balance should be $0 for the payer you are processing.  Any allowed amount, but not paid, would now be showing as the responsibility of another party, either patient or an additional payer.

Prevent claim denials

Identify a DENIAL by a $0 allowed amount.  You should never assume without verification that a $0 allowed amount has been processed correctly by the payer.  Carefully review the adjustment code against payer payment policies, NCCI edits, your billing records for the account and the patient’s medical record.  Only when you are convinced the service has been denied appropriately should you accept this write-off amount.