The clock starts ticking on the life of an insurance claim the moment a patient makes an appointment and doesn’t end until the practitioner is paid. To better understand the life cycle of an insurance claim, Nitin Chhoda offers a first-hand look at the process.
Before patient arrives at the office, staff should already have obtained and verified the individual’s healthcare insurance information to ensure the policy is in force, hasn’t lapsed and who is covered, along with any limitations or restrictions.
Insurance benefits can be tricky to navigate. Clinicians must ascertain exactly what’s covered under the patient’s claim insurance, their deductible and co-pay when they make an appointment. It will impact the client’s available treatment options. Some individuals have coverage under more than one insurance provider. Both policies must undergo the same rigorous verification.
Patients will also be required to sign consent forms allowing the practitioner to bill the insurance company and be paid directly, release information for billing, and for the client to pay any amount not covered by insurance claim. A copy of the client’s identification and insurance card is required, along with a complete health and medical history.
Enter the EMR
All the client’s information must be entered in the practice’s EMR for medical billing. Incorrect or incomplete information will delay reimbursements to the clinic, as will failure to obtain an authorization for procedures. Insurance providers will deny a payment if the correct forms aren’t used, information is incomplete and for other breaches of the company’s particular set of rules.
To document the client’s visit, clinicians will create an encounter form that provides pertinent information about the patient’s complaint, exam, diagnosis and procedures performed. Any secondary problems that are observed must be documented and all the information entered into the EMR. Each diagnosis and procedure code must match or the claim will be denied.
Clinicians can now enter the cost of the visit utilizing their schedule of fees. Each procedure and all materials must be calculated into the final cost, from the use of the exam room to bandages. It’s also time for the patient to determine how they’ll pay for any portion of the cost for which they’re responsible.
That can take the form of cash, check, debit or credit cards, or a payment plan. Collect at least a portion of the payment before the client leaves the office.
Submitting the Claim
A reimbursement claim must be prepared and sent to the client’s insurance carrier, complete with documentation of the patient’s financial and clinical information from their visit. Each claim should be double checked to ensure that codes and patient information match, and that there are no omissions, or the claim will be delayed.
The claim will examined in extensive detail by the insurance company to ensure the client is covered, any restrictions and limitations were adhered to, accurate coding was included and information is complete.
If a problem arises, the clinician will be asked for additional information or to resubmit the claim.
Practitioners can appeal the decision, collect any unpaid amount from the client or write off remaining costs.
It can take a typical claim up to three months to be reimbursed, even without any difficulties. Using an EMR ensures HIPAA compliance, protects against loss, decreases processing time and accelerates the entire process for quicker deposits and better cash flow.