Your Ultimate Guide to Claims & Payment Processing

Your Ultimate Guide to Claims & Payment Processing

Your Ultimate Guide to Claims & Payment Processing

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Running a medical practice requires a variety of skills, and not all of them revolve around the effective treatment of your patients.

Most notably, you need to know how to run a business and successfully claim the money you’re owed for insurance-covered treatments. 

Billing and revenue operations can be challenging to understand and can take up a lot of time. So, in this guide, we’ll cover how claims and payment processing work in detail, so you’ll know what to expect.

Let’s dive in!

The Claim’s Process

In most cases, it’s the doctor’s office’s responsibility to file a claim to the patient’s insurance company. While they might be liable to submit a claim themselves, it’s essential to know how your office should tackle the claims process.

This is crucial to getting paid promptly for the services you provided.

  1. Notify the insurance company based on the notification requirements
  2. Prepare a complete and accurate claim form. 
  3. Claims should be submitted using the electronic payer ID on the health care ID card. You can also submit paper claims to the address listed on the member’s health care ID cards.
  4. All claims must report revenue codes and require the exact dates of treatments and services if they span several days.

…So, there you have it!

What Happens if You Need to Adjust a Claim?

If for any reason, you believe a claim was processed wrong, you can call up the number on the member’s health care ID card. Request any adjustments as soon as possible, to remain compliant with any applicable statutes and regulations. 

The insurance company might inform you that you’ve been overpaid, which must be settled within a set time limit.

If a Claim is Denied

There might be various reasons why a claim is denied by an insurance company, which could lead to a dispute between your practice, the insurance company, and the patient then responsible for the payment. 

Disputes are best avoided by ensuring the treatment is covered by the patient’s insurance before any services are provided. You want to double-check that the patient can present all the necessary membership details.

To keep rejections at a minimum, your front desk will need to request a current insurance card every time a patient requests a service. They must then run eligibility checks to be safe.

Patients may change insurance coverage frequently, and each provider may cover different services.

If your practice handles many patients under the same insurance, like Medicare, it’s prudent your staff are trained to recognize typical coverage for this provider.

Claims Might be Denied Because:

Your claim might be denied in the following scenarios:

  • The patient’s plan doesn’t cover the procedure, medication, or supply. 
  • The insurance company considers the treatment medically unnecessary, experimental, or investigational. The therapy was cosmetic or treated a pre-existing condition. 
  • There might be an administrative error, or your claim was missing information.
  • Treatment was sought without prior authorization.
  • The claim wasn’t filed within the specified time limits.
  • The patient is not a member of the claimed insurance company.
  • The claim is due to the coordination of benefits.

In case of a denied claim, the patient’s liable to pay the bill on their own. This might cause a delay in how quickly you’re paid, so always ensure to take proof of insurance first. Your patients may be able to promptly fix administrative errors with a phone call. 

If the dispute cannot be solved, patients can request that the insurance provider formally review their claim.

Another healthcare professional specializing in the specific medical field takes a look. All this must occur within a strict timeline, or otherwise, the claim might become void.

If an issue isn’t solvable, patients can contact the state’s department of insurance. This exists to protect consumers by ensuring the insurance process is fair.

Billing the Insurance Company

In most cases, health care providers are encouraged to bill the insurance company directly rather than taking payment from a patient first.

If you are billing the insurance company, the patient has to authorize the payment of medical benefits to you. They do this by signing and dating the section of the claimant’s Statement and Authorization Form. 

It’s your responsibility to mail itemized bills to the insurance company, including details of the diagnosis and treatment.

Outsourcing Medical Billing

Medical practices, hospitals, and laboratories often find it challenging to keep up with billing and coding regulations. This can lead to costly errors made by staff and delay when you get paid for treatments rendered.

Difficulties arise due to:

  • Using the wrong code in the claim.
  • Changing billing and coding regulations
  • Untrained or inexperienced staff
  • An overwhelming number of claims leading to bottlenecks in the practice’s tasks
  • Different healthcare providers having other codes

Many medical practices choose to outsource these vital financial processes. This frees up their time to focus on treatments and maintaining their clients.

Medical billing is made complicated by the various state regulations involved, and it is easy to run into coding and billing issues. 

By outsourcing revenue operations, you avoid the likelihood of costly errors. Experts will handle medical billing. They stay on top of the continually evolving medical coding regulations and ensure payment processing runs smoothly.

Claims and Payment Processing Remains a Complex Field to Navigate

Medical billing and payment processing requires a great deal of patience and attention to detail. With treatment codes changing and relying on precise formulations, it is easy to make a mistake and suffer costly results in turn.

So, join other medical practitioners and consider outsourcing your medical billing. Billing Savi can expertly handle your claims and stay on top of changing regulations. Feel free to contact us today to see how we can help you!