Three Ways to Improve the Claims Process at Your Medical Practice

May 19, 2012
P.J. Cloud-Moulds

Here's how to identify potential opportunities where your claims process could go awry and how to keep it on track.

When I first started blogging here, I made a statement that I counted 60 opportunities where things can go wrong with a single medical claim. Since this time, I've shared many of these opportunities, how to identify them and steps you can take to remedy and prevent the issues from returning.

Today I will show you how to identify these potential opportunities broken down by category, so that you can evaluate your practice yourself.

The first area is your front office and that initial contact with the patient. These are the critical items that must be obtained and confirmed:

1. Patient's name - confirming the spelling
2. Patient's date of birth
3. Patient's phone and address
4. Patient's SSN (if applicable for billing insurance)
5. Insurance identification number, phone number from back of card, and the subscriber (which sometimes is not the person you are talking to) and the subscriber's date of birth.

All of these items are necessary when obtaining insurance benefits, or if you need to call the patient back for confirmation, or to let them know if they are covered for the visit.

The next area will be your back office area. These are your second set of eyes confirming the data entry is correct. Don't miss this step, it really is crucial in order to send out clean claims. The back office will be looking at these areas:

1. Confirmation that the patient's demographics have been entered correctly into the system.
2. Confirmation that the insurance information has not only been entered correctly (policy number, subscriber, etc.) but that it matches what the insurance verification states. This includes deductible information, copayment or coinsurance info, out-of-pocket amounts, correct claims address, and who the insurance benefits were obtained from.
3. If any of these areas are in question, they must go back to the front office for clarification or verification. It is important that your back office person has a large knowledge base of insurance companies and their policies. For instance, some Aetna plans have a policy that for the initial visit, the patient has a copay and a coinsurance. Not obtaining this information up front could result in the patient receiving a bill after they have been seen in your office and paid what they were told was their portion of the visit. We all know that unhappy patients are not the most favorite part of the business when there is a billing snafu.

The next area is your billing department. Whether it is internal or outsourced, there still must be checks and balances to review. These are some areas you can inquire about to insure claims are being sent out:

1. Is there an additional "scrubbing" process they go through to make sure they have all of the necessary and correct information from your office?
2. Do the billing codes and modifiers match the diagnosis?
3. How soon after the billing office receives your patient information and billing codes, do they send claims out? Daily, weekly or monthly?

Once the claims go out and the insurance company receives them, you will either be sent a check or a denial. Each time you receive a denial, look at it as an opportunity to modify your internal procedures. Most often, by tracking the denials, you can find trends, and easily fix the issue. For instance:

1. Does the insurance company require chart notes for the initial visit or any subsequent visits? Can these be sent to your billing department along with the billing codes for that day?
2. Does the insurance plan cover what you are coding?
3. Is the physician credentialed with the insurance company?

If you are on top of these areas and do get a check, what happens then? Do you have someone who creates a deposit log from these checks and sends it to your billing department for posting? This is another very critical area and if not done correctly can result in billing patients unnecessarily. Be sure the deposit log includes the patient account number (sometimes you maybe have two or more people with the same name), the check number, check amount, and any referring dates of service. Once this is completed, it can be sent to your billing department for posting. The posting person has a lot of responsibility to not only make sure each transaction is posted correctly in the system, but is accurate in the amounts posted. If you are paid $232.75 for a patient visit, and only $23.75 is posted, the patient will receive a bill and you will get a phone call.

If you are unsure about your billing department's quality control procedures, it's worth a meeting or phone call to find out. You can be paid quickly and efficiently if you take just a few moments to review where things can go wrong. These are just a few areas to look at, so sit down with your staff and ask them to help you create your list today. It will only help you.

Find out more about P.J. Cloud-Moulds and our other Practice Notes bloggers.