Medical Billing–Patient Insurance

Patient Insurance

We know that, patient has to give his insurance information to the Doctor before the treatment. Collecting the patient insurance information is very important data entry part to avoid delayed or denials.

Either at the time of appointment or at the time of patient visit the practice(Check in), patient insurance information has to be collected. If it is existing patient, then we need to verify the existing patient insurance information which is already in the file(or computer system).

Very Important. For New Patient, we need to collect signed copy of HIPAA consent form. For more details, please check here.

The following information has to collect from the patient

1. Insurance Company Name

2. Policy No (Unique number to identify the patient within the insurance system)

3. Policy Group No (Identifies in which plan the patient enrolled with the insurance company)

4. Effective Date (From which date, benefits or covered services are allowed)

5. Relationship to the Patient(Patient may have the insurance on his name, or he/she may be covered by one of the family member)

6. Insured details such as first name, last name, etc if the patient is not the same as insurer.

7. Copay and deductible amount

And also, we need to scan the patient insurance card back and front part into the system. Sample Insurance card here.

        

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How to submit the claims after primary insurance ?

This is another interesting area where lot of automation is required in the software.

Once the primary insurance carrier pays their share of the claim it is then submitted to the secondary insurance company if the patient has one. Secondary claims can also be sent electronically and on paper. Medicare is mandating electronic submissions even on secondary claims. When submitted electronically all the information from the eob (explanation of benefits) is entered into the claim information and submitted to the secondary insurance carrier.

Now days, most of the insurance company accepts electronically if they are secondary payer. Here the term “Secondary payer” does not really mean the number 2. Any insurance after the primary is normally called as Secondary payer, but as per the patient, it may be in the third position. As per new 5010 documentation, it supports the submission of claims containing up to 11 payers (destination payer plus 10 non-destination payers).

Some times, the primary insurance itself forward the claim to secondary insurance and that information will be given in the EOB. This makes easy for the billing team.

I found a good article on how to send the claims to the secondary payer via Paper CMS 1500 FORM. I am just giving that information here.

When the secondary is submitted on paper, the claim is printed out again on a cms form and a photocopy of the eob is attached. If other patients are listed on the eob, their personal information should be hidden. Many offices use black markers to draw through the unwanted information. Secondary is submitted on paper to the insurance companies that are not yet accepting electronic submissions.

New billing staff should understand that the secondary insurance plan cannot process the claim without a copy of the primary carrier EOB.

If there is still a balance after the secondary insurance carrier pays their share, the claim is sent on to the third carrier. It is printed out again on a cms form and copies of the eobs of both the primary and the secondary insurance carriers are attached.

Whenever you send secondary and tertiary claims on paper, make sure the photocopies you attach are clear, easy to read, and for the correct date of service. Many insurance carriers scan the eobs which lightens them a little. If the copy you submitted was already light, by the time the claim is processed it may be sent back to you as unreadable. It takes a lot more time to find the original eob and resubmit a claim than it does to get it right the first time.

Secondary and tertiary claims can sometimes seem like a pain to get paid – especially because they can be for a very small amount of money. It is still important to file and track these claims to keep your receivables under control. It may not seem like a lot of money but it adds up. If you have a system for submitting them it really isn’t that bad

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Claims adjudication and payment

The Following picture demonstrates how insurance company processing the claims received from the clearing house. 

You can also download the PDF Version of the above picture here.

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Medical Billing

 

I strongly feel that Development of PMS Product is more on the domain/business logic other than the technology. So would to like to share the information in PMS thru my blog

There are lot of articles/books/document sitting on my desk which I have collected from various sources for the past 10 years. From that, so I will try to educate on that in a simple and easy to understandable way with an example where never necessary.

Chapter 1: Introduction
1. What is Medical Billing Process ?
2. Different Format of Medical Form.
3. Patient Insurance
4. Electronic Claim Transmission
5. Medical Billing Clearing house
6. Medical Billing Process in detail
7. Healthcare Coding system.
8. Maintaining Patient Insurance in the software.

Chapter 2:  EDI Transactions

1. What is an EDI ?
2. EDI Transactions 
3. Understanding EDI Structure
4. EDI Instruction

 

 

Chapter 3: Payment
1. Types of Reimbursement

Chapter 4: Claim Submission after Primary Insurance
1. How to submit the claims after primary insurance ?


Chapter 5: Claim Processing by the insurance company

1. Claims adjudication and Payment process.?

 

New to Health care Domain ?  Here are some documents which can help you to understand the basics.  I am trying to refer to official link(where i downloaded the document)   and as well as link to my server(some time, official links are broken).

1. Introduction_to_Health_Care_in_USA   (or you can click here to download)
2. Medicare Incentive Program Beginners guide MU Stage 1 ( or you can click here to download)


All about Prescription

•  An Introduction to ePrescription
•  How ePrescribing works
•  Paper Prescription workflow
•  Electronic Prescription workflow
•  Refill Paper Prescription workflow
•  Refill Electronic Prescription workflow

Flow charts

•  Medical Billing Overview 
•  Rooming Overview
•  Medical Billing Flow chart
•  EMR Test Visit Flow chart
•  EMR Patient Examination Flow chart
•  EMR Office visit Flow chart
•  Medical Claim Life Cycle
•  Claim Adjudication and Payment Flow chart
•  EMR Office Visit
•  Billing Flow chart

Medical Billing blogs

• Blog on Medical Billing – Revenue Cycle Management
• Medical Billing and Coding
• Medical billing CPT modifiers
• CMS 1500 claim and UB 04 form
• Medicare Fee Schedule, Payment and Reimbursement
• Insurance claim denial and appeal

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