August 19, 2017

 
Claim Submission Tools

 

Sometimes, when you, as a patient and health care consumer, go to the doctor or other medical provider, you may be told that you have to submit your own insurance claim form. This means that the doctor or facility does not ask the health insurance company to pay for your bill and you must do so. If you have to file your own health insurance claim here are the steps you will need to take along with some helpful tips on submitting your insurance claim form:

1. Obtain Itemized Receipts: You will need to ask your doctor for an itemized bill. An itemized bill lists every service that your doctor provided and gives the cost of each of the services. Your health insurance company will need you to attach the original itemized bills to the claim form.

2. Get Your Claim Form: You will need to contact your insurance company to obtain a health insurance claim form. The claim form should be fairly self explanatory to fill out. It will ask such things as your insurance information, who you want the payment made to, what was the visit for (accident, workers compensation), etc. Your claim form will also give you additional instructions pertaining to what other information they may need from your doctor or health care facility.

3. Make Copies: Once you have your claim form filled out and your itemized bills from your doctor, don't forget to make copies of everything. This will eliminate any errors that may be made in the claim process and make it easier for you to re-file your health insurance claim if it gets lost.

4. Review then Send: To make sure everything is completely accurate, call your health insurance company and tell them you are about to send in your health insurance claim form. Review with them all the paperwork you have and ask them if there is anything else you need. Also, ask your insurance company how long should you expect to wait for your claim to be paid and mark that date on your calendar. Once you have everything in order, send out the claim form to your insurance company. The address to send the claim form should be on the claim form itself. Keep an eye out on your calendar for the claim date that you marked and contact your insurance company if you don't receive your claim within the time frame given to you

 


 
And because the medical practice's revenue cycle begins -- and sometimes ends -- with a denial right here, carefully review your practice’s current claims processing systemsSegregate the percentage of claims submitted within the last 30 days that were delayed, rejected or denied on the first submission and the reasons most frequently given by the insurance companies.Then plug in this data and employ the strategy below.

Denied Wrong Payer  If a high percentage of your denied claims are denied because they were submitted to the wrong payer, take the following steps:

  • For new patients, collect information about insurance coverage when they book their first appointment to allow you ample time to process it. Ask patients to provide the following information about their spouse and dependents as well as themselves: Social Security number, birth date and group/policy numbers for each of their insurance providers, including Medicare and Medicaid.

  • Make it a policy to copy patients’ insurance cards at their first visit to your office. If the patient has secondary coverage, copy the card for that policy as well.

  • Upon each patient’s arrival at your office, review the insurance information you have on file and ask whether it’s current. If the patient makes changes, copy the patient’s insurance card again. Keep accurate records of all insurance information (current and previous) for use in claims follow-up, appeals, disputes or coordination-of-benefits issues.

  • Denied No Coverage  To reduce the number of claims denied due to ineligibility, confirm eligibility for every patient visit – prior to the visit, if possible. Have your staff note when eligibility was confirmed and whether it was accomplished by talking with a payer representative, by using the payer’s automated phone system or online. 

    Denied COB  If your claims are being denied or delayed due to coordination-of-benefits issues, follow these steps:

  • Ask all patients whether they have secondary or other insurance coverage. Gathering this information and using it when billing the insurance carriers can reduce the number of claims that are delayed pending coordination of benefits.

  • Verify whether each payer listed in the patient’s file is the primary or secondary carrier. This can be accomplished when checking eligibility if you do so via “live” telephone contact. In some instances, if the payer is secondary, the person you talk with may be able to tell you which payer is primary. Here’s a rule of thumb for dependent children covered under more than one policy: The payer whose subscriber has the earlier birthday in the calendar year will be the primary.

  • When submitting a claim to the secondary payer, send a copy of the Explanation of Benefits from the primary payer. If you don’t, the claim will probably be denied or delayed pending coordination of benefits.


  • Denied Medicare Info To reduce the number of denied or delayed Medicare claims in your office, try these tips:  
    • Ask new patients age 65 or older (or current patients who’ve turned 65 since their last visit) to show you a copy of their Medicare and other insurance cards, and update your records as needed. Remember it is possible for a patient to have only Medicare Part A or Part B or to be ineligible for Medicare despite being 65 or older. It is also important to find out whether Medicare-eligible patients have group health insurance. Federal laws determine when Medicare is the primary or secondary payer.

    • If Medicare is the primary payer, check to see if Medicare automatically “crosses over" or sends claims to, the secondary or other payer. Many health plans pay Medicare for this service. If the patient’s claim is crossed over and you submit another claim directly to the secondary payer, the latter claim will be denied as a duplicate. The Explanation of Medicare Benefits should indicate when a claim has been crossed over for consideration by the secondary payer.


    Denied as Duplicate  

    If your practice is seeing a substantial number of claims being denied as duplicates, the following steps can help improve your billing process:

                                                                      
  • Establish a minimum rebilling cycle of at least 30 days to allow time for the original claim to move through the payer’s cycle. Resubmitting a claim in less time uses unnecessary resources and is likely to result in the claim being denied as a duplicate.

  • Reconcile claims denials and claims payments at least every 10 days, 

    working through any electronic error and rejection reports in the process. This will help you to avoid common mistakes such as rebilling a denied claim or billing the patient’s portion to the insurance carrier.

  • Don’t automatically rebill all outstanding claims. When a claim requires follow-up, your first step should be to contact the payer (by phone or online) for additional information.

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    Denied Missing Information  If missing or inaccurate information is causing your claims to be denied, double-check every claim for completeness and accuracy prior to sending it to the payer. Common billing errors include providing incorrect or incomplete patient information (e.g., member number, policy number, full name of subscriber) and incorrect or incomplete service information (e.g., date of service, diagnosis codes, CPT codes and modifiers).

     
    Denied Corrected Claims  
    Be aware of the special requirements that each of your payers may have for submitting appeals or corrections. For example, some require that appeals be submitted on a specific form and not include a copy of the original claim.
    To reduce the number of appeals or corrected claims being denied as duplicates, follow these steps:
     
  • Unless the plan directs you otherwise, do not simply stamp a claim as “Second Request” or “Appeal.” Such claims will generally be treated as new claims and denied as duplicates.

  • Be sure that the appeal or correction is submitted to the correct address. Many payers request that appeals be submitted to an address or post-office box that is different from the one used for original claims.


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    Related Resources: 
     
    1. "Making Insurance Companies Pay", By Tara Parker Pope (2010).
     

     
     
    Millions of health care claims are filed every day by hospitals, doctors offices and patients requesting payment covered by insurance policies. So medical claim submission practices and how to submit a medical claim correctly should be first and foremost if timely payment for services rendered is going to take place. This office manager discusses the do's and don'ts.