July 13, 2020



More chances for messed-up claims as the clinic or facility gets ready to close up for the day. During this time, staff examines the volume of patients seen, types of services provided and the "third-party payer mix" to determine their revenue cycle. Whether they generate claims at the end of this day or only once a week, the sooner it's submitted, the sooner that dreaded denial of claim can be prevented. Here's what it looks like after the last patient is out the door.

Pre-authorization, -certification, -determination If needed for a future servicethe staff reviews the health insurer contract‒including its definitions of specific terms, such as pre-authorization, pre-certification and/or pre-determination‒ to ensure that the physician practice complies with the insurer’s verification of a patient’s coverage for benefits.
Staff may obtain a pre-authorization by directly calling the insurance company verification of benefits department. Some insurers allow the physician practice to complete a pre-authorization form that they can either fax or mail.  Others have online pre-authorization processes available. The physician practice determines which method of pre-authorization is the most time and cost-efficient.
In most cases, the health insurer requires pre-certification for a patient’s hospital admission and/or surgical procedure. The physician practice provides the insurer with the required patient informations, including the procedure to be performed, explanation of its medical necessity and the expected length of stay. 
Unlike submitting pre authorization requests, staff
must submit pre-certifications in writing on the physician pactice’s letterhead.  
The purpose of a pre-determination is to request in advance the determination of a patient’s coverage for a specific service or procedure. The health insurer will usually specify which procedures require pre-determination to avoid a denial of claim.  
Charge Capture  The billing staff is responsible for accurately entering the ICD-9-CM and CPT codes and fees as they appear on the practice’s super bill. The practice staff reviews each claim before submission to ensure that they have completed all of the form’s required fields. They might also use a medical billing software program that is designed to flag or prompt practice staff when a required field is missing or the data entered is invalid to avoid a denial of claim. If health insurers regularly challenge practice staff on claims submission issues, the practice staff sometimes schedules weekly phone calls with those health insurers to discuss any outstanding charges. Building a rapport with the health insurer representatives can assist in resolving future issues.

Claim Review   The staff performs random claims reviews—preferable once a month but at least once a quarter. The coding professional also reviews claims each day. This random review will help to ensure that they are submitting claims to the health insurer accurately, based on the medical record documentation. The purpose of the review is also to assess the appropriateness of the physician practice’s coding, billing and documentation and to examine the physician practice’s compliance with federal regulations


There are many ways to complete a claim review. One recommended way is to pull five to ten random medical records. Practice staff can pull this random sample per physician, per payer or by frequently denied codes.

After the review, the practice staff performs the appropriate follow-up action to correct any potential errors. Depending on the circumstances of the errors found, the physician practice follows up with one or more of the following:
  • Assigning targeted staff
  • Providing physician education
  • Resubmitting claim with an explanation/ office notes
  • Seeking advice from a coding consultant or another physician practice expert about resolving the errors

After all of the above is completed, staff generates a claim and either mail it or transmit it electronically to the health insurer, according to its submission requirements, or through a billing service, clearinghouse or application service provider.  
The doctor visit is over, but patients are sometimes required to file and track their own insurance claims. This is usually the case if an out of network provider is seen. It means verifying being charged the right amount, that the insurance paid the required portion of the claim, and what will be owed after everything is settled. When facing a serious illness with multiple visits to health-care providers, it can be even more difficult to track your claims, but a careful system and attention to detail can help:
Get Itemized Receipts  The provider is asked for an itemized bill that lists every service and gives the cost of each. If the patient submits the claim, the health insurance company will need the original itemized bills attached to the claim form. The medical procedures being charged for are verified to have been actually performed to avoid a denial of claim. 

Obtain Claim Form  The patient contacts the insurance company to obtain a claim form. The claim form should be fairly self explanatory to fill out. It asks such things as the insurance information, who the payment will be made to, what was the visit for (accident, workers compensation), etc. The claim form also gives additional instructions pertaining to what other information they may need from the doctor or health care facility.

Make Copies  Once the claim form is filled out and itemized bills attached, copies of everything are made. This eliminates any errors that may be made in the claim process and make it easier to re-file the claim if it gets lost. All notes and other information (letters, bills, receipts, and so on) are kept in a file folder or notebook and well organized.

Call the Insurer  To make sure everything is completely accurate, the health insurance company is called and all information is reviewed with them for completeness.  How long the insured should expect to wait for the claim to be paid is also determined, and that date is marked on the calendar.
Institute Tracking System  Using a three-ring binder, the patient records visit dates and procedures completed. A notebook to record information about disputes, a folder for bills or medical statements, a folder for health-insurance statements, and a folder for resolved bills and claims is employed. The patient records each visit to the doctor in the procedures notebook - the date, the doctor, and any procedures done. They may also record this in a spreadsheet on computer.

Organize Provider Statements  Usually hospitals send out a statement summarizing procedures a week or two after the visit. This is not a bill, but they verify that what was done is listed accurately. If something was listed wrongly, they call and dispute the claim. At this point they may contact the insurer as well. They file these in the bill and statements folder.

Check Against Insurer Statements  Most insurance companies send a statement once a month listing any claims they have received and the amount that the patient will owe the hospital or doctor. The insured goes through the folders and marks off the bills and statements they have already received. If a claim is denied, they contact the insurance company to find out why and to appeal the claim if necessary.


 Related Resources:
1. "Improve AR Days with Claim Follow-Up", Joy Hicks, About.com, (2005).
2. "Reduce Claims Processing Time", Joy Hicks, About.com, (2005). 
3. "How to Track Health Insurance Claims", Miriam C., E-How, (2009).

An example of a typical electronic billing software system in use today. Notice the sheer number of entries involved - each one an invitation for an error and subsequent denial of claim. However, if the right steps are taken proactively - and reliable software systems are engaged - the chances of this happening decline by a lot.