August 03, 2020


It's not even a bill yet, but a denied medical claim often begins before a visit to the provider's office or healthcare facility. Each stage in medical claim preparation is someplace where the claim can get "screwed-up" as it were. if the contract with the insurer is misunderstood or the wrong information is introduced into the process at any point, a denied medical claim is often the result. If this happens, however, it's often possible to spot the problem point. Then, armed with that information, you can often get your claim reprocessed without an appeal, because they know that you know what you're talking about So go through the flow chart, outline and more detailed pages that follow and try to isolate where the process went sideways and proceed from there.

                                                       LIfe of a Claim (Part 1):


Pre-Visit (This is where misunderstandings take place when the insurer contract or certificate of insurance is not read carefully)
1. Reimbursement under the insurer contract - Many health insurer contracts not only fail to to set forth which services they cover but also do not provide enough information for the physician to determine what the health insurer will pay for a service.
2. Changing the reimbursement terms under the insurer contract - A health insurer contract may include language that essentially gives the health insurer the right to unilaterally change the reimbursement terms without the provider knowing about it much less consenting to it.
3. Prompt payment - When a health insurer contract is silent about prompt payment, it does not give the physician any rights to prompt payment or the health insurer any responsibilities to pay promptly. If not fully understood, this often results in a denied medical claim when it is not submitted "timely" and timely is actually arbitrary.
4. Definition of medically necessary - Physicians may not be aware that some contracts define medical necessity according to the health insurer’s own cost criteria, such as the “least costly alternative.”
5. Pre-Authorization requirements - If a physician provides medically necessary care to a patient and finds out after the fact that the health insurer requires prior authorization, the health insurer may deny the claim and refuse to pay for the service provided.

Visit (Really watch this area for errors, especially using an old insurance card or out of date coding book!)

1. Pre-registration - The registration staff collects the patient’s demographic information and health insurance information and enters it into the practice management database.
2. Health insurer benefit verification - The registration staff confirms the patient’s benefits, applicable deductibles and/or co-payments by calling the health insurance company.
3. Patient check-in - The registration staff makes a copy of the patient’s health insurance card to obtain his or her health insurance information. They then enter this information in their health insurer reference log and their health insurer follow-up log for future reference.The registration staff also gives the patient a copy of the physician practice's payment and privacy policies.  
4. Documentation of services provided - The treating physician and/or clinical staff documents the patient’s history, symptoms, and diagnosis and treatment plan.
5. Assignment of codes - The treating of physician and/or clinical staff assigns and documents the appropriate diagnosis and procedure codes in the medical record, and on the physician practice’s super bill.
6. Patient check-out - The registration staff collects the patient’s balance (e.g.,deductible, co-payment) and schedule the next appointment. 

Post-Visit (Many errors happen here too, so a final review of the claim before you press send is well worth the effort!)

1. Code verification and review - The coding professional verifies and review the codes based on the documentation in the medical record.
2. Pre-authorization, pre-certification or pre-determination, as needed - The coding professional contacts the health insurer for pre-authorization, pre-certification or pre-determination  of the patient’s benefit coverage prior to a procedure or service if the health insurer requires this step. The coding professional documents the health insurer’s authorization number and supporting documentation and forwards this information to the staff responsible for billing.
3. Claim generation - The billing staff enters the codes and fees as they appear on the physician practice’s super bill and then generate a paper or electronic claim.
4. Claim review - The billing staff reviews each claim for completeness and accuracy before submitting it to the health insurer.

The wrong diagnosis (ICD-9) or procedure (CPT) code(s) used in medical claim preparation is a common cause of a wrongly denied medical claim. This video provides an overview of  the CPT book. It is useful for the patient also to understand how a doctor visit becomes a bill becomes a claim. If the claim gets messed up, you can talk to the insurer from a knowledgeable place, and they're more likely to reprocess your claim without an appeal.