August 03, 2020



The doctor visit itself is where TONS of denials and underpayments happen - mostly because of bad information being introduced into the process at various times. For instance, a provider's out-of-network tax identification number (TIN) is entered, and instead of a copay, it goes right to your deductible. Old insurance card used? Claim denied for lack of coverage. Understanding how they are generated and processed is paramount in avoiding a needlessly denied claim and getting the claim paid correctly the first time. Below is a general description of a doctor visit that will result in a "clean" and correctly processed claim.

Pre-registration  The registration staff identifies the reason for the visit, gathers the patient registration information (such as the patient’s demographics) and schedules a convenient appointment time. They verify the patient’s health insurance coverage, pre-authorization requirements and/or referral physician information and then complete the necessary forms. They might remind the patient of any outstanding balances and of the practice’s payment policies. Tools that a physician practice might employ to convey patients’ financial responsibility include patient welcome letters, educational brochures, insurance fact sheets and medical cost estimate forms.

Health Insurer Benefit Verification The registration staff verifies a new patient’s benefits and coverage before initiating services. Frequently, patients present outdated health insurance cards with invalid information. Practice staff often have no other way of knowing whether the patient is eligible for coverage without verifying this information directly with the insurer. A denied claim is much more likely if the practice does not verify patient benefits.

It is becoming more common now for physician practices to verify patient benefits online. The most important data to verify are the applicable deductibles and co-payments; benefit coverage for in-network versus out-of-network services; and the patient’s coverage for any procedures, services or tests that the physician practice may perform.

Patient Registration The registration staff obtains a copy of the patient’s health insurance card at the time of his or her first visit. Reviewing the card before the follow-up visit helps the physician practice routinely verify the required patient and health insurance information. They may update patient health insurance information by asking patients at each visit whether their health insurance information has changed.   

Physician practices may try to educate patients about medical treatment decisions, as well as health insurer payment policies. Industry trends indicate that both insurers and employers are shifting more of the responsibility and cost of health care treatment and payment ot the patient. In order to avoid a denied claim, physician practices now often proactively consider revising their payment and collection policies accordingly.
Medical Record Documentation  The physician and clinical staff assess the patient’s condition and thoroughly document the symptoms, diagnosis and treatment plan (including lab requests), and all procedures and services provided in the medical record. This is a critical step in the claims management revenue cycle. An appropriately documented patient medical record can reduce many of the hassles associated with claims processing. It may also serve as a legal document to verify the care provided.
The medical record is a tool of clinical care and communication.  The physician practice supports the ICD-9-CM and CPT codes it reports on the claim form with specific documentation of the diagnosis, procedures and services. If the practice does not document a procedure or service, then as far as the health insurer auditor is concerned, the physician practice did not provide that procedure or service. The physician practice includes the following in the documentation:
  • The site of service
  • The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided
  • Indication of the procedure or services provided, which will support the accuracy of the CPT codes the practice reported
Preliminary Assignment of Codes Physicians include the correct ICD-9 code in the medical record to describe the appropriate patient diagnosis and the CPT codes to describe the services and procedures provided. The physician work included in a CPT code defines a specific procedure or service during a patient encounter.
A coding reference card contains a listing and description of the physician’s most commonly recorded ICD-9-CM and CPT codes in the physician’s own terms. It helps the physician select the appropriate diagnostic or procedural codes for placement on the practice’s super bill. To ensure correct coding, the billing staff frequently update the coding reference card and super bill, incorporating new and revised ICD-9-CM and CPT codes.
Patient Check-out During check-out, the registration staff schedules the next convenient appointment time for the patient, if needed, and collect the patient’s co-payment and/or deductible if they did not collect it during the check-in  process. Therefore, in order to avoid a denied claim, the registration staff refers to the patient’s policy to determine the appropriate co-payment. If the patient indicates that he or she is unable to make a payment for the services provided, they resolve the non-payment issue directly with the patient through a payment plan the practice manager and patient agree upon.
Final Assignment of Codes Physicians and coding professionals work as a team to accurately record the patient diagnosis and services provided. Because the physician is ultimately responsible for the codes selected, he or she provides the ICD-9 and CPT codes describing the diagnosis and services provided during a patient encounter. The coding professional then review the code selections for appropriateness, based on the medical record documentation.

After reviewing the medical record documentation and code selection on the super bill, the coding professional ensures that the physician practice has identified and coded all the physician services rendered as well as medications and supplies the physician practice provided. If appropriate, the coding professional will add modifiers based on AMA CPT coding guidelines and conventions and rank the ICD-9 and CPT codes in the appropriate order. The most comprehensive CPT code is listed first. The coding professional also reports the primary ICD-9 code to the highest level of specificity (e.g., make sure the fifth digit is included when required).

Ultimately, it is the responsibility of the patient to pay for any medical costs associated with medical services. If you have current coverage, you should present your most recently issued card or information at the time that the medical services are rendered. Instead of being surprised when your insurance does not cover all the costs you incurred, make sure you are educated beforehand about your policy coverage. Do not be afraid to ask questions and speak to your insurance company prior to a doctor’s appointment, hospitalization, procedure, or test.  
Gather Insurance Information  The patient brings the insurance card to the appointment.  The receptionist will make a copy of this card.  This card has information that tells the doctor’s office staff who is responsible for paying the bill for the appointment.  Some people have more than one type of insurance.  For example, they might have private health insurance and Medicare. If they have more than one type of insurance, knowing which health insurance is the “primary insurance,” - the insurance the doctor’s office bills first - is important. It is necessary to therefore bring all insurance cards to the appointment in order to avoid a denied claim, 

The staff uses this information to send the health insurance company a request for payment of the medical bill.  The health insurance company requires personal and health insurance policy information before it will pay the bill.  
Staff needs the current health insurance policy information, including the health insurance company name and address, policy number, group number, etc., so the health insurance company can pay the medical bill on time.  Much of this information may have changed since the last visit to the doctor. 
The services covered by the health insurer also may have changed.  This insurance information is required at least annually along with an updated signature authorizing the provider's office to release the information to the insurance company.

Typical Patient Questions:

  • Will the doctor’s office get pre-authorization for certain tests, procedures, and surgeries?
  • Will the doctor accept the insurance company’s payment as payment in full?
  • If having surgery, will there be other health-care professionals (for example, an anesthesiologist) involved in the care who will be billing separately?
  • Does the health-care provider submit the bills to the insurance company or does the patient have to?
  • Is a co-payment required at the time of the appointment?

Related Resources: 
1. "How to Improve Your Revenue Cycle Processes in a Clinic or Physician Practice", Janice Crocker, MSA, RHIA, CCS, CHP, AHIMA's HIM Body of Knowledge, (2006).

Health insurance considerations are all part of the patient flow process described above and in this video. Whether it's a clinic or a top notch institution such as Cincinnati Children's Hospital, improvement in this area is always sought and one goal throughout the process is avoiding that needlessly denied claim.