MBC104-Insurance Follow up and Collections Topic 1

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Insurance Follow up and Collections :

Insurance Follow up and Collections

Learning Objectives:

Learning Objectives At the end of this topic you will understand: Medical staff and how they play a part in the medical billing process Medical records How medical coding issues affect accounts receivables Patient authorizations Importance of verifying eligibility Importance of verifying patient benefits Birthday Rule

Why is insurance follow up important?:

Why is insurance follow up important? Identifying un-collected claims and turning them into cash is a very important activity for the accounts receivable team. If sufficient steps are not taken to resolve problem accounts they are sure to slide to the un-collectable status. Handling medical accounts receivables has become tedious, difficult and time consuming for hospitals and healthcare practices.


Cont. Each time a medical claim is submitted, the end result should be payment from an insurance company. However, this is not always the case as more medical claims are denied due to data entry errors or missing documentation such as medical report, authorizations or primary insurance explanation of benefits .

Why follow up on insurance claims?:

Why follow up on insurance claims? As a medical billing specialist, it is critical to understand why claims are denied and what you can do to increase cash flow for the medical practice.

The Medical Billing Process:

The Medical Billing Process The medical billing process is the first processes you should understand when working on accounts receivables. From the patient to the doctor, every staff member plays a part of the medical billing process.

Medical Billing Process:

Medical Billing Process The beginning process starts when the patient calls for an appointment. Once the patient arrives, the medical front staff will ask the patient to complete several forms this will help create a medical record and financial record for the patient.

Medical Billing Process:

Medical Billing Process Patients will also have to have a recent copy of their insurance card, the card will tell the front office staff which insurance the patient is covered under and it will include the phone number to verify eligibility and benefits.

Medical Billing Process:

Medical Billing Process Once the patient registration form is completed and the insurance card has been copied, the patient will wait to see the medical doctor. In the meantime eligibility and benefits should be verified prior to actually being seen by the doctor, in fact this should be done prior to the patient arriving for the appointment, usually the day before.

Medical Billing Process:

Medical Billing Process After the medical visit, the doctor will indicate on a superbill or encounter form the level of office visit and the diagnosis for the visit. It is very important at least one of each are indicated on the form otherwise a claim cannot be submitted.

Medical Billing Process:

Medical Billing Process After the patient visit the paperwork will be given to the medical biller for the medical office to begin submitting the claim for reimbursement. The registration form, a copy of the insurance card and superbill/encounter form should all be included during a patient’s first visit.

Patient Records :

Patient Records The patient’s records are a very important to the medical billing process, as mentioned earlier in this chapter, the patient records can be a collection of several documents such as: Patient Registration form Insurance Card copy Referral Superbill/encounter form Progress Notes Radiology reports Laboratory Notes

Medical Office Staff :

Medical Office Staff Everyone in the medical office will play a major part in whether or not a claim is paid the first time. For a small medical practice, the staff may include: Physician Front Office/Receptionist Medical Assistant/Nurse Medical Biller/Coder In some cases there may also be an Office Manager or the Physician may act as the Manager of the practice.

Medical Records :

Medical Records A medical record is composed of a number of sections. Be sure you understand how your office’s medical records are set up. You may need to refer back to them especially if claims are denied for medical related reasons such as medical necessity .


SOAP NOTES The most common format for a progress note is the SOAP note. S-Subjective - This describes the patient's current condition in narrative form. The history or state of experienced symptoms are recorded in the patient's own words O-Objective Findings - This section will indicate Vital signs , findings from physical examinations , such as posture, bruising, and abnormalities, results from laboratory tests, measurements, such as age and weight of the patient. A-Assessment - Is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis , a list of other possible diagnoses usually in order of most likely to least likely. P-Plan - This section indicates what the doctor will do to treat the patient's concerns. It should address each item of the differential diagnosis. A note of what was discussed or advised with the patient as well as timings for further review or follow-up may also be included.

Medical Coding:

Medical Coding With medical coding, it is especially important to use either a web-based system for submitted the most current CPT and ICD-9 codes, or the current year’s coding manual. Codes change yearly they are either deleted, moved to another section within the coding manual or new codes may be added.

Medical Coding:

Medical Coding CPT codes are used to bill for services such as office visits, laboratory, radiology, immunizations, therapies, and surgical procedures. ICD-9-CM codes are used to link a diagnosis to the CPT or Procedure code.

Medical Coding Linkage:

Medical Coding Linkage For example, if you bill for an office visit, you must tell the insurance company the reason for the visit by the patient such as nausea, sprain or treatment for diabetes etc. Also the CPT code must link which means if you bill for a short arm cast, you must link a diagnosis code related to having a short arm cast applied such as a broken or sprained arm.


Authorizations If a patient’s insurance is covered under an HMO, or depending on the patient’s health plan, some services must be pre-authorized. A pre authorization is the same as getting an “ok” from the insurance company to provide a particular service to a patient

Eligibility :

Eligibility There may be occasions when a patient will switch insurance plans or become ineligible for medical care, when this occurs it becomes the billing specialist’s responsibility to obtain payment from the patient. One way to avoid this is to verify eligibility at least 1 or 2 days before the patient’s scheduled appointment.

Benefits :

Benefits It is equally important to verify benefits for all new patients. Verifying benefits ahead of time will help avoid unpaid balances owed by patients. Usually benefits can be verified through telephone voice response systems.

The Schedule of Benefits -:

The Schedule of Benefits - Tells what the insurance company pays and what patient’s are responsible for. It lists the deductibles, the insurance percentages they pay, the co-pays the patient is expected to pay at each doctor's visit, etc.

Covered Benefits :

Covered Benefits When working with Government programs such as Medicare and Medicaid, a list of covered benefits are available for your review. Take the time to review all covered services to better inform your patients if at any time during an office visit a non-service is needed. When a non covered service is to be performed, have the patient sign an acknowledgement form agreeing to pay for the service.

Birthday Rule :

Birthday Rule The birthday rule is often used to determine which plan is primary and which is secondary. Under this rule, the plan of the parent whose birthday occurs first in the calendar year is designated as primary.

Birthday Rule Exceptions:

Birthday Rule Exceptions Like most rules, the birthday rule has exceptions: If both parents share the same birthday, the parent who has been covered by his or her plan longest provides the primary coverage for the children.

Birthday Rule Exceptions:

Birthday Rule Exceptions If one spouse is currently employed and has health insurance through a current employer, and the other spouse has coverage through a former employer (e.g., through COBRA), the plan belonging to the currently employed spouse would be primary.

Birthday Rule Exceptions:

Birthday Rule Exceptions In the event of divorce or separation, the plan of the parent with custody generally provides primary coverage. If the custodial parent remarries, the new spouse's coverage becomes secondary. This order of payment can be altered by a court-issued divorce decree or by agreement, but the insurance companies must be notified.


Summary In order to understand insurance follow up and collections, you must first understand your medical office, the staff and how each activity will in the end play a major part in your ability to obtain reimbursement from insurance companies and patients.


Summary It is very important to regularly communicate with other staff to ensure the proper information is collected from patients especially new patients, documentation is legible and accurate. Patient demographic information can change throughout the relationship with the medical doctor, it is the office staff’s responsibility to keep this information current to avoid financial problems down the line.


Summary Begin a process for checking and verifying accuracy of medical/patient information . Check with your supervisor or employing physician for specific processes you are allowed to implement.

End of Topic 1:

End of Topic 1 Congratulations, you have completed the presentation for topic 1 If you have any additional questions, please contact your instructor

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