Chapter 3: Basics of Health Insurance Lesson 2_Topic 4 Claims Processing

Basic Methods of Processing Insurance Claims Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Manually preparing claims for submission In-office electronic filing by fax or computer Contracting with an outside service bureau Use of a telecommunications networking system Some offices may do a combination of all methods to submit claims. Electronic billing is becoming more common, due to HIPAA regulations for claim submission. Smaller office may still complete claims manually.

Basic Steps in Handling an Insurance Claim Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Basic Steps in Processing an Insurance Claim (page 69-70) Have the class discuss each step in the claims handling process described in Figure 3-6B (p. 70). . Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Patient Registration Form Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Patient’s name (first, middle initial, last) Street address and telephone number Business address, telephone number, occupation Date of birth Person responsible for account or insured’s name Social Security number Spouse’s name and occupation Referral source (i.e. physician’s name) Driver’s license number Emergency contact information Insurance billing information refer to Figure 3-7 (p. 71) for the patient registration form. To save time, the form is generally mailed to the patient to fill out. How often should patient information be updated? (every visit) An update form updates all pertinent information from the original registration form.

Insurance Card refer to Figure 3-9 (p. 72) for the insurance card. Both sides of the patient’s insurance card must be kept in the patient’s file. The insurance card should be checked on each visit to confirm coverage and to verify there has been no change in carrier. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Patient Signature Release Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. When is this used? (When a patient assigns medical benefits to the physician, so the physician can be reimbursed for services provided to the patient.) What is an assignment of benefits? (The transfer of legal rights from the patient to the provider, so the provider can collect the amount payable under an insurance contract.) Explain the difference between a participating provider (par) and a nonparticipating provider (nonpar). (A participating provider has a contractual obligation with an insurance plan to render care to eligible beneficiaries, bill the payer directly, and accept the allowed amount; a nonparticipating provider is a physician without a contractual obligation.) Discuss the different assignment of benefit factors for private carriers, managed care plans, Medicaid, Medicare, TRICARE, and Workers’ Compensation. (see Glossary, p. 659, under “Assignment.”)

Encounter Form (Superbill) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Attached to the patient’s medical record during an office visit Combines a bill, insurance form, and routing document Can also be a computerized multipurpose billing form to input charges and diagnoses into a patient’s account Figure 3-13 (p. 76) for the encounter form. What specific information is included on the form? (patient’s name, date, previous balance due, procedural and diagnostic codes for provided service(s), date for follow-up appointment, balance due, insurance carrier, total fee charged, referrals, etc.) The patient should always be given a copy of the superbill at the end of the visit so that he or she is informed of the services performed and billed. The patient should be encouraged to compare his or her explanation of benefits (EOB) to the superbill. This will assure the patient that all services were billed correctly. What are the benefits of an encounter form? (all the information about the patient encounter is included on one form)

Financial Statement (Ledger Card) Figure 3-16 (p. 79) for the financial accounting record. What information is included on the financial statement (ledger card)? (provider information, account number, patient name/address/contact information, insurance company, policy number, itemized fees for services, running balance of amount owed on account, insurance claim submission date, payment from insurance company, any adjustments, any patient payments) Step-by-step instructions for completing a ledger card are included in the procedure on p. 85 of the textbook. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Minimum Information Required on CMS-1500 Claim Form Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. What was done? (services and procedures using procedure codes) Why was it done? (diagnoses using diagnosis codes) When was it performed? (date of service) Where was it received? (place of service) Who did it? (provider name and ID number) Explain what cases these guidelines are used for. (All hospitalized [surgical and medical] patients, all claims in which benefits are assigned to the physician, and special procedures [minor surgery, extensive testing]) What determines the length of time limits for filing insurance claims? (commercial carrier, federal or state program, whether claim is for illness or accident) When can financial losses occur due to a delay in filing a claim? (If the patient has a long-term illness, if several physicians treat the patient)

Provider’s Signature Acceptable formats: Handwritten Computerized Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Acceptable formats: Handwritten Computerized Electronic signature Digital signature STAMPS are NO longer acceptable Describe the responsibility of the physician’s representative when providing signatures. (A physician’s representative signs insurance claims on behalf of the physician. The physician must authorize the representative to do this, with a legally-binding document [Fig. 3-18, p. 81]. The representative must sign claims in a legally responsible manner, or he/she could face fraud or abuse charges.) Have students describe the different formats for an acceptable signature. (Handwritten are actually written by the physician; Signature stamps are ink stamps with the physician’s signature; Electronic signatures use a key entry or a pen pad to capture the live signature; Digital signatures are lines of text or a text box with the signer’s information that attaches from within a software program)