Continuous changes in health insurance reimbursement guidelines result in an often complex medical billing scenario. This is unlikely to change. Evaluate your intake to charge to claim submission workflow and follow the basic best practices to target preventable denials and maximize reimbursement on the first pass.
With insurance company requirements, provider input and government regulations to factor in, it's no wonder that a brief cheat sheet might be necessary to keep your billers sharp. Consider putting these items on the list:
Payers Contracted: Identify at a group and physician level. Include carrier, plan name/type(s), phone numbers, electronic payor identification numbers, claims address(es), website urls, patient portion estimator website urls, contract expiration dates, etc. The document should be set up so that it is easily sortable by any criteria such as plan name, state, physician name, etc.
Filing Dates: Note the filing dates required by each insurance carrier making sure you list the number of days to file a claim after a service is performed as well as timely filing requirements for appeals.
Referrals / Prior Authorizations: Record which payers demand prior authorization and / or referrals for providers including what information is needed to process the authorization. This might be:
Medical records or past medical history
Diagnoses supporting the procedure
Prior treatment
Results from prior treatment
Doctor progress notes
When the illness, symptoms, disease occurred
Time frame in which authorization or referral is required before service rendered
Frequency Allowed / Remaining: This is part of the insurance eligibility check and should be documented in the electronic record or file. This needs to include the number of allowable procedures and detail the process that needs to be followed for billing multiple procedures. There's nothing more frustrating for a patient than having a service denied because his maximum frequency/benefit was reached.
Claims Submission: How can the claim be submitted and on what form? Ie electronic, paper, secondary and corrected claims.
Decision or Payment Receipt: Insurance payers need to submit payments within a certain time, usually 30 days. Know the time frame and become familiar with your state's prompt pay laws. Create a systematic method for follow up by separating no response claims into its own follow up queue list and take action to resolve the issue.
Appeals: Make sure you follow the payer's appeals process to mitigate unnecessary delay. When handled right, appealing medical claims can accelerate payments for denied claims.
Denials: Establish a systematized method for resolving denials while trending patterns to ascertain why it happened so workflow processes can be adjusted to reduce future occurrence when applicable.