Each year, The American Medical Association provides physicians with a National Health Insurer Report Card ( NHIRC). This report covers the percentage of medical claims each year that receive zero payment.
If we look, for example, at a 2009 report for Anthem Blue Cross, 4.34% of their received claims were not paid.
Although these numbers will change from year to year, the fact remains that the percentage of claims denied by Medicare and commercial insurers translates into millions of lost dollars for physicians and health care allied practitioners.
Services provided in good faith and for the purposes of diagnosing and treating disease, should be reimbursed in the same good faith. There is really no reason why any medical claim should be denied and yet the numbers released each year by NHIRC show a different picture.
With the implementation of ICD-10 and the other demanding changes by CMS and private insurers, we need to be more vigilant than ever in making sure our claims go out clean.
There are four major reasons why claims are denied :
Incorrect patient demographics or insurance information.
Lack of referral/ authorization.
Incorrect diagnosis code.
Timely Filing.
Incorrect Patient Information - In an environment where phones are constantly ringing and patients are being checked in and out, the front office may not always be as diligent as they should in obtaining patient information, or when entering patient information into the computer system. Claims are often denied for incorrect spelling of patient names, incorrect address, date of birth, even zip code.
Medicare will deny any claims where the name listed in the transmission of claims does not match the exact name as it is show on the Medicare ID card. Unless Jr. / Sr. or an abbreviated form of the name is shown on the Medicare card, do not put this name into your system.
Another serious issue facing seniors today is that the Medicare managed plans aggressively market Medicare patients and many seniors find the low or no deductible and the prescription plans offered are an attractive alternative to Medicare. Unfortunately, I have found that many seniors are not aware that once they join these plans, they surrender their Part B Medicare coverage. They present in the physicians office, their Medicare card in hand, and often it is not discovered that the patient no longer has Medicare,
until the claim is denied by the private insurer for timely filing. Many of these plans also require a referral so they will also be denied for lack of prior authorization.
This has proven common enough in medical practices that do not perform adequate verification prior to the date of patient appointment, but luckily the problem is easy enough to solve.
1. Create a verification department - Every medical practice should have at least one employee whose sole function is insurance verification. In large practices, where each physician has a staff member assigned to track his daily activities, this task can be performed as part of the daily ritual. Print out your appointment schedule every day and list the verified insurance next to the patients name. When the patient arrives for the appointment, look at the listing and make sure to check that the insurance has not changed between the time of verification and appointment.
An easy way to assure that verification is done correctly is to utilize a practice Welcome Sheet. I understand that in the techo-world we inhabit, many systems have electronic verification, but in order to make sure that we avoid any and all pitfalls to revenue, I still recommend that a paper Welcome be utilized especially since you will learn patient deductibles, and the correct mailing address for every claim. Once your practice recognizes that the Welcome is the best way to verify insurance, it will become an essential part of the daily office routine and the billing department will have easy access to insurance information, since the Welcome for each patient will be attached to the patient encounter.
A new Welcome should be done each time a patient changes their insurance affiliation and should be updated for return patients who have not been seen for three months or longer. For those practices, who refuse to have even one extra piece of paper, the Welcome can be scanned into your system and completed on system and the billing department will still have easy access to the patients information.
The Welcome is completed as follows :
Your patient calls to make an appointment - Whenever a new patient calls to schedule an appointment, the front office or verification staff member will note the patient's personal demographic information for both the primary and secondary plans. This information will also include the relevant demographics for the guarantor of the plan. * I always request that the patient has their insurance card in hand, when I ask for their information *
The patient will provide all insurance ID numbers for both the primary and any secondary insurances. The phone number for member services is listed on the back of the card and this number should also be noted on the Welcome. Some of the smaller insurance companies, and many local and union plans have a variety of phone numbers so it is important to note these for future reference.
After the demographics are noted, the patient is given an appointment, and the Welcome is given to the verification department.
Verification staff calls both the primary and secondary insurance companies and answers all questions listed on the Welcome sheet. They will also make sure to check that the physician who is rendering services is a participating member of the insurance plan. Timely filing requirements for the plan will also be noted. The verification department will also note the date the insurance was verified along with the name of the representative that they spoke with to gain benefit information.
For specialty practices, a section can be created where pre-certification requirements are noted for each procedure. Only after completion of the Welcome is the patient insurance information entered into the system. You can easily adjust any system to accommodate this feature.
The Welcome should be available to attach to the daily encounters or billing sheets and I always attach a copy of the patient referral and authorizations to the encounter as well. If the Welcome sheet is scanned into your system, the physician can also pull this up at time of visit and learn whether the patients insurance covers certain procedures or testing and discuss other options with the patient if they are underinsured.
The Welcome is an easy way to make sure that each one of your claims goes out squeaky clean
Monday : A Sample Welcome Sheet for Your Practice and other tips for Clean Claims....
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