Processing error-free medical claims is the vital task for every healthcare facility to keep reimbursement flowing into the system. There are lots of official procedures and directions that need to be followed when a patient arrives at the physician’s office. It is the responsibility of a front office staff to handle patient’s personal and insurance information and also determine the financial responsibilities of the visit. Entering wrong information or using old insurance card may cause unnecessary delay in claim processing and it often leads to claim denials and delay in payment. Below is a series of steps during a doctor visit that result speedy and maximum reimbursement for patient’s healthcare services.
Step1: Pre-register Patients
Let’s take a look at the healthcare facility where a patient makes a phone call for scheduling an appointment with his/her physician. Typically, front office receptionists are present to pre-register patients. This step is mandatory for the following reasons:
- 1. Scheduling and updating appointments
- 2. Gathering basic personal and health insurance information
If a new patient requires an appointment, he must provide his demographic and insurance information as well as the medical reason for his visit. These all are entered into the database and a suitable appointment time is scheduled. Returning patients are also enquired about the medical reason for their doctor visit.
Step2: Determine Patient’s Financial Responsibilities
This step has immense importance for submitting correct bills to third-party payers for patients’ covered services. Front office staffs must confirm the following details before patients check-in.
- Whether health insurance policy is active or out-dated.
- If patient needs any referral, then verify referral physician information.
- The type of health plan.
- Patient’s health insurance coverage
- Uncovered medical services
- Billing rule of the plan
- Whether the specified policy is primary or not.
After getting confirmation of the above facts, medical insurance specialists ensure that physician’s office would be reimbursed for the medical services provided to patients. It also confirms that patient can pay for the medical expenses that are not covered under the existing health plan.
Step 3: Patient Check-In
Now the patient arrives at the practice for the appointment. Now he is requested to fill out the patient demographic form that includes information about patient’s name, contact details, date of birth, sex, marital status, social security number, employer’s information and also emergency contact information. The demographic form also includes insurance information such as primary insurance company, subscriber’s name and DOB, policy number and group. The policy number helps to recognize the insurance plan that covers the patient’s medical bill. He is also asked to hand over a copy of his medical insurance card. The insurance information provided by the patient needs to be verified.
Input Patient Information:
Health Insurer Benefit Verification:
The staffs at the medical practice first confirm whether the patient’s policy is active or lapsed. Many denied claims are possibly tackled at this stage by necessitating the registration staff to verify with the health insurer regarding the patient’s benefits and coverage, coinsurance and deductible. The patients often visit the medical facilities with wrong or old insurance cards or may provide insufficient information. The registration staffs are responsible at all times to verify proper insurance information prior to initiating medical services.
It is mandatory to check any requirement of pre-authorization, referral or filing of any legal medical documents, especially in case of out of network physician or medical services. While performing the verification process, if it is found that patient’s insurance plan does not cover all the necessary treatment and procedure to be provided, then it should be clearly stated to the patient before commencing the medical treatment.
Step 4: Patient Check-out:
The registration staff arranges for the next appointment at patient’s check out, if required and collect any balances for the medical services utilized in form of co-payment and deductibles. In order to avoid the denied claims, the registration staff makes it sure that the medical services fees are properly charged and recorded in the database.
Once the check-out procedures are carried out, the immediate task is to send the patient’s medical reports to medical coding specialists for documentation.
Medical Record Documentation:
Using the standard ICD-9-CM and CPT codes, the medical coder enters the correct diagnostic and procedural codes in the database. This stage is important where the responsibility lies on the medical coder to properly identify the diagnosis made by the physician and various medical services taken as part of treatment. This document serves as a legal document and verifies the need of a medical treatment. This greatly reduces the chances of a claim being denied.
Preliminary Assignment of Codes:
The proper diagnoses and procedure is entered with use of standard ICD-9-CM and CPT codes. These codes are followed by the physicians or the medical staff to enter the patient’s treatment information. The reimbursement according to the medical super bill is determined with the correct diagnostic and procedural codes. The coding reference card contains a guide to the proper codes and super bill which could be referenced for coding by the billing staff.
Final Assignment of Codes:
For the further stages of the claim adjudicating process, the medical insurance provider checks and review the codes assigned by the physician following the medical documentation in the insurance database. The medical provider takes notice of the physician’s privacy policies and payment guidelines and tallies them accordingly to the patient’s insurance policy to ensure better claims. This completes the medical provider’s responsibilities associated with the patient’s visit and medical treatment at the facilities.
Completion of Super-bill:
After carefully reviewing the diagnostic and procedural codes, the medical coding specialists then complete the super-bill for further processing. The super-bill not only contains vital information on patient’s personal and medical history, sometimes it also includes several other details like patient’s outstanding balance, scheduled follow-up appointments etc. Finally it is then transferred to medical biller for calculating medical fees.