For a process that can be so simple, many make it so hard.

Let's start at the beginning. What software are you using to process your claims? That decision alone can solve a litany of problems. There is not enough space available to analyze all and it would not be fair to promote only one.

Is the software easy to understand? Does it allow you to make additions, corrections, subtractions, and other modifications on the fly? If you have to stop at one spot and back up to go to another just to make a simple change, it is not efficient and will cost you money. How much time does it take to get someone proficient on that software? This is where the old adage of KISS (Keep It Simple Sweetheart) really comes into play. Once you have selected an appropriate software, you need an interface between you and the insurance companies so you will be able to transfer your claims. Most claims now go electronically, but a few still drop to paper. You must have the correct address for the paper claim. That should come from the patient information. The electronic transfer should focus on a connection that is as direct as possible to the payer. Most software companies will attempt to get you to use a clearinghouse from an approved list. They want to continue making money from you after you purchased the software and that may not be what is best for you. It may be quick and easy, but it may not be as reliable as it is made out to be. I prefer to have direct connections with as many of my payers as is practically possible.

Next, your billing staff, are they adequately trained? I get a lot of applicants right out of technical school, and yes they have a smattering of knowledge, but they are not ready to begin keying data. I usually train them for at least another six months before they get their own accounts. Once I am confident they have an understanding of the basic architecture of the software, I then put them with a mentor while they work on their first account.

It is not easy to tell someone every nuance necessary to key every claim. They just have to be taught as the situation arises. Some things happen so seldom that you cannot cover every single aspect of what has to go into what spot. You must have someone on your staff who has spent several years keying data into a particular software before they are fully versed in the needs of filing each and every claim.

Now that we know we have software and data entry that can handle the day to day of filing claims, we need to focus on the front office. Are they adequately trained in getting the information necessary to get the claim paid? The front office must control the encounter with the patient. The patient profile form and releases must be complete to the extent that all information necessary to identify this patient is provided. The form must ask for and retrieve all of that data. The patient must fill it out. Do not allow a patient to skip over a portion or leave a portion blank.

If the patient does not have a secondary or tertiary insurance, require that they state so on the profile form. Have them write NONE on the space for secondary or tertiary. Many patients will object to having to give you all of the information, but you need to make a decision as to whether you are in the charity business or a practice that will sustain itself and provide a profit for you and your family. I have had patients come up to me and say "I don't have to give you all this information." I do not object, I simply agree and say "You are absolutely right, you do not have to give me all of that information if you wish to pay cash for today's visit. There will be deposit of $300.00, will that be cash or check? However, if you wish for me to file your insurance, you will need to provide me with the information on the form." They always back down and begin to fill out the form.

While we are on the subject of the form, make sure it is legible. If your front office cannot decipher what is written down, rest assured that the medical billing office will not be able to either. Make copies of all supporting documents (front and back); insurance cards, drivers license, and any other documents. Again, make sure those copies are legible. There is no better time to do that. You have everything right in front of you right now! If the copy is not legible have the front office physically write the numbers and identification information from those cards onto the copy paper and adjacent to the copy of each pertinent card.

Next, call the insurance company or go on-line and verify the coverage. What is the start date, what is the term date, is there a co-pay, is there a co-insurance, is there a deductible, what is the deductible and has it been met? Never trust the information on the card-verify. While you are verifying the payment information get the correct address to mail a paper claim. Even if you do not intend to file a paper claim, this is the time to get that information. You never know when you might need it. Your patients are asking you for credit and you must verify that they are creditworthy! Develop protocols and insist that your staff follow them. If they cannot follow them, you have the wrong staff. Try going to WalMart to buy an item with an expired card and see what happens. Their staff will not let you slide and neither should your staff.

Now that we have all the pertinent information, the task rests with you, the physician. Do your part; document, document, document. When you are filling out your encounter form, write down everything you do. Leave nothing out. If you do not ask for it, you will not get it paid. Your staff should know whether a modifier needs to be applied, but I encourage you to understand them as well. Today I saw a fee ticket where the provider put down an after hours code but had not listed an E&M procedure. After hours codes are in addition to the service performed. The current code under consideration was 99050. Next, put down a diagnosis code that supports the procedure(s) you performed. Make sure it is to the greatest degree of specificity. Give your staff copious ammunition to get you paid.

Once you have completed your task, turn the paperwork over to that well trained medical billing staff utilizing that efficient software and you are as good as paid.


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