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Claims Processing: How Claims Are Authenticated

Payment for medical services can be a complicated process due to the involvement of a third party (insurance) with interests of its own. You may already know what the process of submitting a medical claim is like, but what happens after the claim leaves your desk and is sent on to the insurer? Here, we’ll discuss the standards set forth by medicare for authenticating medical claims, standards that are typically followed by other insurers.

What has to happen before a medical claim can be processed?

Medical Billing Process

Before a medical claim can be processed, it must first be authenticated through a rigorous process of signature analysis. This process is important for physicians and medical practices to understand so that they can submit authentication materials properly. What does an insurer look for in claim authentication?

First of all, any service that is provided or ordered for a patient must be signed for by the ordering practitioner, and this signature must be handwritten, electronic, or in the case of physical disability, stamped. Electronic signatures must come from a system that is protected against modification and signatures used to prescribe medication must be submitted through a qualified e-prescribing system. The signing physician and practice are responsible for the authenticity of the signature.

All signatures must be legible so they can be identified by those reviewing them. Failure to provide a signature or the presence of an illegible signature will result in the medical practice being assessed an error. If there is a failure to sign, the medical practice may submit an attestation statement from the author of the medical record, or progress notes showing intent to order tests.

If a signature is illegible, submitting a signature log may resolve the issue. A signature log is a document that contains physician names with their corresponding unique signatures, and can be used to establish ownership of a signature. Submitting a signature log initially may help reduce delays going forward.

It is very important that all medical claims can be accurately authenticated to avoid unnecessary services and overpayments. While this process may seem lengthy, it protects the patient, physician, practice, and insurer.

Filing medical claims can be a stressful process that weighs heavily on the staff of any medical practice. It doesn’t have to be, though. Simplify your medical billing and avoid costly, time-consuming errors by hiring a clearinghouse like Apex EDI. Apex EDI has everything you need to effectively file medical, vision, dental, and chiropractic claims without putting such a strain on your practice. Request a demo today, and see what a difference the right clearinghouse can make.

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Claims Processing: How to Write a Claim Letter

A health insurance claim letter is a letter a claimant writes to a health insurance company if the claimant’s doctor has not properly filed a medical claim. This letter typically seeks for a reimbursement to the patient after the patient has already paid their medical bill, per the agreement between the claimant and the insurer. It is only effective if the services in question are covered under the claimant’s insurance, and is not intended to be used to seek reimbursement for items not usually covered.

Who is responsible for submitting the Claim Letter?

Mature Woman Reading Letter After Receiving Neck Injury

The claimant will be responsible for paying any deductions necessary, and these payments will not be reimbursed. As well, the claimant needs to be aware of all documents and forms that must be included in the claim, and they must correctly fill out and submit these papers. While these may be different from one case (or one insurer) to another, the basic forms should include the following:

  • The completed claim form
  • Any bills for services rendered such as prescriptions, treatments, or tests
  • Receipts for medical bills
  • Hospital discharge papers
  • Surgeon’s bill (if relevant)

If your insurer requires original copies of these documents, it’s wise to retain copies. Any additional documents supporting the claim may be helpful even if they are not strictly necessary.

The letter itself should be short and contain only the details of your request and your insurance policy number. The letter should cite the terms of the policy that apply to claim. Most insurers require that you submit these claims within 7 days of completion of treatment, so timely submission is important.

At Apex EDI, we’re interested in taking the mystery out of medical billing, and making it easier for everyone. Our medical clearinghouse services are to help simplify the medical claims process, and save medical, dental, vision, and chiropractic practices time and money that they can put towards taking better care of their patients. Want to see what our company can do for your practice? Request a demo today, and stop doing claims the old fashion way.

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Claims Processing: How Claims Are Paid

The claims process starts when a service is rendered to a patient who has medical insurance. Once the service is provided, the patient may be responsible for some out of pocket expense, but the rest will be paid through insurance and will involve communication between the medical practice and the patient’s insurance provider. Here, we’ll discuss how those medical bills (or claims) get paid.

Invoice with pen and calculator; document is mock-up

Who is responsible for Billing?

Medical practices are responsible for billing the insurance company when the patient has an HMO, government sponsored plan like Medicaid or Medicare, or when the patient has a PPO and the medical practice is in the patient’s network. The medical practice should have a department that is in charge of creating bills by adhering to claims filing policies (which may be insurance-specific), and by assigning codes for each service rendered to the claim. Claims contain medical billing codes as well as patient identification information, and are submitted to the patient’s insurance in order to receive payment.

Once the insurance company receives the claim, they will look it over for errors and choose to do one of the following:

  1. Accept the claim and pay the full amount requested.
  2. Deny the claim due to errors and return it to the practice for correction.
  3. Reject the bill due to an incompatibility of benefits.

It’s important that claims are submitted correctly in order to get an accurate, timely payment. Services offered by us at Apex EDI can help you! We’re a third party clearinghouse that verifies claims before they get sent on to insurance companies. Having a third party clearinghouse allows medical practices to spend less time, money, and manpower on their medical billing while avoiding the costly mistakes that are often made through the complicated process of filing. Request a demo today and take the mystery out of medical claim filing.

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Claims Processing: The 5 Keys to a Successful Claim

Apex EDI is dedicated to simplifying claims management. Laying a good foundation with some basics steps to a good claim can help reduce stress and lead to a better result, so we’ve gathered 5 helpful keys to successfully filing a claim.

Wooden Blocks with the text: Claims

1. Determine Your Priorities

The first step to successfully managing a claim is setting a goal for what you want to accomplish through the process. Does a larger settlement outweigh a faster one? Are you more interested in the claim being processed smoothly or are you looking to generate cash flow? Your goal for the claim will help you and your team make decisions throughout the process.

2. Have a Team of Professionals Ahead of Time

Your insurer has a team of experts who know how to reduce their responsibility to you as much as possible. Because of this, it’s important that you, too, have a team of experts that can help you evaluate the responsibility of the insurer to your benefit and combat the team that the insurance company has put together. Having these people available and organized before you need them is ideal.

3. Have a Plan

It’s important to have a well-laid plan of how you’re going to deal with claims ahead of time to ensure that all steps are taken care of and all requirements are met throughout the claims process. Talk to claims management professionals to help you develop your plan, and engage with them when you need to argue a claim.

4. Prioritize Your Claims

Claims take time and attention to process correctly. Prioritize your claims by investing your time and money on the front end so that you don’t end up paying for it over the long term. Having dedicated employment for such matters, or hiring a third party to help deal with it for you, will be your best bet in ensuring that you get what is owed.

5. Manage All Your Information

Incorrect or incomplete information can cause a claim to get dragged on for much longer than it needs to be. Ensuring that you have all the correct information up front and double checking for errors can save you a lot of time and money in the long run.

When filing medical claims, it’s important not to waste time on mismanagement of claims. Let the professionals at Apex EDI clearinghouse help you get better results faster, and with less expense to you. Our feature-rich claim filing programs will help you get the most out of your billing team and your filing software, all at a competitive price. Learn more about what we have to offer by contacting us or visiting our website.

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Claims Processing: 5 Things You Must Know About Denied or Rejected Claims

Denied and rejected medical claims result in substantial financial losses for medical, dental, and vision practices. This is why it’s important to stay vigilant about these denied and rejected claims and keep on top of resolving them. Here are a few things that you should know about these claims that will help your office better deal with them.

1. The Difference Between Denied and Rejected Claims

Denied and rejected claims are not the same. A denied claim is one that is determined unpayable by the insurance company. Sometimes these are due to error on the part of those submitting the form and sometimes it is due to patient ineligibility for services rendered. Either way, the insurance company will let the office know what the reason for denial was on the Explanation of Benefits (EOB).

These claims can be appealed, but it’s better to try and avoid these if possible. A rejected claim is sent back due to errors, and is simply resubmitted with corrected information. Because constantly appealing and re-submitting denials and rejections can be costly and time consuming, it’s worth investing time and resources into ensuring claims are filed successfully the first time.

2. The Most Common Reasons for Denials and Rejections

Insurance companies have very strict requirements when it comes to how claims should be filed. Some of the most common reasons for rejections include incorrect service or diagnosis codes, missing or incorrect patient information, and insurance specific requirements that aren’t met. Hiring a reliable clearinghouse, like Apex EDI, that can scrub for errors and keep track of insurance specific requirements will help you avoid these errors, and save you time and money in the long run.

3. How to Resolve Issues Quickly

Many claim errors are made because of imperfect or out-of-date information somewhere along the line between scheduling an appointment and submitting the claim. Small oversights such as failing to consistently ask patients about changes to their insurance or patient information during sign in, or failing to keep up to date with insurance-specific requirements can lead to many unnecessary denials and rejections. Communication is key to ensuring that the most correct information is always used on claims.

4. Trends in Your Denied and Rejected Claims

Keeping track of trends in denied and rejected claims can help you catch repeating issues. By digging a little deeper you may find that a specific code or repeated error may be to blame for a large number of denied or rejected claims, and you may be able to significantly reduce the time and money you spend on resubmitting by simply resolving the error for future claims.

5. How Apex EDI Can Save You Time and Money

Using a reliable, hard working clearinghouse can help you reduce administrative costs, reduce the number of denied and rejected medical claims you have to deal with, and save you the time and money that is often lost through mismanaged claims. We have a feature rich program that makes it easier than ever for you to file your claims and catch mistakes the first time. Click here to discover all the features we offer and to learn more about how we can help you get paid faster with fewer headaches.

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