Chiropractic claims are a little different than most other medical claims. Chiropractic services have only recently been considered medically necessary, and only under very specific circumstances. This makes it even more important for claims to be done correctly so as not to be rejected by insurance companies.
Who Covers the Procedures?
Most insurance companies will only cover procedures where a patient’s spinal column is manually manipulated to correct an issue of alignment, physiological function or movement integrity. This does not include any other services the chiropractor may offer such as diagnosis of the issue, although a diagnosis is necessary to show the insurance company that the service was medically necessary. As well, the patient must exhibit a significant health problem that justifies the use of manual manipulation of the spine.
This means that subjective comments from the patient, objective findings, diagnosis, and treatment must all support the medical necessity of the procedure in order to receive payment from the insurer. It’s important to make sure that you are using the proper billing codes so that it is clear what is being charged for and that the services meet all of the necessary requirements. Codes should be specific to the region that was treated, even if the entire spine was manipulated as part of the treatment. As well, patient information must be accurate and updated frequently to avoid claim denials and rejections.
Chiropractic medical claims require more explicit accounting practices than other more traditional medical claims, and mistakes can lead to headaches when having to deal with insurance companies that are hesitant to cover services. Consider hiring a medical clearinghouse that knows the ins and outs of chiropractic billing, and can ensure that you’re sending the most accurate billing information the first time. Apex EDI offers services to medical, dental, vision, and chiropractic practices and thoroughly vets claims before they are sent on to insurers. Request a demo today to see how Apex EDI can help your chiropractic practice get their claims in order.
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.
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:
- Accept the claim and pay the full amount requested.
- Deny the claim due to errors and return it to the practice for correction.
- 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.
It’s important to stay on top of medical claims and ensure that they are being filed correctly. It will save you and your patients time and money that would otherwise be spent missing or chasing errors with the insurance company. The best way to keep ahead of these mistakes is to conduct medical claim audits from time to time.
What does it take to conduct an audit of your business’s medical claims?
You’ll need to organize either an internal or external review of how your medical claims are being filed, and determine where there are insufficiencies. You will need to determine whether a full audit of all recent medical claims is plausible or if you will instead take a random sampling. Some of the items that you will be examining include the following:
- Reviewing coding accuracy, and making sure staff are assigning the correct codes for services rendered.
- Identifying outdated codes.
- Correctly identifying opportunities for reimbursement.
- Identifying mistakes that may put the practice at risk for liability.
- Reviewing changes to policies or procedures.
Once you have identified any possible discrepancies in these categories, it’s important to create a report that can be addressed by an administrator. A plan should be put in place to adjust training or implement new checks to ensure that these discrepancies are taken care of so that medical billing can run more efficiently.
Internal medical audits can be costly, as they take a lot of personnel and hours to complete. Many practices do not have these resources available, so an external review would be better suited to their needs. Hiring a reliable clearinghouse such as Apex EDI can take much of the stress out of audits, and our professional staff and excellent software will ensure that you get accurate reports every time. Try a demo for free and start streamlining your medical claims filing today.
At Apex EDI, we’re interested in helping you find the best solutions to your medical claims issues, and avoid pitfalls that cost you time and money over the long run. We know that the world of insurance can be confusing and intimidating, so we want to help pull back the curtain a bit on what goes on behind the scenes of filing insurance claims.
Something we get asked about a lot are the viability of claims management companies, companies that file complaints against financial institutions on behalf of a client. They go after these financial institutions for you for unpaid claims and disatisfaction with service, and promise great large and timely compensations.
These claims companies will do all the work for you. They will represent you to the company that you are filing a complaint against and fight on your behalf for the highest payout possible. They employ professionals who know the ins and outs of how to settle disputes with financial institutions, and may have more insight than you do into the value of your claim.
Financial institutions have an incentive to keep their liability as low as possible, and it can be difficult for a lay individual to catch them in the act or know how to combat them effectively. Hiring a claims management company can help you get the best payout possible. If you choose to use a claims management company, make sure that it is a reliable one. You can vet the company by checking that it is regulated by the Ministry of Justice and a member of a professional body.
Looking for more professional help with claims? Filing insurance claims is our specialty at Apex EDI, and we offer the professional support and high tech features you need to save time and money on processing your medical, dental, or vision claims. Contact us today to learn more about how we help you get the most out of your team and your software by making it easier than ever for you to reduce the number of denied and rejected claims you receive.
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.
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.