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Avoid Medical Claims Billing Problems

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All providers want to be reimbursed promptly and accurately for their services. Unfortunately, human and electronic errors are unavoidable and can slow down medical claims processing. Our goal at APEX EDI is to reduce as many of these delays as possible and accurate reimbursement.

There are some very basic information errors that can be quickly eliminated by using a medical claims software. Inaccurate patient information such as a misspelled name, date of birth, address, or insurance ID number can lead to a rejected claim.

Mismatching medical codes or confusing ICD, CPT or HPCS codes can result in too many or too few digits for a claim to be processed. Insurance policy numbers, addresses, and contact information can also be difficult to enter correctly when required numerous times during service. If you can reduce the number of these simple errors in your medical billing, you’ll have a much higher percentage of claims that pay you for service quickly.

Poor documentation and misinformation such as coding for a less serious or extensive procedure than the patient received can also cause serious problems. Intentionally misrepresenting the work performed on a patient is considered fraud and illegal, even when the intent is to help the patient save money.

It’s important to stay current on medical billing regulations and be proactive by preventing problems before they occur. Always have clinic staff double check for errors and communicate quickly about any billing questions. At Apex EDI, we have a highly trained team of experts ready to answer questions about billing regulations.

Our software can also help eliminate many simple billing errors. The investment in a few preventative actions and tools will pay off greatly. You will have the peace of mind knowing your medical claims are being handled with speed and excellence.

Contact Apex EDI for a demonstration of our software today.

Posted in: Medical Claims

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Medical Claims Can Be Appealed

Medical appeals form
Processing medical claims can get confusing, especially when someone files an appeal. According to the Department of Labor (DOL) Employee Benefits Security Administration (EBSA) there are four determinations during the medical claims process that can be appealed by anyone.

An urgent care claim is one that would substantially impact the life of the claimant or result in severe chronic pain unmanageable without treatment. Pre-service claims are those that require precertification by a healthcare provider before services are rendered. Post-service claims are those payments due after health services are rendered. Disability claims are those that create a medically related barrier to the claimant’s return to work.

All claims and appeals must be responded to as soon as reasonably possible. Administrators only have up to 30 days to respond, with the possibility of a one-time 15 day extension. Any requests for additional information or clarification must be detailed and specific.

The claimant has up to 45 days to respond. He or she is also entitled to any rules, protocols or medical basis for the determination free of charge. This exchange can make the burden of claims processing expensive and quite time consuming.

We want to take care of this headache for you, so you can focus on the care of your patients. The APEX EDI medical claim filing software simplifies the claim payment process. Our award winning team understands the laws related to claims processing, protecting health information and they want to save you time and money.

Contact APEX EDI for a demonstration of our software today!

Posted in: Medical Claims

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Are You Ready to Handle a Medical Malpractice Claim?

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Medical malpractice claims have become so common that 42% of physicians will face one at some point in their career according to the American Medical Association. The process of investigating, processing claims and responding to legal requests can be quite complex and time consuming for you and your clinic.

The legal process itself can take up to five years, but there are several ways to prepare your staff. First, medical records and treatment notes must be thorough. Memories years after the treatment can be sketchy. You’ll want to be prepared to provide a detailed account of the patient’s medical case, the treatment, and all communication with the patient.

The physician will be required to respond to a series of questions during the legal process. Accurate and complete information about the patient’s medical case and claims processing decisions made must be available. During deposition meetings and court testimony, the doctor will be required to answer questions from attorneys for several hours under oath.

Your medical claims software must be capable of storing accurate and detailed patient records. You will want your staff to be able to retrieve information quickly during an investigation. You will also want to feel confident that all medical claims have been processed perfectly.
When you are faced with a malpractice claim there is not much you can do to speed up the process of responding. However, the Apex EDI software will make the burden a little easier for you. With accurate information at your fingertips, there is a good chance your malpractice claim could be withdrawn or dismissed early.

Contact us today to request a free software demonstration.

Posted in: Medical Claims

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How to Settle Medical Billing Disputes

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Health care insurance billing is very complex and can be quite confusing. At some point in time you will no doubt find yourself in a billing dispute trying to determine what has been paid for and what payment is due. It’s important to know how to dispute a medical billing issue, how to appeal a denial and to be able to strengthen your case for receiving payment.

The best prevention is a little preparation up front. Make sure you keep a record of all communications you have about the patient’s healthcare. You will want to note phone calls made with the date and time of the call, the number you called, the people you spoke with, and exactly what you discussed. Also save copies of emails or written communications.

You will also want to have a copy of the insurance plan’s Summary Plan Description (SPD) on hand for reference. This document clarifies all billing services covered by insurance. You will also find a list of any exclusions in it. If you have questions about the policy, you can use the SPD to find the answer.

When there are billing discrepancies, you will want to be certain first that the health care provider billed the correct insurance plan. Simple errors in name, policy number, or address can result in rejected claims. It’s important to understand your plan’s annual deductible, the different terms and limits set forth in the plan for the medical services.

Also check for errors and make sure all charges were applied correctly to the insurance provider. You will want to make sure that there aren’t multiple bills being sent for the same service. If a payment was delayed, it’s not uncommon for a patient to receive a follow up notice for the same service although they may have already submitted the payment.

If a claim has been rejected or denied, find out the specific reasons why. When a patient disagrees with the reasons, they may file an appeal with the insurance company. It’s important to take this action quickly and provide any documentation supporting the patient’s position.

While we are certain you will be faced with questions about medical billing and insurance coverage, we can simplify the record keeping process and minimize errors for you with our electronic billing software.

Contact Apex EDI to request a demonstration of our software today.

Posted in: Medical Claims

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Medical Claims Processing Laws

Between dealing with physician, patient, and insurance data, staff in your billing department will be handling a lot of sensitive information. This is why it’s important for everyone in your billing department to understand the laws protecting that information and what they and the practice are responsible for, when it comes to the laws surrounding medical claims processing. Here are just two of the most important medical compliance agencies that medical billing specialists should be aware of.


HIPAA Regulations documents on a desk apex edi

Many people are at least aware of the existence of HIPAA, a set of guidelines that governs the way that medical information is protected. While HIPAA covers many aspects of patient protection, the part that applies most pressingly to those working with medical claims is found in Title II, which governs how and with whom patient data can be shared. HIPAA simplified the process of medical billing by providing universal identifiers for providers, employers, and patients, and by standardizing the requirements for electronic claims processing software.

Billing staff will be required to stay in compliance with HIPAA by protecting patient information and not sharing it with unauthorized parties. Medical practice employers should review HIPAA with all of their employees during the onboarding process.


The OIG was established to enforce HIPAA and prevent medical fraud. To remain in compliance with OIG, it’s important that medical billing staff refrain from activity that may be considered fraudulent. Fraudulent activity is generally classified as purposely falsifying information for benefit. At its worst, this involves practices providing false information on a patient’s medical record for financial gain. The OIG investigates and prosecutes practices that are found guilty of this type of behavior.

Best practices as outlined by these guidelines will help you keep yourself, your patients, your employees, and your practice safe.

At Apex EDI, we’re dedicated to making the medical claims process easier and helping medical practices get back to helping patients. We’re experts in medical claims processing policies and laws. We can help you better manage this confusing but important part of your practice.  We provide your practice with the tools and assistance necessary to cut down on claim denials and simplify medical claims filing.  Want to learn more? Request a demo today.

Posted in: Apex EDI, EDI, Medical Claims

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