News & Events

Posts Tagged claims processing

Claims Processing: Medical Claims vs. Vision Care Claims

When handling claims regarding eye health, there are a few things to be aware of. For example, there are specific differences between what can be billed to a vision plan and what should be billed through medical insurance. Let’s discuss the difference between the two claims, and why eye care professionals need to know the difference.

girl with glasses

The Difference

Vision plans cover routine wellness exams for eye health. This means examinations for near- or farsightedness, astigmatism, and corrective lenses. Medical eye care on the other hand is for the treatment of specific medical conditions related to the eye, such as pink eye, cataracts, double vision, etc.

Why It Matters

As we discussed above, vision plans cover annual exams for eye health. When an exam reveals a condition such as pink eye, cataracts, glaucoma, dry eye, or another condition, the diagnosis and treatment is billed through the medical eye care insurance. A medical eye condition typically requires a more intensive treatment plan than what is covered through a run of the mill vision plan, which is why medical insurance typically steps in.

As the provider, you will want to ensure that you are billing the correct insurance in order to receive the fees you are due. Many eye care professionals bill the vision plan first, and then reach out to the medical plan if any fees have yet to be covered. It is also important to discuss the plan of action with the patient so that they are aware of how the services will be billed to their insurance and that they are aware of any fees that may accrue due to their specific plans.

The Solution

In order to ensure the best possible care for your patients and management of your optometry practice, implementation of a clearinghouse for claims billing is recommended. A clearinghouse verifies vision and medical claims before they can be sent to the payer for final submission.

Apex EDI is a user friendly and fully integratable clearinghouse that works to get you paid faster. For more information about how Apex EDI can be used to benefit your optometry practice, click here.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

Posted in: Claims Processing

Leave a Comment (0) →

Medical Claims Processing: How Do Medical Claims Work?

medical expensesThe medical claims industry is only a small part of the trillion dollar healthcare field. However, it is arguably one of the most important aspects for providers, as the medical claims process allows physicians and practitioners to maintain their clinics and businesses by receiving payment for their services. Let’s take a look at how medical claims actually work.

Services Rendered

The first step is for a patient to request services from a healthcare provider. The healthcare provider then grants services to the patient, be it in the form of a physical exam, diagnostic procedure, or any other billable service.

Each service is recognized in the medical industry with a unique code specific to that service. When the physician completes the patient report, the report will be submitted to medical claims with the appropriate medical codes for the services rendered.

Processing The Claims

The next step is to process the claims. This can be completed via traditional methods, such as fax or postal service. However, many practices are now implementing electronic claims processing, as it is significantly more cost effective, efficient, and secure than traditional methods.

The claims preparer examines the physician’s report on the patient. The preparer verifies that the claims codes are correct for the services that were rendered. The preparer creates the claim that will be sent to the insurance provider for that specific patient. The preparer might use a software such as Apex EDI for secure and efficient transfer of documents to the insurance company.

The claim is then processed by the insurance company.

Payment, Denial, and Appeals

Once a claim is processed, it is either approved or denied. A claim can be denied for a variety of reasons. The reason for denial could be as simple as the insurance company requesting more information before approval, or it could be that the service rendered is not an eligible service under the patient’s insurance coverage.

When a claim is approved, the insurance provider issues payment to the clinic or physician that submitted the medical claim. When a claim is denied, it may be resubmitted by the preparer, or the patient can appeal the denied claim to their insurance company. Typically a denied claim will require out of pocket payment from the insured patient in order to cover the cost of services rendered. However, a few exceptions have been made through lengthy appeals processes.

While medical claims billing might seem like a fairly straightforward process on the surface, there is a bit more to it than this article can provide. If you would like to know more about the medical claims billing process and how this aspect of your business can be streamlined with an EDI software, be sure to reach out to us by filling out the contact us form here. The professionals at Apex EDI will be happy to assist you with any questions you may have about improving your medical claims process.

http://www.medicalbillingandcodingonline.com/medical-claims-process/
http://www.apexedi.com/medical-claims/

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 


Posted in: Medical Claims Processing

Leave a Comment (0) →

2016 Medical Claims Processing: Who Determines the “Value” of Value-Based Payments?

With all the discussion around value-based payments and quality-incentive programs newly instituted by Medicare, one begs to question…who decides what’s quality? How do we know that what’s considered value to one is legitimately valuable to everyone?

Of course the answer to both questions is relative. In terms of medical care (and most everything else for that matter) it’s hard to define what “quality” really means. Our hats are off to CMS for at least attempting to define it and for trying to incentivize physicians, practitioners and facilities for value over volume. Though it seems like a nightmare in terms of submitting medical claims, the end goal is to increase the quality and efficiency of medical care, and that’s a win for everyone.

Here’s how they’re doing it…

The value-based payment program is comprised of two basic components. The first is the Quality and Resource Use Report (QRUR), which is basically a confidential report about both the cost and quality of care provided to Medicare patients. Secondly, there’s a Value-Based Payment Modifer (VBPM) or “score sheet” that adjusts payments up or down according to the results of the QRUR.

Thankfully, for those of us in medical claims, payment adjustments don’t happen in real time. It would be incredible if rates were charged according to the actual care given at any particular office visit or during a particular procedure, but we aren’t there quite yet. In 2015 CMS started applying the new score sheet to a select group of physicians, all based on performance data collected from their patients back in 2013. And that’s how things will continue. In 2016, the Value Modifier will be applied a specific group of physicians, based on performance in 2014.

For more information on value-based payments visit the CMS website at https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html.

Posted in: Medical Claims Processing

Leave a Comment (0) →

Medical Claims Processing: Practice Accelerator™ Part 2

Previously we learned The Practice Accelerator™ is a proprietary process Apex EDI has developed to help healthcare professionals to receive the benefits of clearinghouse services from Apex EDI. This detailed step-by-step process will help office staff understand how Apex EDI will boost the financial performance of your practice.

In this part of the series we will cover phase two of the Practice Accelerator. Steps four through seven make up the second half of the process. These four steps cover your ongoing interactions with Apex EDI—where Apex EDI can make a significant impact on your business.

The PowerTools System™

4Entering the core of The Practice Accelerator™, this step in the process will allow you to interact with our robust set of online tools.

This is the core of what we provide your practice. All the tools available from Apex EDI help you know what is going on in your practice. The PowerTools System helps you create, track, and correct your claims. In addition, we help you better understand how, when, and who will pay for each of your claims.

The TotalCare Program™

5No matter your question or issue, you always have a dedicated team of account managers ready to answer your question.

You have personal, direct connection with a knowledgeable representative you can trust to be ready to help. In fact, your service representative will even call you every few months to check in and make sure your Apex EDI solution is running smoothly.

The Daily Advisor™

6Each day you manage your practice. Our comprehensive tools allow you to monitor your practice.

One of the greatest benefits of The Practice Accelerator is the data you have available at your fingertips. Each and everyday you can access our tools to see where your claims are in the process.

The Cash Delivery™

7The final phase in our revenue management cycle is a constant dedication to providing accurate information to payers to ensure you get paid.

We are dedicated to working to make sure you get paid. We know it is what let's you continue to do the good work you do.

Apex EDI's staff and processes will help you get the most out of your practice. Apex EDI is absolutely committed to providing the fastest, most personal, and most capable customer service and technical support in the electronic claims processing industry. That commitment starts with a unique, personalized approach to customer service you simply won't find anywhere else.

The Practice Accelerator™ will help you better understand how your practice is running and how we can help you improve your practices ability to generate revenue.

About Apex EDI

Apex EDI is a leading healthcare claims clearinghouse for medical and dental professionals. Apex EDI serves thousands of physicians, dentists, and other medical providers nationwide with its Apex OneTouch® solution. The OneTouch® solution is a Web-based electronic claims reimbursement system that increases productivity and profitability while facilitating fast payment of insurance claims and providing additional reporting and analysis. Founded in 1995, Apex EDI is based in American Fork, Utah.

Posted in: Medical Claims Processing

Leave a Comment (0) →

Medical Claims Processing: Practice Accelerator™ Part 1

The Practice Accelerator™ is a proprietary process Apex EDI has developed to help healthcare professionals to receive the benefits of clearinghouse services from Apex EDI. This detailed step-by-step process will help office staff understand how Apex EDI will boost the financial performance of your practice.

In this two part series we will cover the two phases of the Practice Accelerator. Steps one through three make up the first phase of the process. These three phases cover your initial interactions with Apex EDI—as you start your account and we help you set up your connections and get you paid.

The Profile Builder™

1Step one is an installation and customization of our software on your practice computers.

During this step we work closely with your practice to gather the information we need to create your account. We also work directly with the personnel in your office who submit claims to install the Apex EDI software.

The PayerLink Setup™

2During the second step of the process we work with you to enroll you with the payers that reimburse your practice for your claims.

Enrolling with payers can be frustrating and difficult. The Apex EDI enrollment team works closely with your staff and payers to get your practice enrolled and creating the vital link that gets you paid.

The Program Launch™

3After your initial setup we will help to train your staff on how to get the most out of our products.

One of the most valuable services Apex EDI provides to you is the free training we give to your practice. In this step we thoroughly train your practice and get you up and running. In fact we prefer to send a claim during the training process to assure you that everything is operating correctly.

The Practice Accelerator™ will help you better understand where you are in the process of creating your account and how we can help you improve your practices ability to generate revenue.

The next article in this series will cover steps 4-7 and focus on how Apex EDI's staff and processes will help you get the most out of your practice.

About Apex EDI

Apex EDI is a leading healthcare claims clearinghouse for medical and dental professionals. Apex EDI serves thousands of physicians, dentists, and other medical providers nationwide with its Apex OneTouch® solution. The OneTouch® solution is a Web-based electronic claims reimbursement system that increases productivity and profitability while facilitating fast payment of insurance claims and providing additional reporting and analysis. Founded in 1995, Apex EDI is based in American Fork, Utah.

Posted in: Medical Claims Processing

Leave a Comment (0) →
Page 5 of 7 «...34567