Medical Model

Getting on Track with the Medical Model: Claims Management Billing

By Jerry Godwin, MBA, CEO, Optometric Medical Solutions


January 14, 2015

When it comes to a medical record, the rule is: “If it isn’t documented, it didn’t happen.” The medical record is a linear history of the patient’s ocular health. It must be clear and consistent from one exam to the next. It must tell the story of the care of the patient. The medical record must be accurate to support clean claims. It’s imperative that the doctor document correct CPT, DX codes, and PQRS for a billing specialist to produce accurate, clean claims that match the medical record.

Scrub claims prior to submission to the payer. The patient demographic and insurance information must be correct prior to creating and submitting claims. Review your systems after claims are submitted to ensure acceptance by the clearinghouse and subsequently directly with the payer.

Validate your reimbursements when you receive your Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). Carefully review your EOB/ERAs to identify inaccurate fees. If there is no contractual adjustment on EOB/ERA, this is an indication that fees are too low. The EOB/ERA is the best indicator of needing to adjust your medical fees. You cannot charge different fees for the same code to different payers (medical or vision). The fees must be the same for each carrier.

Each month, review your Insurance Aging Report (30-60-90-120+). The Aged Accounts Receivable (AR) report tells the story of how well you are managing your money. Identify coding or data input issues of patient demographics that may be causing denials, train doctors and staff prior to creating claims. Denials should be the exception, not the rule.

Checklist of Duties: Claims/Billing

• Review fee schedule and compare to reimbursements.

• File claims on a daily basis.

• Scrub claims: review demographics, insurance information, place of service, procedures, diagnoses and fees as a basic rule.

• Review clearinghouse reports after you submit claims to ensure payer acceptance.

• If claim is not paid in 14 days, contact the payer to determine the status of the claim.

• When an EOB is received, immediately post payment to the ledger, review any unpaid amounts and determine if balance due is patient responsibility.

• File all medical claims through a clearinghouse where claims can be tracked for rejection, acceptance, and processing by payer. This includes claim tracking number and Proof of Timely Filing report that ties back to reimbursement.

• Reviewed and resubmit Denials upon receipt or at least once a week.

• Review the Accounts Receivable Reports regularly for both Insurance and Patient balances is the starting point to identify claims that may have been missed and never filed, not received by payer, or exist as unpaid balance for some other reason.

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