Tips from Billing and Coding Pros

You’ll find these tips helpful because they come from seasoned medical billing and coding professionals and will keep you sane when you’re knee-deep in coding.

Verify patient benefits

To avoid unpleasant “Gotcha!” moments, call the payer to check for remaining deductibles, co-insurance responsibilities, and any applicable copayments, and collect them prior to admission from the patient. Also verify the need for a prior authorization for any planned procedures.

Get vital patient info at check-in

Collect patient demographics and get a copy of the insurance card upon patient arrival. You need this information when the time comes to code and submit the claim.

Also verify patient identification. If your office doesn’t have one already, institute a policy that all patients must present a government-issued ID upon arrival; then make a copy and place in the record.

Review the documentation ASAP

Although you technically have a few days before you must code and send the claim off, don’t delay. Your goal should be to have the claim out the door within 72 hours. Review the medical documentation as soon as possible after the encounter to see whether it is as complete as you need it to be. If you find any omissions or ambiguities, query the physician as soon as possible.

Play nice with others

Your claim will go either directly to the payer or to a clearinghouse and then to the payer. In either place, it can get hung up. Regardless of what the problem ends up being — or where it occurs — the best way to resolve an issue is to make the person you’re talking to feel like the two of you are a team. Be friendly and you will yield results!

Follow up on accounts receivable daily

Set time aside each day to review the accounts receivable reports. Be sure to pay attention to whether the claims have been received; then watch the accounts receivable aging reports to monitor all outstanding accounts. If you see that some are stalled, get on the horn with the payer to resolve the issue.

For every claim over 60 days old, call the payer. Verify that the claim is in process and make note of the claim number and when payment can be expected.

If the representative tells you that the payment has been issued, get the date, check number, and the amount of the check. Also verify the address the check was sent to and ask whether it has been cashed.

Know your payer contracts

The more familiar you are with all payer contracts, the more quickly and accurately you can process claims. Payer contracts stipulate things like what procedures are covered and whether prior authorization or referrals are needed.

They also outline billing requirements, such as how long you have to submit the claim, how long the payer has to make payment before interest is earned, and other payer specific quirks, such as revenue code requirements or value codes that are expected.

Make payers show you the money!

Make sure you follow up and appeal any claim that does not pay as expected. If your provider has a contract with a payer and the claim didn’t pay according to the contract, base your argument solely on the contract. If no contract exists, call the payer and ask what method was used to price the claim.

Claims that were paid “usual and customary” should be challenged. If a silent PPO was accessed, ask for the contract to be identified and then notify the network in writing that you wish to terminate the relationship.

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