Medical Billing & Coding For Dummies
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Perhaps it goes without saying, but to do the medical coding and billing of a claim well, you need to verify the patient’s plan and coverage for yourself. Why? You need to know not only the difference between the types of commercial providers, but also their network affiliations, kind of coverage, and more.

This is because submitting a claim to the wrong entity delays correct processing. The few minutes it takes to verify benefits and claim submission requirements can save days in accounts receivable and hours of follow-up chasing the claim.

Luckily, gathering the information you need is a fairly straightforward task,.

Look at the insurance card

How do you tell what kind of plan — a PPO network, a TPA, or a commercial payer — a patient has? Fortunately, a commercial insurance company that underwrites plans and administers those plans for the membership is usually easy to identify. Just look at the patient’s insurance card.

The card provides phone numbers for members and providers to call. By calling the appropriate number, you can get a summary of plan benefits. Most commercial payers also have websites that enrolled providers can use to verify benefits and eligibility.

A company that is self-funded but part of a larger network (or networks) has a benefit and eligibility number on the patient’s card, along with the address to which claims are to be sent. It also has the logos for the networks to which it belongs. When you verify these patient benefits, you may need to call both the payer and the network.

A patient is your first line of defense with verifying payer information. Treat each patient with respect and assure him that you’re trying to do your job, which is to help his claim get processed in a timely and accurate fashion.

Contact the payer and/or network

When you (or the front office staff) call to verify coverage, your first call is probably to the payer, who can verify plan benefits with regard to in-network coverage and out-of-network coverage.

The payer can also advise you about any remaining deductibles, coinsurance responsibilities, and applicable co-pays. If the provider participates only in certain levels of the network (say, if the provider is a PPO-provider only), then you want to verify the patient’s PPO benefits.

If you have any doubt about coverage, the next step is to contact the network and verify that the payer does actually participate in the network with which the provider has a contract. If the provider is PPO only, verify that the plan is enrolled in the network PPO.

If you don’t fully verify eligibility and benefits when a network is the pricing intermediary, you can’t be certain that the claim will process as expected.

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