What Claims Matching Means to a Medical Biller and Coder - dummies

What Claims Matching Means to a Medical Biller and Coder

By Karen Smiley

To pay for services rendered, the payer relies on the claims to be correct and truthful, often using a method called claims matching. When specific services are performed, several providers submit claims for the same patient.

Here’s an example: Say that a patient has a surgery. The surgeon submits a claim; the hospital or facility submits a claim; and the anesthesiologist submits a claim. Each claim is slightly different, of course, because each provider rendered a different service, but the surgeon’s bill, the anesthesiologist’s bill, and the facility’s bill should match — that is, the same procedural codes should be on all three claims.

If you are a facility coder, you are actually breaking compliance rules if you call the physician coder to ask what he or she submitted. Stick to the coding. Both claims are based on the physician documentation, and if you follow coding protocol, the claims should match pretty well.

If the bills don’t match, the payer may request supporting documentation from any or all providers. In addition, if the surgeon and facility each bill for a completely different body part than that submitted on the anesthesia claim, an inquiry will likely occur. (Note: Some payers won’t pay for facility charges or the anesthesia charges until after they’ve reviewed the surgeon’s bill.)

Working together with other providers gets claims paid faster. And that should always be your goal: coding correctly and efficiently to secure accurate and prompt payment for your provider. If additional information is requested from a payer, promptly provide it. Failure to cooperate delays not only your claim but all related claims as well.