Before I was able to submit my first claim, I needed to understand what all the insurance lingo meant. Another huge barrier I encountered was talking with insurance representatives on the phone. Everything can seem quite intimidating as a new provider and the representatives themselves can be vague in the information they provide and the information can even vary from one representative to the next. In this session, I will be discussing what you need to know about filing claims for your clients.
1. Learning the insurance vocabulary
Being an in-network provider means you must first familiarize yourself with the jargon. Healthy Bytes has provided a comprehensive list that you can reference and bookmark whenever you have any questions.
2. Perform eligibility checks
Performing an eligibility check is absolutely essential prior to meeting with a new client so you will know exactly what their coverage is or if they even have insurance coverage. This will allow you to collect any copays or coinsurance payments at the time of their appointment.
Beyond that, medical insurance is confusing to most people. The client will feel much more comfortable if you take the time to explain their coverage to them. If the client has to meet their deductible before the claim will be reimbursable, I always contact the client before the day of the appointment to let them know how much they will owe and why.
Here are a few tips for performing eligibility checks:
1. Always record a reference number when talking with a representative.
- When performing eligibility checks, record the reference number for the call, the name of the representative, and all of the information the representative gives you.
- The best place to document this information is in the client’s medical chart.
- Reference numbers are very helpful to have anytime you need to appeal a claim.
2. Have all the information you will need to perform an eligibility check in front of you when calling an insurance company.
- Your EIN or NPI
- Client’s member ID
- Client's date of birth
- Client's address
- Client's diagnosis and procedure codes
Tip: Creating a list of frequently-used diagnosis codes as you see more patients can save you time in the long run!
3. Submitting your claims
One advantage to using an EMR such as Kalix, is the built-in billing features to create standard insurance claim forms. Claim forms are then submitted to a separate clearinghouse, such as Office Ally to bill your claims to different insurance companies.
Medical billing clearinghouses help take claim information from a billing service or provider, check the claims for errors, and send this claim information electronically to insurance companies. Claims sent electronically are paid much faster than paper claims.
Another efficient way to submit claims is using Healthy Bytes for your full billing and insurance needs. They will help with eligibility checks for new clients as well as claim submissions in real time. Using Healthy Bytes will not require the extra step of using a clearinghouse.
9 additional tips for accepting insurance
1. Prior to their initial consultation, obtain the client’s full insurance information when setting them up as a new client and run an eligibility check using the codes you will be billing with.
2. Make sure the client understands there is always a chance the insurance company will not accept part of or all of the claim.
3. Be sure to obtain information for both primary and secondary insurances if they have both.
4. Medicare will only cover for renal disease and diabetes diagnoses. If a client has Medicare as their primary insurance and you know the claim will be rejected but would like to use their secondary insurance, you must still submit the claim to Medicare first.
5. Medicaid will not cover Medical Nutrition Therapy with a Registered Dietitian.
6. When performing an eligibility check, ask the representative the following:
- Diagnosis restrictions
- Number of visits they will cover per year
- Copay or coinsurance
- Is there a deductible that has to be met?
- Is there a need for a physician referral?
7. Note in your medical record when your client’s calendar year for their plan starts over. This will be important for whether their deductible applies and starts over.
8. After submitting claims, check Explanation of Benefits (EOBs) frequently to make sure you are being paid correctly. If a claim has been rejected or not paid correctly, you must resubmit it. This may take some investigating before re-submitting.
9. Balance billing is generally illegal. Balance billing is when an in-network provider bills the client for the difference between a provider's private pay rate and the contracted amount of the insurance company. The provider also cannot bill the client if they feel the insurance company is taking too long to pay.