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Billing Begins with Following the Basics

Continuous changes in health insurance reimbursement guidelines result in an often complex medical billing scenario. This is unlikely to change. Evaluate your intake to charge to claim submission workflow and follow the basic best practices to target preventable denials and maximize reimbursement on the first pass. With insurance company requirements, provider input and government regulations to factor in, it's no wonder that a brief cheat sheet might be necessary to keep your billers sharp. Consider putting these items on the list:
  • Payers Contracted: Identify at a group and physician level. Include carrier, plan name/type(s), phone numbers, electronic payor identification numbers, claims address(es), website urls, patient portion estimator urls, contract expiration dates, etc. The document should be set up so that it is easily sortable by any criteria such as plan name, state, physician name, etc.
  • Filing Dates: Note the filing dates required by each insurance carrier making sure you list the number of days to file a claim after a service is performed as well as timely filing requirements for appeals.
  • Referrals / Prior Authorizations: Record which payers demand prior authorization and / or referrals for providers including what information is needed to process the authorization. This might be:
    • Medical records or past medical history
    • Diagnoses supporting the procedure
    • Prior treatment
    • Results from prior treatment
    • Doctor progress notes
    • When the illness, symptoms, disease occurred
    • Time frame in which authorization or referral is required before service rendered
  • Frequency Allowed / Remaining: This is part of the insurance eligibility check and should be documented in the electronic record or file. This needs to include the number of allowable procedures and detail the process that needs to be followed for billing multiple procedures. There's nothing more frustrating for a patient than having a service denied because his maximum frequency/benefit was reached.
  • Claims Submission: How can the claim be submitted and on what form?  Ie electronic, paper, secondary and corrected claims.
  • Decision or Payment Receipt: Insurance payers need to submit payments within a certain time, usually 30 days. Know the time frame and become familiar with your state's prompt pay laws. Create a systematic method for follow up by separating no response claims into its own follow up queue list and take action to resolve the issue.
  • Appeals: Make sure you follow the payer's appeals process to mitigate unnecessary delay. When handled right, appealing medical claims can accelerate payments for denied claims.
  • Denials: Establish a systematized method for resolving denials while trending patterns to ascertain why it happened so workflow processes can be adjusted to reduce future occurrence when applicable.

Testimonials


I just wanted to inform you that your staff went the extra mile on my behalf and we truly appreciate your assistance.
Thank you for your fine business conduct. We are very grateful.
I applaud you for having staff members who show utmost professionalism, knowledge, patience and respect.
We have had a good working relationship...we can pick up the phone and discuss issues easily and in person.
We receive excellent service and solutions to solve whatever problems that we may have had.
I can't thank you guys enough for helping me negotiate my bill. I'm so glad there are folks like you around.
I have been extremely satisfied with the performance of RMK. They have worked very closely with our practice helping us to carry out the billing process efficiently.
Thank you for working with me and my situation to repay my balance.
RMK is very competitive and works hard to recover revenue for delinquent patient accounts.
We appreciate being alerted to issues, that if adjusted in our practice, could increase our revenue.
The response to our questions, concerns, and requests for specific information has been very prompt and accurate.
I have many medical bills that have much larger balances than the one I have with you. Thank you for working with me instead of being sent to an automated payment system.

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RMK Holdings Inc.

111 North Avenue
First Floor, Suite 104
Barrington, IL  60010

866-446-4800 toll-free phone

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