When a patient comes in, they undergo pre-authorization. The physician’s office pre-approves the patient of certain treatments and prescription drugs by this process.
At this stage, the payers or the insurance companies decide whether the prescription drugs, procedures, services or equipment is medically necessary or not. Based on the decision, they will reimburse for the services rendered. The pre-authorization aspect faces certain exceptions in case of a medical emergency.
Pre-authorization doesn’t certainly mean that all insurers must cover its cost, which is why the process is repetitive and needs continuous verification. It is always a good idea to double-check any doubts related to coverage with the insurance company. This goes for both the providers and the patients.
Insurance Eligibility & Verification
The process is downright demotivating over the phone because it demands a lot of patience. Therefore, a set function must be a part of the revenue cycle management (RCM) software to cater to it. Artificial Intelligence could play a pioneering role in this phase of recognition, as it will automate the function.
Once patients go through with the care delivery, the Explanation of Benefits (EOB) statement incorporates all the details of the services or treatments paid on their behalf by the insurance company.
ICD Coding and Charge posting
When the patient checks in at the office, the visit transforms into a set of codes. There is a high probability of human error in these codes, which is why professional medical coders are the go-to people for it. The codes have to follow a certain set of rules and concur with the CPT guidelines and the latest ICD-10 coding system.
Out of Pocket (Co-payments and Deductibles)
Every health plan comes with a deductible and a co-payment. Some have high and some have low deductibles. Whatever the amount is to be, the patients pay up the co-pays at the doctor’s office before they go back home. The deductible is the amount fixed in a health plan that you have to pay before the insurance company starts paying for those health care services.
Submission of claims is the vital stage in the overall process because the reimbursement directly depends on it. If it is flawed, the chances for reduced payments or outright denials increase. As soon as the biller prepares the claims, they are filed with the insurance companies via a clearinghouse. The clearinghouse makes sure they are clean and free from errors.
Internally if both practice management and medical billing software connect; it will initialize the operational process of the revenue cycle management. The billing company follows up with the insurance company in light of those claims. It ensures the payer reimburses promptly.
Reimbursement for the Services Rendered
It is time for the insurance company to pay up. The payers match the procedures with their charges under the coverage limit. If the bills are appropriate, the process of acceptance becomes smoother and returns maximum reimbursements.
In the case of erroneous claims, incomplete patient information, or any other issues, the denials are inevitable. Most low-dollar claims tend to pile up unless the RCM is playing to its full potential.
For the claims which suffer rejection, they are resubmitted soon after they are scrubbed for coding mistakes. The resubmissions or the process of appeals demands critical screening with a finger on the pulse of the latest coding guidelines. Besides, minute details are checked against the patient profile and it makes the billers work directly with the payers.
When there is reduced reimbursement from the payers, it means the health plan does not cover all the services. So, the billers have to send those outstanding payments to the patient and follow-up.