1. Billing the Insurance Company

Accurate billing is crucial for ensuring timely reimbursement from insurance providers. The process begins once the service is rendered. The claim will include details like the date of service, procedure codes, diagnosis codes, and the patient’s insurance information. Depending on the payer's requirements, claims may be submitted electronically or via paper.

Key steps in billing:

• Confirm patient insurance details before service.

• Submit claims using the correct coding (ICD-10, CPT codes, etc.).

• Include necessary documentation (e.g., medical records, physician referral).

2. Collection of Fees from Patient

While insurance often covers a significant portion of medical expenses, patients may still be responsible for certain out-of-pocket costs, such as co-pays, deductibles, or non-covered services. It's important to communicate clearly with patients regarding their financial responsibilities and the insurance claims process.

Best practices for collecting fees:

• Inform patients of their estimated out-of-pocket costs before treatment.

• Collect co-pays at the time of service.

• Send statements promptly for any outstanding balances after insurance payment.

3. Understanding the CMS 1500

The CMS 1500 form is the standard paper claim form used by healthcare providers to bill for services provided to Medicare and many other private insurance companies. It includes vital patient and service information, such as:

• Patient's demographic details (name, insurance number).

• Date of service and procedure codes.

• Diagnosis codes for the medical condition being treated.

• Charges for the services rendered.

Ensure that all fields on the CMS 1500 are completed accurately to avoid delays or denials.

4. Electronic Claims Submission

Many insurance companies now prefer electronic claims submission over paper claims. Electronic submission streamlines the process, reduces errors, and speeds up reimbursements.

Benefits of electronic claims submission:

• Error reduction: Many clearinghouses automatically check for common mistakes before submission.

• Faster processing: Claims are processed faster and often result in quicker reimbursement.

• Cost savings: Reduced costs associated with paper, ink, and postage.

Key points for electronic submission:

• Use a clearinghouse or practice management system that supports electronic claims.

• Confirm payer’s acceptance of electronic submissions and ensure all required information is included.

5. Filing Primary and Secondary Insurance Claims

When a patient has both primary and secondary insurance, the primary insurance must be billed first. After receiving payment or a denial from the primary insurer, you can submit the claim to the secondary insurance.

Process for submitting primary and secondary claims:

1. Submit the claim to the primary insurer and wait for payment or denial.

2. If the primary insurer pays, submit a copy of the Explanation of Benefits (EOB) or Explanation of Payment (EOP) to the secondary insurer.

3. If the primary insurer denies, ensure that you address the reason for the denial before submitting the claim to the secondary insurer.

4. Track the progress of the claim using the EOB/EOP and ensure all necessary documentation is included.

6. How to Read Your EOB or EOP

An Explanation of Benefits (EOB) or Explanation of Payment (EOP) is sent by insurers to detail what is covered by the insurance policy, including payment amounts, denied charges, and any remaining patient balance.

Key elements of an EOB/EOP:

• Claim number: Identifies the specific claim.

• Diagnosis and procedure codes: Shows the codes that were submitted with the claim.

• Patient responsibility: Details any outstanding balance for the patient.

• Amount paid: The portion paid by the insurer.

• Reason codes: Explains why charges may have been denied or reduced.

Understanding the EOB/EOP will help in resolving any issues and ensure accurate billing for future claims.

7. Electronic Funds Transfer (EFT)

Electronic Funds Transfer (EFT) is a method where insurers directly deposit funds into a provider’s bank account for faster and secure payment processing.

Key steps to set up EFT:

• Submit a voided check or account verification letter to the insurance company.

• Complete the EFT authorization form and send it to the insurer’s financial services department.

• After approval, payments will be directly deposited into your designated bank account.

While EFT offers quicker payments, identifying and reconciling the payments can be challenging as they may not come with detailed breakdowns of each claim. It’s essential to match the deposit amounts with the corresponding EOB/EOP.

8. Handling Denials and Errors

Denials are a common part of the claims process. However, many denials can be resolved by reviewing the EOB/EOP, contacting the insurer, and resubmitting the claim with corrections if necessary.

Common reasons for denials:

• Incorrect patient information (e.g., name, date of birth).

• Missing or incorrect codes (ICD-10, CPT).

• Lack of medical necessity or preauthorization.

• Inadequate documentation, such as missing physician referrals.

Steps to resolve a claim denial:

1. Review the EOB/EOP for the reason for the denial.

2. If unclear, contact the insurer's claims department for clarification.

3. Correct any errors or provide additional documentation (e.g., physician referral).

4. Resubmit the claim with “Corrected” written at the top if required.

Document all interactions with insurers, including call dates, representative names, and reference numbers, to ensure clarity and accuracy.

Filing insurance claims effectively is a crucial aspect of running a successful practice. By understanding the process, leveraging technology, and staying organized, dietitians can reduce claim denials, streamline administrative tasks, and improve cash flow.

Need more Support?

Need help with managing insurance claims for your practice? Dietitian Practice Pro offers coaching and support for dietitians to streamline their billing and insurance processes. Get in touch today to optimize your workflow and ensure timely reimbursements. Contact us for a consultation and get the support you need!