Updating Patient Insurance Information, Post By: Kay Ouellette, Billing Manager

Many people don’t realize how important giving the correct insurance information at the time of service is.  It can create great headaches for the Practice and the patient.  When the Office does not have the correct information and a claim is billed to the wrong insurance company it starts a chain reaction, which ultimately ends up to the patient’s responsibility.

Let’s start at the top:

-     Patient checks in at the window and does not update the sheet for any patient changes and marks same. 

-      Provider sees the patient and a claim is created. 

-      Billing looks over the claim to see whether the claim needs special attention according to the insurance company such as a needed authorization attached, medical notes, or accident date on the claim. (this really depends on each insurance company, example Medicare, Wcomp, auto, or commercial insurance all have different requirements.) The biller is assuming the claim is correct due to do patient update, so at this point the Provider has spent the time to see the patient, the biller has taken time to review the claim or charges and file the claim. 

-     The claim is sent to the insurance company. The insurance company can take anywhere from 30-45 days to process the claim and sometimes much longer, only to receive a denial for the claim stating it has rejected, because the patient does not have coverage at the time of service.

-     Now the provider has to work the denial and try to research if it denied in error or not.  Upon researching the claim the patient didn’t have this insurance at time of service and then the balance gets transferred to patient responsibility. 

-    The patient’s receives a bill and is not happy. 

Needless to say there is a lot of time, effort, and resources to bill an insurance company and if you have several patients a day that do not give the correct insurance update then there is a lot of time and money that is lost.

We at Central Florida Pain Management are very grateful for all who on conscious of their current insurance and make an effort to update it.   Thank you.

Post By:

 

Kay Ouellette, CPC

Billing Manager

Prior Authorization, Post By: Teresa McPherson, CEO

 

In today’s world of so many insurances to choose from and not really knowing which one is the right plan for your care can be confusing when it comes to choosing a plan.  Some insurances plans such as HMO’s may require a prior authorization for any services to be rendered.  I would like to take a few minutes and help our current and potential patients understand what a prior authorization is:

Pre-Authorization

Pre-authorization is a term used for obtaining prior approval from your insurance before having a procedure or service done.  We here at Central Florida Pain Management try to make sure we obtain authorization that is needed prior to services being rendered so you can receive services that are needed for your care.

Insurance Denial and Appeals

Sometimes even with a prior authorization on file a provider can still receive a denial for services that have already been rendered to the patient.  A denial means that the insurance company has decided not to pay for the procedure or other service that your doctor recommended or preformed due to many reasons such as the insurances own medical necessity guidelines which may not be met (yes, that’s correct your insurance can decide what services are acceptable over your own doctors recommendations) based on the procedure to be performed, related diagnosis code and how many times the patients may have already received this type of service already .  There are even some still pre-existing policies out there as well.  We here at Central Florida Pain Management strive to try and make sure that any services that require a pre-authorization are obtained and meet your insurances guidelines.  However even the most diligent providers office can still be denied payment for some services.  Sometimes the provider can appeal with a letter and medical documentation to convince the insurance company to change their decision and provide coverage for the service.   However in some cases if the provider is participating with the insurance plan and the appeal is denied the provider does not receive any reimbursement for the services that were provided to the patient.  It is not only important for your doctor’s office to understand your insurance plan and what it will and will not cover but it’s also just as important that the patient understands what plans/polices they are choosing to sign up with.  Only with both parties informed can the doctor and patient make the right decisions together for any future care.

Post By:  Teresa McPherson, CEO