All pediatric practices need to manage the medical claim process so the practice receives revenue for their services. The medical claim process has various steps and aspects to the process and starts with the front desk team and the patient insurance. The first step is important that the front desk team verifies the patient insurance with each visit using the real time or automatic eligibility feature of the EHR system. Some patients might have insurances that require manual verification of the eligibility (e.g. call to the insurance carrier).
After confirming the eligibility, it is important that the front desk team enter the insurance information consistently for each patient and scan a copy of the insurance card. At this point, the front desk team should be collecting the patient co-pay and any due family balance from the patient being seen or other patients in the family. No medical claim has been generated yet because the providers and medical assistants have not recorded the details of the visit including selecting the level of service, procedures provided and vaccines given. An integrated pediatric EHR and revenue cycle management system will help reduce the admin work of providers and staff remembering details related to vaccine admin codes and procedure billing rules. The provider should record and select all appropriate services provided for the patient then close their chart.
After the provider closes their chart, the medical information available in the system includes the patient demographics, insurance information for the patient, as well as the services/procedures performed during the visit. A medical claim can be created using this information. The claim should be reviewed for accuracy prior to being sent to the clearing house for processing to the insurance company.
Once a medical claim is reviewed and processed by the billing team, the claim is sent to the insurance company. Each insurance company receives thousands or millions of medical claims per day. Insurance companies develop and maintain their own processing rules for medical claims. As part of this process, the insurance company determines the amount paid by the insurance company and patient based on the patient’s insurance policy. An electronic file or paper explanation of benefits displays to the biller the details of how the claim was processed by the insurance company containing the payment amount per code and the amount paid by the insurance carrier versus the patients. If there is a patient responsibility, the biller prepares the patient statement and sends to the family. If there is no patient responsibility due, the biller closes out the claim.
Note that payers change claim edits from time to time and there are claims and/or CPT codes that are rejected or paid inappropriately. A strong billing team has both people and processes to follow-up with the claims and issues to optimize the collection rate to the contract amount for the pediatric practice.