Insurance

Managing Your Patient Accounts Part 1: All About Claims

Insurance Claim

There are many moving parts to managing your patient accounts. You want to find ways to improve your efficiency while making sure things aren’t slipping through the cracks, and this post is here to help!
This Part 1 post is all about claims: We’ll explore how to create insurance claims quickly & efficiently, track any follow-ups you’re doing with insurance about those claims, and all that comes with handling insurance payments (including partial payments, more than one payment on a claim, and dealing with insurance overpayments and how to handle it when they short pay or want you to return funds).

1. Creating New Claims

Option A: Create claims from the patient’s account
  • In the patient’s Account, click the New Claim button.
  • A claim will be created for ALL completed procedures that have not been billed to insurance.
  • If you want to create a claim only for specific procedures, select the procedures, then click the New Claim button.
  • Once a claim is created, you can click the Send button or send all claims at the end of the day from the Manage Module’s Send Claims area.
Option B: Create claims all at once for procedures completed that day (or in a date range)

This can be done from the Manage Module >Send Claims > Procs Not Billed (upper right) or from Reports > Standard Reports > (Monthly Section) Procedures Not Billed to Insurance (same destination no matter how you get there)

  1. Enter a date range, and select the report criteria (see our manual page for more information on the various options), then click Refresh.
  2. Check the Automatically Group Procedures check box in the upper right when creating claims from this window. If checked, and procedures for a patient have different clinics or place of service, claims for each clinic/place of service will be created. If unchecked, claims will not be created for patient procedures that have different clinics/places of service.
  3. Select multiple procedures, or click Select All at the bottom to select the procedures you want to create claims for.
  4. Click New Claims. It will warn you that you are about to create a number of claims. If you want to proceed, click OK.
  5. It will tell you how many claims were created. Click OK, then Close.
  6. The claims you just created are now waiting for you in the Claims Waiting to Send area.
    TECH TIP: Unsent preauths are also displayed here – if Date Service shows 01/01/0001, it’s a preauth, not a claim.
  7. Select the claims you want to send, then click Send eClaims to send your claims electronically.
    If you’re using Clinics, use the dropdown next to the Send eClaims button, and select the clearinghouse you want to use to send your eClaims.
    If you are printing claims, select claims, then click Print.

OOPS! Created and sent a claim with the wrong procedures?

Take a look at our manual page on this to see the best way to handle different scenarios.


2. Tracking Claim Statuses and interactions with insurance

Create your own Custom Tracking Statuses to track claims in a way that makes sense for your office.

  1. Create Custom Claim Statuses in Setup > Definitions > Claim Custom Tracking.
    TECH TIP: Enter a Days Suppressed if you want certain statuses to not show in the Outstanding Insurance Claims report for a certain number of days.
  2. Create Claim Error Codes in Setup > Definitions > Claim Error Code. This is useful to track why a claim might have been rejected. (e.g. missing an attachment)
  3. Update the status of the claim in the Edit Claim window – Status History tab, or update the status for multiple claims from the Outstanding Insurance Claims Report.
  4. Use the Outstanding Insurance Claims Report to keep an eye on claims and follow-up when needed.

3. Receiving Payments

Depending on how insurance pays, you may need to receive the payment on the claim a little differently.

Insurance pays on one claim in full.

If you are entering a payment for one single claim, do this:

  1. In the claim, receive the procedures by clicking By Procedure.
  2. Enter the paid amount and write-off for each procedure, then click OK.
  3. Click This Claim Only to finalize the payment.
Insurance pays on multiple claims in full.

If you are entering a batch claim, you have two options:

  1. Go to the first claim, and click By Procedure
  2. Enter the paid amount and write-off for each procedure, then click OK.
  3. Repeat steps 1 & 2 for each claim on the EOB.
  4. Once you complete these steps for the final claim on the EOB, click Batch to finalize the payment.

or

  1. In the Manage Module, click Batch Ins.
  2. Click Add to create the check, then attach the claims.
  3. Click Add, then enter the payment information for the EOB.
  4. Pick the Insurance Carrier, then click OK.
  5. Search the Outstanding Claims list to find the needed claims.
  6. Click Attach to immediately attach the claim to the check, or double-click the claim to make edits first.
  7. Once all claims are attached, click Close to finalize the payment.
Insurance made a partial payment on a claim.

If insurance paid on only one or some of the procedures on a claim (and you are still expecting payment), do this:

  1. In the claim, click on the procedures that were NOT paid.
  2. Click the Split Claim button in the upper right.
  3. These procedures will be split off onto their own claim with a status of “Sent” – this will maintain the visibility of this unpaid portion until you receive payment.
    TECH TIP:  By splitting the claim, the correct outstanding amount will continue to be visible in the Outstanding Insurance Claims Report.
Insurance made multiple payments to the same claim.

If insurance is making multiple payments on the same claim (e.g. Ortho payments) do the following:

  1. Enter the first payment on the claim as normal.
  2. For each subsequent payment, open the claim, highlight the paid procedures, then click Supplemental.
  3. Enter the paid amount for each procedure.
  4. Then click This Claim Only (if this is a single payment) or Batch (if this is part of a larger EOB) to finalize the payment.
Insurance overpaid on a procedure.

Insurance may do one of two things when an overpayment happens:

If insurance asks for a refund:

  1. On the overpaid claim, create a negative supplemental payment for the overpaid amount (e.g. -100.00).
  2. Click This Claim Only to create the refund check and finalize. Ensure the amount is negative (e.g. -100.00) to show money is going back to insurance.

or

If insurance is allocating the refund to another patient:

  1. On the patient with the overpayment, create a negative supplemental payment for the amount overpaid.
  2. On the patient the money is being allocated to, create a positive supplemental payment for the amount.
  3. Click Batch, then attach both supplemental payments to this check to finalize. This transfers the balance from one patient to the other.

 

OK, you’ve got the claim process handled, and are tracking payments and other activity. Mission Accomplished!
Stay tuned for Part 2 in this series, which will discuss Adjustments, Quick Procs, and Repeating Charges.

Have a quick question that needs a quick answer right away? Chat with us!

Categories: Insurance, Tips & Tricks

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