Cheat Sheet for Medical Billers

Every task of the medical office responsible for the billing and collections of payments - from the moment a patient is scheduled for an appointment until the time payment is received from the insurance company - is equally important to maximizing insurance reimbursements.  The complexity  of medical billing and the requirements of the various insurance companies can make it difficult for medical office to successfully submit and collect medical payments.

Creating a cheat sheet for your medical office staff can help to make billing and collecting payments a lot easier.

Here are 7 items to include in your medical office cheat sheet.

1
Insurance Payers

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Begin your list by identifying the payers that the physicians or facility is contracted with.  This should include all contact information such as claims address, website, and provider information phone numbers. 

Don't forget to include:

  • Medicare
  • Medicaid (By State)
  • Blue Cross Blue Shield (By State)
  • Cigna
  • Aetna
  • United HealthCare
  • Tricare

2
Timely Filing

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Be aware of timely filing deadlines for each insurance carrier. Indicate the number of days a provider has to file a claims after services has been received.  Timely filing limits are specified in the provider agreement.

Some examples of timely filing deadlines include:

  • Medicare: Claims should be submitted within one year after the date of service.
  • United Health Care: Timely filing limits are specified in the provider agreement
  • Cigna: Unless state law or other exception applies -
    1. Participating health care providers have three (3) months (90 days) after the date of service.
    2. Out-of-network providers have six (6) months (180 days) after the date of service.
  • Aetna: Unless state law or other exception applies -
    1. Physicians have 90 days from the date of service to submit a claim for payment.>/li>
    2. Hospitals have one year from the date of service to submit a claim for payment.
  • TRICARE: Claims should be submitted within one year after the date of service.

3

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Indicate which insurance payers require prior authorization and/or referrals and for which procedures. Also include the process of that each payer has in place for obtaining authorization and what information they need to process the authorization.

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4
Frequency

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Specify the frequency allowed for specific services or procedures by payer. This should include the number of procedures allowed and the process for billing multiple procedures.

5
Claims Submission

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Indicate the method and type of claim needed to submit clams to each insurance payer including electronic claims, paper claims, secondary claims, and corrected claims.

Most payers require electronic submissions for both primary and secondary claims using the correct format for professional or institutional claims.

6
Payment Requirements

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Insurance payers are required to submit payment within a specific time frame, typically 30 days. Check with your payer contract in order to determine what time frame you can expect to receive payment from each payer for following up on claims status.

7

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Identify the appeals process required for each insurance payer. Each insurance company has a timely filing deadline and sometimes when claims are not resolved right away, they can be left in accounts receivable for too long failing to make the filing deadline.

When done correctly, appealing medical claims can be an effective way to resolve and receive payment for those claims that are denied due to reasons other than for simple registration errors.

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