Getting the Best Results From Your Medical Claims Billing

There are many pitfalls to medical claims billing. Understanding these pitfalls is essential to ensuring your claims are processed and paid quickly.

Pitfalls of Medical Claims Billing

With the world’s economy being in a constant state of volatility, it is more important than ever to make sure that medical claims are billed in a timely and correct fashion. Failure to do so will have a negative impact on a Doctor’s cash flow. These errors can have the following consequences:

unnecessary rejections;
late payments of claims;
members running out of day-to-day benefits; and
worst of all … non payment due to stale claims!

All applicable details need to be captured correctly from the outset to avoid rejections such as “patient’s dependent code incorrect” or “date of birth incorrect”. Selecting the correct medical aid plan is very important as the benefits on these plans differ from plan to plan. Selecting the incorrect plan might lead to a healthcare professional missing out on well-deserved revenue.

How to Avoid the Pitfalls of Medical Claims Billing

Practices can avoid these pitfalls if they have the correct medical practice management software.

Patient Validation

Features you should look for include the ability to validate patient details,to ensure the medical aid details are correct, as well as the ability to check whether the member has funds available (benefit check).

Authorisation

Other aspects that need to be taken into account are that some medical aids require authorization, and the authorisation number and referring Doctors details must be captured on the claims.

ICD10 Coding

Correct ICD10 coding is crucial and codes must be captured in the correct sequence. The incorrect sequence of ICD10 codes or using invalid or unauthorized ICD10 codes will delay the payment of claims. This is especially important for PMB (prescribed minimum benefit) claims.

Medical Claim Billing Modifiers

The understanding and application of additional billing rules are also important, such as the application of modifiers. Knowing when and where to apply these modifiers will reduce time spent following up with the medical aids and speed up payment of claims.

Medical Industry Updates

Medical practice management software needs to be regularly updated with the latest tariff pricing; changes in medical aids, stock and NAPPI codes; as well as new billing rules. Failure to do so, will result in claims being rejected as they fall outside acceptable billing rules and standards.

Understanding Prescribed Minimum Benefits (PMBs)

PMBs are conditions that are paid from the patient’s PMB benefit. PMB conditions are usually attributed to both life threatening as well as emergency conditions and procedures.

Due to government legislation there are 270 conditions that have been identified as PMB conditions. PMB claims must be paid to the practitioner, up to 300%, exception being if Doctor is signed up on a specialist arrangements with the medical aid.

Adding the correct ICD10 codes from the start is essential to having these claims paid promptly.

Submitting Medical Aid Claims

The majority of medical aids can now process real-time claims. This means the claims are submitted electronically and a response to these submissions is received within seconds indicating if the claim will be paid in full or partially paid, with a reason.

Some medical aids don’t have this feature available, so it is important that your medical practice management software can identify which medical aids require a paper claim. This will eliminate delays in paying your claims.