Some of the ways you can help to ensure the accurate processing of your claims and avoid payment delays include:
Before providing services
- Review your contract with the health plan regarding the claim submission requirements, preauthorization requirements, fee-schedule and adjudication process.
- Obtain preauthorization (also called precertification) if that is required.
- Verify that the patient’s insurance covers the service before providing treatment. Ask the company if there are any limitations or restrictions, such as the number of visits or length of the sessions.
When submitting a claim
- Use the required forms and check that all claim submissions are completed fully and accurately.
- Follow the payers’ requirements for claims submission as described in their contract or provider manual.
- Check your procedure codes and diagnosis codes to ensure they are accurate and, if necessary, HIPAA-compliant.
After receiving notification of adjudication
- Carefully review the notification for accuracy and confirm that you were paid for the correct services, that no diagnosis or procedure codes were changed and that you were paid the correct amount.
- If a claim is denied and you believe denial was improper, submit a timely appeal letter and ask the insurance carrier for reconsideration.
On a regular basis
- Establish and follow a schedule for submitting claims on a routine basis.
- Inquire regularly with the health plan or intermediary about the status of unpaid claims, generally within one month after filing.
- Keep current information on file regarding the terms of your clients’ insurance policies.
- Know how to access provider manuals and other documents related to your contract. Many are available online. Read health-plan bulletins and newsletters to keep track of the most current information and be alert to upcoming changes. File documents describing any changes with your contract and provider manual.
- Understand the collection policies required by various payers. For example, while acknowledging that there may be circumstances affecting patients’ ability to pay, it can be considered fraud for providers not to collect copayments from beneficiaries.
Two final tips for problem resolution
- Psychologists in states with prompt payment laws may be able to use such laws to press insurance companies to pay within the required time. These laws typically require the company to pay within 30 days of receiving a “clean claim” that contains all of the information that the payer needs to process the claim.
- The state insurance commissioner’s office is a potential source of help, especially if there is a pattern of problems or an egregious situation with a payer.