Typically a medical office’s front desk will obtain and verify a patient’s coverage prior to the office visit. For practices that use electronic medical records, a scanned copy of both sides of the insurance card should be on file along with the date it was scanned. Human error occurs when registering a new patient. Billers expect that. Some receptionists cannot different between Medicare B and a Medicare Advantage Plan or which payer is primary or secondary. A biller dealing with a denial can resolve many claim issues with card access.
No matter how accurate the insurance information is when recorded, payers still process claims incorrectly and it is to their advantage when a medical biller writes off the balance without a query or appeal.
The first thing you want to look at is the patient information. Is the name spelled correctly? Is the date of birth correct? Sometimes the office will have the correct date of birth but the payer will have entered the wrong one. This is very common. Are the letter prefixes correct or the id numbers transposed?
Insurance Cards and Medical Billing
Now look at an insurance card. The first feature you will notice is the payer’s logo linked to the payer’s name. You will then see a member ID number and usually a group number linked to the ID. The group number represents the company the subscriber (primary insured) works for. Depending on the carrier, ID numbers may contain a suffix to indicate who the primary insured is, and the remaining family members will fall into sequence, such as subscriber, spouse, child number one and child number two, etc. The primary insurer’s ID could end in either a -00 or a -01 indicating he is primary and billers should know this information per carrier should there be a denial problem. Also, in today’s society, there are divorced families and same-sex marriages which can alter the normal sequence of suffixes or how a claim is billed. For example, a divorced dad may be suffix number one and child “one” from the first marriage is number “two” and new wife may be number “three” and new baby in the new marriage is number “four”. It gets complicated but if you are aware of these issues, it is easier to resolve a denied claim.
Some carriers read claims by the first few letters of the first name and the last name. If you are billing for a Josephine Martin, you may discover the insurance denied under her spouse, “Joseph” Martin due to sex and date of birth discrepancies.
You may see co-payment amounts associated with office visits, behavioral health visits and emergency room visits on the front of the card and an Rx will indicate the patient has prescription coverage. Not all dollar amounts are accurate on a card. If you are billing additional money for co-payments once the insurance has paid, make note in the medical record.
The back of the card contains information for claim submissions. Although the majority of claims are submitted electronically, a physical mailing address should be recorded from the back of the card as well as claim inquiry telephone numbers. Billers need the electronic address from the card that links to the health plan. These numbers are always consistent with each plan but note that some billing software use different electronic addresses and will provide you with a crosswalk that indicates the common electronic address and the number they use.
Lastly, every health plan has a website where you can verify information such as patient demographics, claim status, appeals processes, etc.