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Class # 7 "Commercial Heath Insurance" 

Commercial health insurance is a type of health insurance that covers medical expenses and disability income for the insured. Commercial health insurance can be categorized according to its renewal provisions and type of medical benefits provided. Commercial policies can be sold individually or as part of a group plan.

Put plainly, commercial health insurance is any healthcare policy that is not administered or provided by a government program. Most commercial health insurers are publicly traded companies that operate to generate a profit for shareholders. Some commercial health insurers are non-profit organizations. The Blue Cross Blue Shield Association, for instance, has member organizations that operate for profit, while in some states the local Blue Cross Blue Shield plan is a non-profit entity.

Most people purchase their health insurance through their employer. Employers contract with commercial insurers to provide healthcare benefits to their employees to retain employees, to make the workplace more attractive to job applicants, and for tax savings realized for non-monetary workplace benefits. Because employers can offer a larger number of premium-paying customers to insurers, the rates charged per beneficiary is less than if a person were to purchase health insurance on his or her own. The economy of scale that employers offer insurers makes it worthwhile for insurers to offer a bulk discount. These are known as group plans, rather than individual plans. Individuals who are self-employed or who opt to otherwise purchase health insurance on their own, pay more than people who participate in a group plan.

Professional medical billers who submit claims to commercial healthcare plans are already familiar with the basics of how claims are arranged and services are reported for reimbursement. The terms are similar to the process used to submit claims to government healthcare programs. The Centers for Medicare and Medicaid Services (CMS) devises payment and coding methodologies to manage the national healthcare reimbursement system. Medicare Part A covers inpatient services that patients receive, while Medicare Part B covers outpatient services. While the reimbursement policies of these programs differ, they are comprehensive, and many commercial insurers employ them in their own proprietary contracts with healthcare providers and beneficiaries.

All healthcare claims are submitted to third-party payers in industry-standard medical code. The definitions and uses of codes are guided by various professional bodies, such as the American Medical Association, and the American Hospital Association, as well as CMS. Private insurers are free to develop their own interpretations of procedure codes, and combinations that they feel should not be reported together. A commercial insurer’s interpretations are published in their own proprietary manuals that are available to healthcare providers who contract to provide services to the insurer’s patients.

Additionally, private health insurance policies can publish medical policies to guide contracted providers in how certain services should be delivered, and in which situations. When the definitions of procedure codes are made available to the industry, the procedures are not generally tied to specific conditions. Private insurers may rule that some procedures are not medically necessary when reported with a set of diagnosis codes. Likewise, they can rule that a procedure is experimental, or that is does not provide a proven medical benefit. Based on these policy determinations, some services may be contractually non-covered.

Healthcare providers are not forbidden to perform non-covered services, that is left up to their professional judgement. According to the terms of their contracts with private payers, healthcare providers are not allowed to receive reimbursement for these procedures. Some policies prevent providers from billing patients for the non-covered services, while others may require that the patient sign an informed consent that he or she will be responsible for the charges, prior to receiving services.

As a medical billing specialist, it’s critically important that you minimize any coding and processing errors as you file claims. Healthcare providers receive the majority of their revenue through the processing of successful claims, so any mistake you make could cost your employer. This course is designed to help you avoid the most common errors and keep denied and rejected claims at a minimum.

Understanding the Difference Between a Denied and a Rejected Claim

First, you need to know the difference between a denied claim and a rejected claim. A denied claimis one that has been determined by an insurance company to be unpayable. Typically, insurance companies explain the reasons in the Explanation of Benefits (EOBs) attached to the claim. Claims are often denied because of common billing errors or missing information, but can also be denied based on patient coverage. Denied claims can be appealed and reprocessed in some cases.

A rejected claim has been rejected because of errors. An insurance company might reject a claim because a medical billing specialist incorrectly input patient or insurance information. Once a medical billing specialist amends the errors on a rejected claim they can resubmit it for processing with an insurance company.

Common Errors Made When Filing a Claim

It is easy to overlook parts of a claim when you’re processing many in a given day. But if you can identify some of the more common mistakes medical billing specialists make, you can try to avoid them. Here are some of the most common mistakes made when filing a claim:

  • Entering incorrect information for the provider (name, address, contact information, etc.)

  • Entering incorrect information for the patient (name, sex, date of birth, insurance ID information, etc.)

  • Entering incorrect information for the insurance provider (policy numbers, address, contact information, etc.)

  • Inputting the wrong codes or confusing codes such as CPT codes, point of service codes, or ICD-9-CM codes

  • Entering too few or too many digits for ICD-9-CM codes

  • Inputting mismatched treatment and diagnostic codes

  • Forgetting to input codes at all for services performed by a physician or another healthcare official

Again, every piece of information on a claim has to be accurate in order for it to be processed correctly. It is particularly important to make sure the correct codes are used. Be sure to familiarize yourself with all the relevant codes as well as patient, provider, and insurance information prior to filing a claim.

Other common billing errors include the following:

  • Not having access to EOBs on denied claims: Sometimes an insurance company may forget to attach the EOB to a denied claim. In these cases, you won’t know the reason the claim was denied because the insurance company didn’t provide it at all or it was mistakenly sent to another provider. You can minimize problems with the EOB by keeping track of denied claims as soon as you receive them from insurance companies.

  • Not verifying a patient’s insurance coverage: A patient’s health insurance can change at any time, sometimes without the patient knowing it. As a medical billing specialist, part of your job is to verify insurance coverage.

  • Duplicate billing: Duplicate billing is an issue that occurs when you bill for the same service more than once. This might happen if more than one person at a provider’s office reports that a patient received services without checking whether or not those services had been paid for. The best way to avoid duplicate billing is for you to be extra vigilant about suspicious entries on a patient’s superbill and to communicate your concerns to a physician about them.

Some billing errors are simply beyond your control including the following:

  • Upcoding: Upcoding occurs when physicians or medical coders enter codes into a patient’s superbill for services not received. Typically this is done to inflate the total amount a patient owes for receiving care at a healthcare provider. Upcoding is illegal and can lead to fines and criminal prosecution.

  • Undercoding: Undercoding occurs when a physician or a medical coder leaves out codes from a patient’s superbill or codes them for less treatment than they actually received. Healthcare providers might undercode for healthcare services in an attempt to avoid audits or to minimize a patient’s cost. Undercoding is also illegal and can have legal repercussions.

  • Sloppy documentation: Medical billing errors can also arise when physicians or other healthcare providers turn in sloppy documentation to medical billing specialists. A physician might have illegible handwriting, for example, making it hard to assign codes and bill for a patient’s healthcare. A physician’s documentation may also cause you to inadvertently undercode a patient’s bill.

How to Catch and Correct Errors Early

To avoid common medical billing: stay vigilant about simple mistakes on your end, be thorough when reviewing a patient’s superbill, and consult with your physician whenever you have questions about what should or shouldn’t be billed for. Most medical billing errors can be avoided well before claims are sent for processing with an insurance company, and it’s up to you to keep the claims moving through the system quickly and accurately. Here are a few tips to help you stay on track:

  • Coordinate with everyone at the provider’s office: You aren’t the only person responsible for the information you in a claim. The physician who administered the actual healthcare and the personnel who collected a patient’s co-pay and insurance information also contributed to the superbill. So if you have any concerns about a claim, you can check with them to work out any issues before submitting the claim.

  • Double-check patient and insurance information before filing a claim: Entering patient and insurance information incorrectly is one of the easier mistakes to avoid, but they still happen. The strategy for avoiding this mistake is simple: double-check your work.

  • Study billing and coding trends: You can guard against coding mistakes by staying up to date on the latest medical billing codes. Medical billing codes change over time to accommodate modifications in healthcare regulations, newfound illnesses, and new treatments for illnesses and conditions. Be sure to study new codes and billing procedures as they become available.

  • Follow up on claims: You can avoid and anticipate errors by following up on claims filed with insurance companies. A representative working on the claim for the insurance company might be able to tell you of any errors they find on their end, and thereby provide you with an opportunity to resubmit a claim before it gets denied.


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