The COVID-19 pandemic has urged healthcare organizations systems to utilize remote healthcare — from telehealth visits to remote patient monitoring (RPM). The demand to swiftly promptly care for people from their homes while also detecting potential major health concerns has ushered in the industry’s future. This improves patient outcomes while also lowering morbidity and death. This change has been made financially achievable for doctor’s offices and hospitals— thanks to reimbursement from private and government health insurers.
A surge in interest in remote care programs has prompted the Centers for Medicare & Medicaid Services (CMS) to increase its support for RPM. CPT codes can help doctors’ offices earn from RPM programs while increasing overall patient care. These guidelines establish a financial framework for physicians to be compensated for their time and equipment.
Definition of Health Insurance Claim
A health insurance claim is a request for direct payment or reimbursement made by the health care provider for medical services obtained by an insured person.
For Remote Patient Monitoring (RPM) program, if an insured patient receives medical service(s); to monitor his physiological parameters as part of the treatment plan, an insurance claim is made for direct payment or reimbursement under CPT Codes 99453, 99454, 99457 and 99458. It is also called the bill or invoice that is submitted to an insurance company. Basically, a claim is a formal request to the patient’s payer, like an insurance company for reimbursement against losses covered under the patient’s insurance policy or contract.
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CPT Codes and ICD Codes
Current Procedural Terminology (CPT), is a set of medical code used to report medical-surgical, diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation and accreditation organizations, while the method of classifying diseases, injuries, and the cause of death refers to International Classification of Disease (ICD).
When health care providers give services, they always document these services with the assistance of the medical coders. The medical coders encode ICD and CPT Codes. ICD codes indicate the patient’s diagnosis example ICD–Code J45.50 is a billable ICD-10 code used for healthcare diagnosis reimbursement of Severe Persistent Asthma while CPT codes define the procedure during the consultation. For example, CPT Codes 99453, 99454, 99457, 99458, 99091 are used for remote patient monitoring (RPM) reimbursement.
When the event the happens, especially when medical services was obtained by an that an insured person and is covered under the patient’s policy. Claims are filed and they use these codes to form a summary, includes information like the National Provider Identifier (NPI) of the treating clinician, ICD-10 (diagnosis) Code/s, CPT (procedure) code/s, and the patient’s insurance information for the insurer.
Medical Claims Processing
According to the Health Insurance Association of America (HIAA), a “member” is a person enrolled under an insurance policy. A health insurance is a coverage that pays the benefits as a result of sickness or injury.
When a patient or a member with valid health insurance consult a health care provider (HCP) that is in-network, after rendering the service, the provider may submit a claim to the health insurance company. A claims processor will investigate the claim for completeness, accuracy, and whether the service is covered under the patient’s health plan.
The process of reviewing and remittances or denying the claim includes layers of customer service and administrative work. If it is a clean claim, the health insurance company will process it. The member then is provided with an Explanation of Benefits (EOB). If a balance needs to be paid, the HCP will bill the member.
What is a Clean Claim?
An efficient billing process has one important factor, and that is submitting a clean claim. It has no mistakes. The health information contained in a clean medical claim is “accurate” from start to finish. It can also be processed without additional information from a third party.
How to check if a claim is clean?
- The eligibility of the patient, it means that the health insurance cover the service provided and the coverage was in effect on the date of service.
- The healthcare provider must be licensed to practice on the date of service and is not under investigation for fraud. An active Medicaid provider ID is also a must.
- The form has no expired or deleted codes. To eliminate questions about medical necessity, each procedure code must have a supporting diagnosis code.
- The claim form must have all the required information such as patient’s name, address, date of birth, identification number, and group number and written in the correct fields.
- The form must correctly identify the ID number and the mailing address of the payer.
- The claim must be submitted on time.
Health Insurance Claim Forms
Claim transmissions are completed electronically as mandated by HIPAA regulations, but it doesn’t mean that all claims are submitted electronically. There are exceptions to this rule, for example, a manual claim can be submitted a practice experienced a power outage, mainly if those claims must be submitted on time.
The UB-04 (CMS 1450) and the HCFA-1500 (CMS-1500) are the two common types of medical claim forms. These forms are not interchangeable even if they may operate and look similarly.
The claim form UB-04 (CMS 1450) is generally used by in-patients, nursing facilities, hospitals, and a specific facility provider or institutional healthcare facilities, while HCFA-1500 (CMS 1500) is a medical claim form used by individual doctors, nurses, and other healthcare professionals, including therapists, chiropractors, and out-patient clinics. It is for non-institutional or private practices.
The Electronic Billing
Electronic billing ensures faster processing and payment of claims. For permanent record retention all claims must be checked for imaging and microfilming. Electronic billing tracks each claim that was sent, it minimizes clerical data entry errors and eliminates the cost of sending paper claims. In processing an electronic billing, all required fields must be completed and should include additional documentation when necessary. High quality copies must be submitted and the required documentation must be there or otherwise the medical claim form may be returned unprocessed. The claim may also be denied for untimely filing.
Reviewing the Data before Submission
To avoid claims rejection. It important to review claims prior to submission. These are the important things to check in reviewing claims prior to submission:
- The authorization information of the patient.
- The spelling must be checked and the accuracy of all fields.
- The NPI of the healthcare provider because for every claim, they are required to submit their NPI.
- The validation of the CPT/HCPS/ICD-10 codes against the documented services in the member’s record.
What is a rejected claim and a denied claim?
Failing to do the billing validation may result to a rejected claim status. When the claim is prepared to be sent to the payer, billing validation is a must, it is the process that the claim goes through in billing, this may include validations for any payer-specific requirements. Rejected claim contains one or more errors found before the claim was processed. If insurance companies reject a claim because data requirements were not met, they do not keep a record of that claim in their system, meaning, the medical claims will never be entered into their computer system.
The claims that were received and processed by the payer but deemed unpayable are considered denied claims but when an insurance company denies a claim, they have a record of that claim in their system. Here are some reasons why claims are denied:
- Pre-Certification or Authorization Was Required, but Not Obtained.
- Claim Form Errors: Wrong Patient data, procedure codes and diagnosis
- Claim Was Filed After Insurer’s Deadline.
- Insufficient Medical Necessity.
- Use of Out-of-Network Provider.
The process of medical billing involves health and money, the goal of the medical biller is to make sure that the provider is reimbursed for their services. Unfortunately, both human and electronic errors are inevitable that’s why it is important to reduce as many of these errors as possible
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