Best Billing EHR Systems, Practice Management Software & Insurance Verification

Setting up billing EHR systems is crucial for the smooth operation of your medical practice and ensuring timely reimbursements. Here’s a step-by-step guide to establishing a comprehensive billing system, focusing on Electronic Health Records (EHR), practice management software, and billing software.

EHR Systems 101

Electronic Health Records (EHR) and Practice Management Software

Investing in an integrated EHR and practice management software can streamline patient management, documentation, and billing processes. We recommend using Practice Better for its seamless integration with the clearinghouse Claim MD for insurance claim submissions.

  1. Choosing Practice Better:
    • Features: Practice Better offers comprehensive features for scheduling, patient management, documentation, and billing.
    • Integration: It integrates easily with Claim MD, simplifying the insurance claim submission process.
  2. Setting Up Practice Better:
    • Sign Up: Create an account on the Practice Better website.
    • Customization: Customize the system according to your practice’s needs, including patient forms, appointment types, and communication templates.
    • Training: Train your staff on using Practice Better to ensure everyone is familiar with its features and functionalities.
  3. Integrating Claim MD:
    • Clearinghouse Account: Set up an account with Claim MD.
    • Integration: Follow the instructions to integrate Claim MD with Practice Better.
    • Training: Train your billing staff on how to use Claim MD for submitting insurance claims, tracking claims status, and managing rejections.

Billing Software

Using specialized billing software can help manage insurance claims, track payments, and handle accounts receivable efficiently.

  1. Choosing Billing Software:
    • Compatibility: Ensure the billing software is compatible with your EHR and practice management software.
    • Features: Look for features like claim submission, payment tracking, denial management, and reporting.
    • Support: Choose software that offers robust customer support and training resources.
  2. Setting Up Billing Software:
    • Sign Up and Installation: Create an account and install the software as per the provider’s instructions.
    • Data Migration: If you have existing billing data, migrate it to the new system.
    • Customization: Customize the software to suit your practice’s specific billing workflows and needs.
    • Training: Provide comprehensive training to your billing staff to ensure they are proficient in using the software.

Implementing the Billing System

  1. Patient Registration and Insurance Verification:
    • Collect Information: During patient registration, collect all necessary insurance information.
    • Verify Coverage: Use the billing software or a dedicated insurance verification tool to verify coverage and benefits.
  2. Coding and Documentation:
    • Accurate Coding: Ensure accurate coding of diagnoses and procedures using ICD-10 and CPT codes.
    • Detailed Documentation: Maintain detailed and accurate documentation in the EHR to support claims.
  3. Claims Submission:
    • Create Claims: Use your billing software to create claims based on the documentation and coding.
    • Submit Claims: Submit claims electronically through the clearinghouse (e.g., Claim MD).
  4. Tracking and Managing Claims:
    • Monitor Claims: Use the billing software to monitor the status of submitted claims.
    • Address Rejections: Quickly address any rejected or denied claims by correcting errors and resubmitting them.
  5. Payment Posting and Accounts Receivable:
    • Post Payments: Once payments are received, post them in the billing software to update patient accounts.
    • Manage Accounts Receivable: Regularly review accounts receivable reports to follow up on outstanding balances and ensure timely payments.
  6. Reporting and Analytics:
    • Generate Reports: Use the reporting features of your billing software to generate financial and operational reports.
    • Analyze Performance: Analyze the reports to identify trends, monitor cash flow, and improve billing processes.

Additional Tips for Effective Billing Management

  1. Stay Updated on Coding Changes:
    • Regularly update your coding knowledge to stay compliant with current regulations and coding standards.
  2. Regular Training and Education:
    • Continuously train your staff on new billing procedures, software updates, and industry changes.
  3. Audit and Review:
    • Periodically audit your billing processes and documentation to identify and rectify any issues or discrepancies.
  4. Communication with Patients:
    • Maintain clear communication with patients regarding their financial responsibilities, insurance coverage, and billing procedures.
  5. Outsource if Needed:
    • Consider outsourcing your billing to a professional billing service if it becomes too complex or time-consuming for your in-house staff.

By investing in integrated EHR and practice management software like Practice Better, coupled with efficient billing software and the clearinghouse Claim MD, you can streamline your billing processes, reduce errors, and ensure timely reimbursements. Regular training, accurate documentation, and proactive management of claims and accounts receivable are key to maintaining an effective billing system.

Verify Patient Insurance Information

Verifying patient insurance information before providing services is crucial to ensure that services are covered and to avoid claim denials. Here’s a step-by-step guide to verifying patient insurance information effectively.

Insurance Verification

  1. Initial Contact:
    • During Appointment Scheduling: Ask for insurance information when patients call to schedule appointments.
    • At Check-In: Verify insurance details when patients check in for their appointments.
  2. Insurance Verification Process:
    • Check Eligibility: Use your practice management or billing software to check patient eligibility and coverage.
    • Benefits Verification: Confirm the patient’s benefits, including coverage limits, copayments, deductibles, and coinsurance.
    • Prior Authorization: Determine if prior authorization is needed for the scheduled service or procedure.

Collect Necessary Information

  1. Patient Insurance Card:
    • Insurance ID Number: Record the patient’s insurance ID number from their insurance card.
    • Group Number: Note the group number associated with the patient’s insurance plan.
    • Insurance Company Contact: Obtain the contact information for the insurance company, including the customer service phone number.
  2. Patient Personal Information:
    • Full Name: Ensure you have the patient’s full legal name as it appears on their insurance card.
    • Date of Birth: Verify the patient’s date of birth.
    • Address and Contact Information: Confirm the patient’s current address and contact information.

Step-by-Step Verification

  1. Online Verification:
    • Insurance Portals: Use the insurance company’s online portal to verify patient coverage. Most major insurers provide online tools for eligibility verification.
    • Integrated Software: Utilize your practice management or billing software’s integration with clearinghouses (e.g., Claim MD) to check eligibility and benefits online.
  2. Phone Verification:
    • Contact Insurance Provider: Call the insurance company’s provider services number. Be prepared for possible hold times.
    • Provide Necessary Details: When speaking with a representative, provide the patient’s insurance ID, group number, name, and date of birth.
  3. Verify Key Information:
    • Coverage Dates: Confirm the dates the insurance coverage is active.
    • Covered Services: Ask about coverage for specific services or procedures to be provided.
    • Copayments and Deductibles: Verify the patient’s copayments, deductibles, and coinsurance amounts.
    • Prior Authorization Requirements: Check if prior authorization is needed and if it has been obtained for the scheduled service.

Documentation & Follow-Up

  1. Record Verification Results:
    • Update Patient Records: Enter the verification details into the patient’s electronic health record (EHR) or practice management software.
    • Notes: Include notes on coverage, benefits, and any prior authorization requirements.
  2. Inform Patients:
    • Discuss Coverage: Inform patients about their coverage details, including any out-of-pocket costs they may incur.
    • Payment Responsibilities: Explain the payment process and their responsibilities regarding copayments, deductibles, and coinsurance.
  3. Prior Authorization:
    • Obtain Authorization: If required, follow the insurance company’s process to obtain prior authorization for services.
    • Track Authorization: Keep track of prior authorization numbers and include them in the patient’s records.

Handling Insurance Issues

  1. Discrepancies:
    • Investigate Issues: If there are discrepancies or issues with the verification, contact the insurance company for clarification.
    • Patient Assistance: Assist patients in resolving any issues with their insurance coverage.
  2. Uninsured or Underinsured Patients:
    • Alternative Payment Options: Discuss payment plans or alternative funding options with patients who are uninsured or underinsured.
    • Charity Care: Consider if your practice offers charity care or sliding scale fees based on income.

insurance verification Best Practices

  1. Regular Training:
    • Train staff regularly on insurance verification processes and updates.
    • Ensure they are familiar with different insurance plans and requirements.
  2. Automate Where Possible:
    • Utilize automated verification tools and integrations to streamline the process and reduce manual work.
  3. Consistent Verification:
    • Verify insurance information for every patient, even if they are returning patients, to ensure there have been no changes in coverage.
  4. Documentation:
    • Keep thorough documentation of all verification steps and communications with insurance companies.

Effective insurance verification ensures that services provided are covered by the patient’s insurance, minimizing the risk of claim denials and ensuring timely payments. By following a systematic approach and utilizing both online and phone verification methods, you can streamline the verification process and improve the overall efficiency of your practice.

Medical Necessity

Understanding and appropriately documenting medical necessity is crucial for obtaining insurance reimbursement for services provided to patients. Here’s a detailed explanation of medical necessity and its importance in healthcare.

Definition of Medical Necessity

Medical Necessity refers to healthcare services or products that are justified as reasonable, necessary, and appropriate based on evidence-based clinical standards of care. These services must be required to diagnose, treat, or prevent an illness, injury, condition, disease, or its symptoms and must meet accepted standards of medicine.

Key Criteria for Medical Necessity

  1. Purpose: The service or product must be for the purpose of evaluating, diagnosing, treating, or preventing a medical condition.
  2. Evidence-Based: The service must be in accordance with generally accepted standards of medical practice and supported by credible scientific evidence or guidelines.
  3. Appropriate: The service must be appropriate in terms of type, frequency, duration, and setting, and must be considered effective for the patient’s condition.
  4. Not for Convenience: The service must not be primarily for the convenience of the patient, physician, or other healthcare provider.
  5. Cost-Effective: The service must be the most cost-effective option that meets the patient’s needs.

Examples of Medically Necessary Services

  • Diagnostic Tests: Blood tests, MRIs, X-rays, and other tests required to diagnose a condition.
  • Surgical Procedures: Surgeries needed to treat or alleviate a medical condition.
  • Medications: Prescriptions necessary to manage or treat a condition.
  • Therapies: Physical therapy, occupational therapy, or speech therapy prescribed for rehabilitation.
  • Preventive Services: Vaccinations, screenings, and other preventive measures to maintain health and prevent disease.

Importance of Medical Necessity in Billing and Claims

  1. Insurance Reimbursement:
    • Insurance companies require documentation of medical necessity to approve and reimburse claims for services rendered.
    • Lack of documentation or inadequate justification can lead to claim denials.
  2. Compliance:
    • Properly documenting medical necessity ensures compliance with insurance policies and regulatory requirements.
    • Reduces the risk of audits, fines, and legal issues.
  3. Quality of Care:
    • Ensures that patients receive appropriate and effective care tailored to their medical needs.
    • Enhances patient outcomes by aligning treatment with accepted standards of care.

Documenting Medical Necessity

  1. Patient History and Assessment:
    • Document a thorough patient history, including symptoms, medical history, and physical examination findings.
    • Include relevant diagnostic test results.
  2. Clinical Guidelines and Evidence:
    • Reference clinical guidelines, standards of care, and scientific evidence supporting the service or treatment.
    • Use evidence-based protocols and best practices.
  3. Treatment Plan:
    • Clearly outline the treatment plan, including the rationale for the chosen intervention.
    • Specify the expected outcomes and how the treatment will address the patient’s condition.
  4. Progress Notes:
    • Maintain detailed progress notes documenting the patient’s response to treatment and any modifications made.
    • Include objective measures of improvement or justification for continued treatment.

Challenges & Tips

  1. Insurance Company Criteria:
    • Different insurance companies may have varying criteria for what constitutes medical necessity.
    • Familiarize yourself with the specific policies and guidelines of the insurers you work with.
  2. Denial Management:
    • If a claim is denied for lack of medical necessity, review the denial reasons and provide additional documentation or appeal if warranted.
    • Keep detailed records of all communications with insurers regarding denied claims.
  3. Continuous Education:
    • Stay updated on changes in medical necessity guidelines and clinical standards.
    • Provide regular training for your staff on proper documentation practices.

Medical necessity is a fundamental concept in healthcare that ensures patients receive appropriate, evidence-based, and cost-effective care. Proper documentation of medical necessity is crucial for obtaining insurance reimbursement, maintaining compliance, and delivering high-quality care to patients. By understanding and applying the principles of medical necessity, healthcare providers can effectively navigate the complexities of insurance claims and enhance patient outcomes.

Information to Collect from the Patient at the Initial Visit for Successful Insurance Billing

Collecting accurate and comprehensive information from patients during their initial visit is critical for successful insurance billing and claim submission. Here’s a detailed list of the necessary information to gather:

Patient Personal Information

  1. Full Legal Name:
    • Ensure it matches the name on the patient’s insurance card.
  2. Date of Birth:
    • Important for verifying identity and eligibility.
  3. Gender:
    • Required for insurance claims and medical records.
  4. Social Security Number:
    • Used for patient identification and insurance verification (optional in some practices).

Contact Information

  1. Current Address:
    • For billing and communication purposes.
  2. Phone Number:
    • Primary and secondary contact numbers.
  3. Email Address:
    • For communication and sending statements or reminders.

Emergency Contact Information

  1. Name:
    • Full name of the emergency contact.
  2. Relationship to Patient:
    • E.g., spouse, parent, friend.
  3. Phone Number:
    • Contact number for emergencies.

Insurance Information

  1. Insurance Card:
    • Photocopy: Make a photocopy (front and back) of the patient’s insurance card(s).
  2. Insurance Company Name:
    • Name of the primary and secondary insurance providers if applicable.
  3. Insurance ID Number:
    • The unique identification number on the insurance card.
  4. Group Number:
    • Group identification number associated with the insurance plan.
  5. Policyholder Information:
    • Name: Full name of the policyholder if different from the patient.
    • Date of Birth: Policyholder’s date of birth.
    • Employer Name: If the insurance is employer-sponsored.

Additional Insurance Details

  1. Effective Date:
    • The start date of the insurance coverage.
  2. Copayment and Deductibles:
    • Information on copayment amounts and deductibles.
  3. Prior Authorization:
    • Verify if prior authorization is needed for initial or future services.

Medical History and Information

  1. Primary Care Physician (PCP):
    • Name and contact information of the patient’s primary care physician.
  2. Medical History:
    • Major illnesses, surgeries, chronic conditions, and ongoing treatments.
  3. Current Medications:
    • List of current medications, dosages, and prescribing doctors.
  4. Allergies:
    • Known allergies, including medications, food, and environmental factors.

Consent and Authorization Forms

  1. Consent for Treatment:
    • Obtain the patient’s signed consent to receive medical treatment.
  2. HIPAA Authorization:
    • Signed authorization to release medical information for billing and insurance purposes.
  3. Assignment of Benefits:
    • Authorization for the insurance company to pay benefits directly to your practice.

Financial Responsibility Agreement

  1. Payment Policy Acknowledgment:
    • Patient’s acknowledgment of understanding your practice’s payment policies, including responsibility for copayments, deductibles, and any services not covered by insurance.

Summary Checklist for Initial Visit

  • Personal Information:
    • Full Legal Name
    • Date of Birth
    • Gender
    • Social Security Number (if required)
  • Contact Information:
    • Current Address
    • Primary and Secondary Phone Numbers
    • Email Address
  • Emergency Contact:
    • Name
    • Relationship
    • Phone Number
  • Insurance Information:
    • Photocopy of Insurance Card (front and back)
    • Insurance Company Name(s)
    • Insurance ID Number
    • Group Number
    • Policyholder Information (Name, Date of Birth, Employer)
  • Additional Insurance Details:
    • Effective Date
    • Copayments and Deductibles
    • Prior Authorization Requirements
  • Medical Information:
    • Primary Care Physician Contact
    • Medical History
    • Current Medications
    • Allergies
  • Consent and Authorization Forms:
    • Consent for Treatment
    • HIPAA Authorization
    • Assignment of Benefits
  • Financial Responsibility:
    • Payment Policy Acknowledgment

PRO TIP: Have Patients Verify their own Insurance Benefits

You should have your patients verify their insurance benefits. This takes way to much time away from you and your staff. If they have insurance and want to work with you, they can take the time to call their insurance company to verify their insurance benefits.

PRO TIP: Have your patient sign a liability form that states your patient is responsible for verifying their insurance benefits and paying for the service if your insurance claim is denied (make sure to collect a credit card to book the appointment).

Continue Learning

Continue learning about insurance reimbursement best practices, growing your medical private practice revenue, researching ICD 10 codes, and much more:

Best EHR Systems

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All content contains personal experiences and is not intended to provide medical advice. For personalized medical guidance, please consult with a qualified healthcare professional. The author and associated entities assume no liability for actions taken based on the content herein.