Different Types of Medical Insurance Claims

People think of medical billing and they think there is just one type called medical claims. But there are different types of medical claims and different types of insurance plans and sometimes they have to be submitted in different ways on different forms. Knowing which type of claim is being billed and knowing which type of form to bill it on are key to getting claims paid and maintaining a consistent cash flow.

Regular commercial medical insurance is the most common claims you will come across in medical billing and they are billed on CMS 1500 forms or electronically thru a clearing house. Most plans are employer sponsored and patients have them from either their job or their spouse’s job. They can be indemnity plans, HMO’s, PPO’s, EPO’s or group health plans.

Medicare is government sponsored insurance for the elderly or disabled. In most instances Medicare claims including when Medicare is the secondary policy must be submitted electronically. Small practices can obtain a waiver. Patients with Medicare have the option to enroll in a Medicare Advantage Plan at no additional cost. It is very common to receive denials from Medicare stating the patient has a Medicare Advantage plan.

Medicare Advantage Plans are the plans that patients can opt to have in place of their Medicare. Usually patients have a copay for most services instead of co-insurance and a deductible. Patients with an Advantage plan would not usually have any secondary insurance. You can sometimes get info from Medicare regarding which plan a patient has if denied for other insurance. Medicare advantage plans can be submitted on CMS 1500 forms or electronically. Most Medicare advantage plan carriers accept electronic submissions.

Medicaid is a state sponsored plan for low or no income people. Since it is a state sponsored program the laws vary from state to state. It is important that you know and understand the laws for any state you are billing in. Many states allow their Medicaid claims to be filed on CMS 1500 forms. Some states, like NY have special forms that they require. Many states do accept electronic claims. Some even have the ability to submit claims online thru their website.

Auto accident claims or No Fault claims are claims for services relating to an automobile accident. They are filed on CMS 1500 forms to the auto insurance carrier – not the medical carrier. Some no fault carriers do accept electronic claims but most don’t. And it’s not uncommon to have to attach something like notes, or a statement authorizing benefit payment to be made to the provider. There is a place on the CMS 1500 form, box 10 where you indicate if it was related to an auto accident and the state that the accident occurred in.

Worker’s Comp claims are claims for services relating to an accident at work. The rules of billing workers comp vary from state to state. You really need to check the regulations in the state you are billing. Many states including New York require use of a special form when billing worker’s comp services. It can usually be printed out from the worker’s comp website. Copies of all claims must be sent to worker’s comp board as well as the worker’s comp carrier. Rules for worker’s comp in NY changed drastically on December 1, 2010. Prior to that a provider just submitted claims with the allowed codes. The codes had been the same for over 20 years. For example, a chiropractor was only allowed to bill a 99203 for the first visit and a 99213 for any visits after the first. It didn’t matter what services the dr did, they could only bill those codes. Most comps didn’t require any kind of authorization and the patient could come as long as they wanted to. Occasionally the comp carrier would request an IME (independent medical examination) and then cut the patient off. But most patients received treatment for years. Under the new rules the providers must bill different codes and the patients can only receive treatment for a short period of time. Then the provider must request a variance for ongoing treatment. The variances are requested by submitting a form that also can be obtained on the web site. It is now much harder for a provider to treat a comp patient for much longer than a three month period.

Personal Injury claims are claims for services that are the result of some sort of a personal injury such as a slip and fall at a grocery store. For example, the other day my father-in-law fell outside of a Big Lots. He tripped on the curb right in front of the door, fell and cut his head open and the store manager called an ambulance. They took him to the hospital for stitches. (Thankfully he was ok except for that gash above his eye.) My brother-in-law and I arrived at the store after the ambulance had left. The store manager handed us a paper with all of their insurance information on it, including the address for us to submit claims. These claims are submitted on CMS 1500 forms to the insurance carrier for the responsible party. They are billed the same as you would bill to a regular insurance carrier, you just mail them to the personal insurance carrier for the responsible party. Same codes, regular fees.

Facility claims
are claims for services rendered at a provider that is classified as a facility such as a hospital, drug and alcohol rehab, eating disorder clinics ambulatory surgery center. Claims for facilities are usually filed on UB04 forms with Rev codes instead of CPT codes. The forms are quite different from the CMS forms but they really aren’t that bad. The biggest issue is that most practice management systems don’t print them so you need separate software. There is a UB04 form filler software available for about $250 that is really a pretty good software. And our book on completing the UB04 is very comprehensive. Providers that require billing on the UB04 can make great clients. We go into greater detail on Facility Billing in that section.

There are many different types of claims. Even though most are submitted on the CMS 1500 form (or electronically) it’s important to know the different ones and understand the differences.

How Will the Supreme Court Ruling on ObamaCare affect Medical Billing?

The Supreme Court is expected to make a ruling today on ObamaCare. There are a couple of different scenarios and I personally have no idea which one will play out. But this is monumental in my eyes and I am anxiously awaiting the decision to see where ObamaCare is going.

But my interest actually has nothing to do with my profession. Personally I don’t believe that today’s ruling will affect medical billing at all. Whether ObamaCare is upheld or not medical billing is something that is here to stay. And it’s such a crucial job for the office to run that it is important that the provider(s) have a qualified, capable person doing that billing.

Some providers do have very effective in house billing, but I believe that many would (or do) benefit from outsourcing to a medical billing service. Of course that opens a whole new can of worms. Unfortunately there are many billing services out there that don’t do much more than the not-so-good in house billing system. We recently took over some work from a biller with over 20 years experience. I’m not even going to start on how bad things were. I’m just going to say that the providers are getting money for services from last year that they never dreamed they would see.

Anyway, I’m way off point. Back to today’s ruling! Whether or not the Supreme Court upholds ObamaCare, completely throws it out, or finds some happy place in the middle, I truly don’t believe it will have much impact on the field of Medical Billing.