February 17, 2022
A consistent, repeatable insurance verification process is the easiest way to cut down on inaccurate treatment plans.
Verification and Billing are so intertwined, and function best when they operate in tandem.
Preparing for an accurate treatment plan starts long before the patient is in the office. Being able to obtain the patient's insurance plan and subscriber information a few days before their appointment gives you an adequate amount of time to ensure that their benefits are properly built in to your practice management software.
Once the plan is built in to your PMS and attached to the patient's account, treatment planning and filing claims should be a breeze. Your software should have the calculations completed for you, as long as the insurance plan details are accurate and entered properly. When payment is received, posting the patient's account should be a quick and easy task.
Posting payments also gives you the opportunity to cross-reference the plan information that was built into your software during insurance verification. Checking the category percentages, fees, and deductible information with what you see on the EOB gives you the most accurate representation how the plan pays for certain procedures. If you notice a discrepancy you can then correct the error in your software to improve the accuracy of future treatment plans.
Clinical requirements are standards set by the carrier to establish the minimum clinical diagnosis required for a claim to be paid. These requirements are established at the carrier level, not the plan level. Claims knowledge is understanding what the insurance carrier is going to do before they do it, and what they are looking for when determining payment.
For example:
Cigna (D2740): Not allowable if the tooth has questionable periodontal, endodontic, and/or restorative prognosis.
If you know that the tooth being treated does not meet Cigna's clinical requirements, you can more accurately prepare the patient in the event that the claim is not paid.
