The basic flow of work from the patient encounter to collection for the practice is described here. Please understand that this is customized for you based on the needs and comforts of each individual practice. For example, some practices prefer to prepare their own deposits and copy explanations of benefits rather than use a lockbox service. Likewise, some practices find it easier to input demographics and charges at their site and electronically transmit the information. This is discouraged because of level of precision usually necessary to properly enter demographic and coding information.
So please keep in mind that whatever your unique needs are, we will custom tailor this process to meet them.
The Process Explained in Depth
- Patient Registration Form (KLA)
- Assignment and Release (KLA) — Not necessary to send to KLA but required by law to bill
- Copy of Front & Back of Insurance Card
- Fee ticket such as a Super bill (KLA) or Hospital Card (KLA)
- If no change in insurance or demographics, fee ticket (KLA) — There must be a unique identification such as a chart number so we can match it with the proper patient
- If there HAS been a change in insurance, we need copies of the new insurance card with a notation as to when it went into effect
- If there HAS been a change in other demographics, we need a new copy of the Patient Registration Form
- Daily Work Summarized
KLA will work with practice to develop a cover sheet to summarize the data being sent to KLA. At a minimum we require that the number of charge documents being sent and the total of payments made by patients be totaled.
- Work is Sent to KLA
KLA will provide you with preprinted envelopes which will quickly identify the work and have it routed to the proper workgroups at KLA. Depending on your location, KLA will either provide courier pickup or Federal Express Service for your work.
- Data Input
Work will be input by KLA professionally trained staff. Queries as to potentially missed charges will be forwarded to your office. (For example, if a super bill should come in with a well patient exam diagnosis code and no well patient exam.)
Claims that pass original staff screening will be run through our many pre-filing audits including global and bundling screenings and LMRP, CCI, NCD and LCD guideline screenings.
Queries are sent to your office concerning any claims that do comply with coding standards.
Within three business days of receipt, clean claims which qualify are submitted to third party payers electronically. Documents necessary to support manual claims such as claims with more than three surgical procedures and worker's compensation claims are attached and submitted with claims.
On a daily basis, electronic correspondence from most private and government payers is downloaded into our system. Denials are researched in office. If we have inadequate information, requests for information are sent to the practice. Patients are contacted by KLA should denials be because of incorrect insurance or demographic information.
Handling of claims diverges here ...
If the claim is paid in a timely manner (within 45 days)
Payments are deposited directly into practice's account. The practice controls where the payments go. KLA will setup electronic deposits by insurance companies into the practice's bank account whenever possible. KLA suggests using a bank lockbox service to prepare your deposits. Payment would mail payments to a PO Box. Mail is picked up and deposits prepared by the bank.
Copies of checks and explanations of benefits (EOBs) are forwarded to KLA.
KLA posts all payments and adjustments to patient account. KLA uses open item accounting. Therefore payments are posted against the individual date of service and the individual procedure code that was paid. This is CRITICAL in the reporting phase to determine what procedures are most profitable.
If some of the procedures are paid and others denied, KLA researches the reasons for the denials. If the denial is inappropriate, the claim is appealed.
Secondary insurance is filed.
If there is no secondary insurance, the patient is billed up to three times
If the claim is denied by insurance company
The reason for the denial is researched. If appropriate, the claim is appealed. If denial is for lack of coverage, the patient will be contacted by KLA. If denial is for lack of appropriate authorization by the practice, you will be contacted. It's your practice and your decision how you wish the claim to be handled.
If the claim has not been paid or denied within 30 days from the date of initial filing
KLA has staff specifically assigned to following up on claims that fall into the Dead Zone with many practices. As many as seventy percent of the claims that are in the greater than ninety day section of our aged accounts receivable, will not be on file with the insurance company. This happens even though the claims have actually been filed. Why? There is no obligation on the part of an insurance company that does not have or has not in the recent past had your patient on their rolls to inform you that you've filed with the wrong insurance company. Thus claims filed to the correct insurance but the wrong address go into a dead letter office. These claims must be followed up.
* As a part of our ongoing commitment to consistently strive to improve and streamline our billing process, as of the end of September we have initiated a new step that we will be testing to determine its effectiveness. We began sending letters out to patients at 30 to 45 days to ask for their help in getting their insurance to pay. The letter simply states that we have filed multiple times with their insurance without receiving a response, so we ask the patient to take a moment and review the insurance information for accuracy. If the information is accurate, we then request that the patient place a call to their insurance company to ask them if there is anything they need to provide to expedite payment.
We hope this will prove to be useful and if it is, we will incorporate it into our regular billing process. We will keep you updated on results. If you have any questions regarding the implementation of this new step, please feel free to contact us. Thank you!
If a claim has not been paid or denied within 60 days, the claims is denied and the patient billed
Many insurance companies now consider a claim delinquent and refuse to pay if it has not been received within 90 days. If an oversight at your office allowed a patient to be seen without verifying insurance, a patient needs to be made aware of his liability before it's too late to get the insurance company to pay. We keep your patient fully informed.
After all insurance resources are exhausted
KLA will bill your patient up to three additional times per encounter. If the patient is a recurring patient with a new encounter, balances that have already been billed three times will be included on the new statement. KLA does not do hard collections. We will provide information to your collection agency at your request.