The world of health insurance and medical billing and coding can be a complicated one. Even experienced billers have to face ever-evolving changes from insurance companies and government regulations. It makes it even more challenging when your office has hired a new biller or someone with less experience who needs to get up to speed quickly with all of the correct information and processes.
Today, we want to share a quick list of some of the most common insurance and billing terms and definitions that every optometry biller should know. This list can be useful when you're on-boarding billers or getting the rest of your optical team familiar with the insurance process.
Important Insurance and Billing Definitions
Aging: Aging refers to claims that haven't been paid or open
balances still owed by a patient. Aging claims can lead to denials if they miss a company's filing deadline. It is recommended to keep a close eye on your aging reports to know what money you have outstanding to collect.
Credentialing: This is the application process for a provider to coordinate with an insurance company. Once a practice is credentialed with a company, they can work to provide more affordable healthcare to patients.
Denial: Denied claims have been received by the payer and can't be resubmitted because they have already been processed. Denied claims need to be appealed with proper modifications and requirements.
Explanation of Benefits (EOB): An EOB is a document attached to a claim where the insurance company explains the services they will cover for a patient's healthcare. EOBs will also contain details about why a claim may have been denied.
Electronic Remittance Advice (ERA): An ERA is an electronic version of an EOB that explains the details of payments made on a claim by an insurance company or a patient.
Group Health Plan (GHP): A group health plan is provided by an employer to provide healthcare options to a group of employees.
Modifier: A modifier is a two-character code attached to a procedure code to explain an important variation that doesn't change the definition of the actual procedure.
Provider: A healthcare facility, like your eyecare practice that provides healthcare to patients.
Privacy Rule: As defined by HIPAA, the Privacy Rule sets standards for privacy regarding a patient's medical history and treatments.
Rejection: Claims that don't meet the requirements or format to be processed by the payer. Rejected claims must be resubmitted when the errors have been fixed.
Revenue Cycle Management (RCM): Revenue Cycle Management is a service offered by companies who take insurance filing out of the hands of your office. You get a dedicated team of experienced billers who file and reconcile medical and vision claims for your practice so you don't have to hire a staff member or worry about staff turnover.
Scrubbing: The process of how insurance claims are checked for errors before being sent off to an insurance company for processing. Proper scrubbing helps reduce denials and rejections.
Secondary Insurance Claim: A claim that is filed with a second insurance company after a primary insurance company has paid for their portion of the costs.
Supplemental Insurance: Can be a secondary policy or another insurance company that covers a patient's care costs after primary insurance. These plans typically help patients cover high deductibles and copays.
Tertiary Insurance Claims: A tertiary claim is filed after primary and secondary insurances have paid, and helps cover remaining costs.
Utilization Review: An audit performed to optimize the number of specific services a provider performs.
Write Off: This refers to a difference between a provider's fee and the amount the insurance company is willing to pay for those services that a patient isn't responsible for.
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Editor's Note: This post was originally published on August 29, 2017. It has been updated for relevance and richness of content on April 23, 2019.