The insurance payment process in managed care has several steps. In this assessment, create a timeline of the steps involved in the claim process from the patient encounter through the payment.
Evaluation Title: Patient Claim Process
Assume the role of a claims process manager in a primary care medical office. An existing patient comes in to be seen for a knee injury sustained over the weekend playing football with children. A full physical exam is done, and three x-rays are taken. The patient is provided with a referral to orthopedics, as well as two prescriptions for an anti-inflammatory and a pain medication. The patient is also provided an ACE elastic wrap in the office and shown how to properly use compression wrap on the injured area.
Instructions:
- List the steps of the patient claim process from the conclusion of the appointment through the MCO payment.
- For each step, provide the following:
- A brief description of what is happening in each step of the process.
- Estimated time for completion of each step.
- Responsible parties and others involved in each step.
Expert Solution Preview
Introduction:
The insurance payment process in managed care can be complex and involves several steps. As a claims process manager in a primary care medical office, it is important to understand the steps involved in the claim process from the patient encounter through the payment. In this assessment, we will create a timeline of the steps involved in the claim process for a patient who comes in for a knee injury.
Answer:
Steps of the patient claim process from the conclusion of the appointment through the MCO payment:
1. Claims submission: The medical office submits a claim to the managed care organization (MCO) for the services provided during the patient encounter, including the physical exam, x-rays, referrals, and prescribed medications.
– Estimated time for completion: 1 day
– Responsible parties and others involved: Medical office staff and MCO staff
2. Claims processing: The MCO processes the claim by reviewing it for accuracy and determining coverage based on the patient’s plan.
– Estimated time for completion: 10-14 days
– Responsible parties and others involved: MCO staff
3. Claims adjudication: The MCO determines the amount of payment for the claim and sends an Explanation of Benefits (EOB) to the medical office and the patient.
– Estimated time for completion: 5-7 days
– Responsible parties and others involved: MCO staff
4. Patient billing: The medical office bills the patient for any amount not covered by the MCO and provides a copy of the EOB for their records.
– Estimated time for completion: 1 day
– Responsible parties and others involved: Medical office staff
5. Payment posting: The medical office receives payment from the MCO and posts it to the patient’s account.
– Estimated time for completion: 1 day
– Responsible parties and others involved: Medical office staff
6. Account resolution: The medical office reconciles the patient’s account, ensuring that all charges and payments are accurately recorded.
– Estimated time for completion: 1 day
– Responsible parties and others involved: Medical office staff
By understanding the steps involved in the patient claim process, claims process managers in primary care medical offices can ensure that claims are submitted accurately and in a timely manner, leading to faster payments and better financial outcomes for the medical practice.
