Friday, 16 August 2013

Maintaining Patient Insurance

Many patients only have one insurance plan but it is possible for a patient to have two or three medical insurance policies. The first insurance billed would be the primary insurance. The next one billed would be the secondary, and the last would be the tertiary.

After payment is received from the primary insurance, the secondary is then billed on a new claim with the information regarding payment from the primary insurance in the form of a photocopy of the explanation of benefits. If there is a tertiary insurance, it would be billed after payment from both the primary and secondary insurances is received. Copies of both
the primary and secondary eobs would be attached to a new claim with the tertiary insurance information on it.

Another example of a person having two insurances is when both the husband and the wife work and both are eligible for health benefits from their employers. Their own policy would be primary and the spouse’s would be secondary. If they have children there are rules that determine which policy is prime for the children.

How patient insurances are maintained  in the EMR/PMS software's ?

Today, software's are maintaining the patient insurance in difference ways. Each method has its own cons and pros. I will list those methods which i found in my past experience.

Before getting into detail, let us see the terms "Primary",  Secondary, Tertiary and 4th Insurance". In some software, instead of calling 4th Insurance, they will call as Quaternary Insurance.

Actually, there is no defined process or method to identify which is patient primary insurance , and which is patient secondary insurance, and so on. For more details,
please download this article and you will know how it has been identified. Since there is no defined way, most of the time, reception people will enter the secondary insurance information into primary and vice versa. That's the reason, all the software's providing swapping option for the insurance

And also, we should know how secondary insurance billed and get paid. Please download this document to know more on that.
Now let us see how software's are maintaining the patient insurance.

Method 1 : Maintain 2 or 4 insurance at the Patient Level

Here you can always maintain 2 or 4 insurance at active state. Give important to the word "Active" here. But, HIPAA EDI 837 Transaction allow up to  11 insurance.  So what happens, at one point of time, the existing insurance get expired and patient got new insurance ? Well, you cannot remove  that insurance from the system it because it is tightly linked to Billing (Claims) Module. So only the option is to de activate the existing primary insurance and add new insurance in the active state as primary Insurance.

The advantages in this method is : Insurance are maintained only at one place i.e. at the patient level. So any changes done here, it will impact all the claims linked to that.  This might be useful when there is error in the data entry and after the correction, they want to re submit all the claims linked to that insurance.

And also, at one point of time, there will be huge number in the inactive state, and no idea which claims are linked to that.
But what happen, if the patient is coming for two different visit types : For example, you may have a patient that is being treated for injuries sustained   from an auto accident that is covered under one insurance policy; yet that same patient may receive treatment during the same visit for a condition    unrelated to the auto accident where a different policy may be billed. So in this case, you need to maintain two primary insurance dependent on the visit type.In the above method, it is not possible, so that is one of the disadvantage.

Method : 2

Another way is to clone the patient demographics insurance while claim is created and therein after maintain the copy of all insurance at the claim  level. 
In this method, initially, the insurance are maintained at the patient level. But when the claim is created, software will take a copy of all insurance and will maintain along with part of the claim details. So here, after the claim is created, the insurance at the patient level is plugged off and will not have tightly linked with the claim. If any error in the policy details, of course, first we should correct at the claim level and then at the patient level for error free future claims.
if the patient is coming for two different visit types, then we can easily handle here because, we need to change only at the claim level.

Method : 3

And final method is patient case. This method not only to maintain the insurance, but it can also provide a template kind of stuff to create same  kind of claim data for the same patient again  and again to save the time.
In order understand, simply you can think patient case is nothing but to maintain group of insurances.  Let us see detail now.

EDI 837 P Budget Number Example