Friday, 16 August 2013

Maintaining Patient Insurance

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.

What will be in the patient case. ?
1. Patient case is by patient
2. Software allows to create N number of patient cases for each patient.
3. The following details will be maintained at the patient case

  • Referring Physician
  • ICDs and CPTs
  • Insurance (Here you can define upto 11 Insurance)
  • Insurance Authorization information for each insurance if available
  • ICDs and CPTs
  • For hospital type of visits, maintain different dates such as admitted date, discharge date, accident date, etc..

Creating individual cases for why a patient is being seen by a provider simplifies the selection of insurance policies and the order in  which two or more insurance plans may be billed for various types of treatment and conditions. 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.
Creating individual cases for patient treatment also simplifies how paperwork and claims are processed when a case involves an attorney lien or    Workers' Comp claim. For example, you could have an existing patient that has been previously seen for an illness; and later sustains an injury at his    place of employment that may involve a worker's comp claim. How claims are handled for each of these two cases is quite different. In a situation like    this, you would simply locate the existing patient record; and then create a new case for that patient that covers treatment for his injury.
In this method, we can maintain different set of primary, secondary, etc. depending upon the visit types. And also, collecting insurance from the patient is handled by the front desk people and creating the claim for the visit handled by the back office people. So there is no idea for the billing people which insurance has to select on the claim, because they may not aware what is the purpose of the visit.

If we maintain case, then it is job of the front desk to select the case at the appointment level or at the check in level. Then this will be helpful for the billing team to generate the claim for the insurance for the selected case and send to the insurance company.

Happy Insurance Maintaining !!!!!!

Welcome to the Most challenging part of the Medical Billing !!!!

Interested to see some sample screen shots for Patient case ?
Here you go.


Questions or feedback are always welcome. You can email me at

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