All STAFF REQUIREMENTS

Dress Code

Employees are expected to dress in a professional manner.

Accepted clinic uniforms are expected:

Clothing must be clean, wrinkle and stain free

Shorts are not allowed

Acceptable Scrubs are:

Shoes must be enclosed. Flip flops and sandals are not allowed

No jeans are allowed except on special theme days

No sleeveless tops are allowed

Blouses are to be appropriate and with no low cut necklines

Perfume is not allowed

Excessive jewelry is not allowed

Appropriate dress is considered:

I have read and understand the dress code of ______clinic.

______

Employee NameDate

NEW PATIENT CHECKLIST

FORMS:

  1. TREATMENT OF MINORS
  2. HIPAA Privacy Acknowledgement
  3. Confidential Medical Information
  4. Contact Form
  5. Authorization form signed for next of kin

FRONT DESK:

  • COPY DRIVER'S LICENSE
  • COPY INSURANCE CARD (FRONT & BACK)
  • FORMS FILLED OUT COMPLETELY (FINISH IN RED PEN)
  • HIPAA PRIVACY ACKNOWLEDGEMENT FORM SIGNED
  • NEXT APPOINTMENT MADE
  • ADD TO BIRTHDAY LIST
  • ADD TO MAILING LIST
  • NEW PATIENT LETTER SENT
  • THANK YOU SENT TO REFERRING PATIENT

INSURANCE:

  • FINANCIAL ARRANGEMENTS MADE
  • INSURANCE ASSIGNED
  • INSURANCE VERIFIED
  • FORMS SIGNED
  • COPY OF INSURANCE POLICY
  • ATTORNEY AGREEMENT (LIEN) SENT
  • DIAGNOSIS VERIFIED
  • TICKLER FILE FOR REPORT MADE

DOCTOR:

  • EXAM FINDINGS CHARTED
  • X-RAY FINDINGS CHARTED
  • DIAGNOSIS DONE
  • TREATMENT PLAN MADE
  • FIRST VISIT CALL MADE
  • PERSONAL THANK YOU CARD SENT

10 Steps in Collection Process

for Insurance Claims

  1. Gather the complete data to ensure filing process. Copy insurance card, front and back. Make sure you know if the patient is the insured or a dependent. Make sure you verify all policies. Know which policy is primary. Know the policy limitations. On minors, know the “birthday rule.” Determine if the provider is in-network or out of network.
  2. Insurance collections depend on documentation of procedures billed. Not documented, not done. Request for additional documentation and/or reports may be necessary.
  3. Correct coding is essential, both ICD-10 and CPT-4 with modifiers must be accurate.
  4. Primary “clean claim” must be produced and filed, either electronically or manually, in a timely manner. Secondary and tertiary claims are filed once the primary payer has paid and the claim is send with a copy of the EOB from the primary/secondary payers. Some primary payers automatically send notice to other carriers if the information is on file in their computers or the information is properly filled out on the claim form.
  5. Follow-up on unprocessed or delayed claims within 15 to 30 days. Payments should be made within 30-60 days depending on the type of carrier. Electronic claims may pay within 14 days; liability claims do not pay until time of settlement of the completed case.
  6. Adjudication – claims that are not paid correctly may be reprocessed by phone calls, filing a corrected claim form or through an appeals process that may require additional documentation and a letter of explanation written to the claims adjuster.
  7. Record all payments to the patient’s account by date of each claim. Never, post a payment to an account without verifying the proper dates of service.
  8. If the insurance payment does not match the expected amount anticipated, audit the claim to ensure that the difference is not due to clinic error, policy limitation, or human error. If the claim is paid incorrectly, follow #6 adjudication process.
  9. If the unpaid amount is due to “contracted rate” – immediately write off the unpaid portion to balance the patient’s account, copy EOB to daily back up for proof of posting.
  10. If the unpaid amount from the carrier is transferred to the patient portion, (deductible, non-covered, out-of-network, patient responsibility, copay, or other), bill the patient with a copy of the EOB (explanation of benefits) immediately.

Insurance Verification

Patient Insurance Information

Complete Appropriate Questions

Insurance Verification Summary

Policy Limits

Effective Date Of This Policy:What is the date the insured became eligible for benefits under this policy?

Deductible Amount per year:What is the deductible amount the patient must pay out per year?

Deductible Met To Date:How much has the patient paid toward the deductible this year?

Next Deductible Due on:When will the insured have to meet another deductible?

Maximum Paid First Visit: Is there a maximum amount allowed by the insurance policy for the first visit?

Maximum Paid a Visit:Is there a maximum amount allowed by the policy per visit?

Amount of X-Ray coverage:What is the percentage to policy pays towards x-rays?

Maximum Ceiling on x-rays: What is the maximum amount the insurance policy will pay towards x- rays per year?

Maximum Visits A Year:What is the maximum number of office visits allowed by the insurance policy per year?

Maximum Visits a day:What is the maximum number of office visits allowed by the insurance policy per day?

Deductible is Per:Does the percentage apply to individual family or occurrence?

Deductible Applies To:Does the deductible apply to actual charge or limited charge?

Policy Percentage per Visit:What percentage does the policy pay toward each treatment?

Percentage Applies To:Does the percentage paid by the policy apply to the actual charges or limited charge?

Co-Pay a Visit:How much is the patient co-pay per office visit?

Does this Policy Pay For?

CMT (Adjustments)Will the policy pay for chiropractic manipulation?

Chiropractic Initial ExamWill it cover a comprehensive exam? Ex. Evaluation and Management 99213?

Comparative ExamsWe use therapy on our acute patients. Does the policy pay for therapy?

Therapies Max/DayIs there a maximum number of therapies the policy allows per office visit?

DiathermyDoes the policy pay for Diathermy?

UltrasoundDoes the policy pay for Ultrasound?

Muscle StimulatorDoes the policy pay for muscle stimulation?

Intersegmental TractionDoes the policy pay for Intersegmental Traction

Manual Therapy TechniquesDoes the policy pay for manual therapy technique 97140?

Therapeutic ExercisesDoes the policy pay for therapeutic exercises 97110?

Neuromuscular Re-educationDoes the policy pay for neuromuscular re-education 97112?

SupportsDoes this policy pay for lumbar supports, cervical collars, and support pillows?

OrthoticsDoes the policy pay for orthotics?

Nutritional SupplementsDoes the policy pay for nutritional supports?

Comparative X-RaysDoes the policy allow for comparative x-rays?

Accident Provision In Policy

X-Rays Applied To Deductible

FINANCIAL POLICY

Thank you for choosing this office for your health care needs. To ensure that your services are delivered at the most affordable basis, we have adopted the collection policy outlined below. We ask you to read the policy carefully and sign prior to any treatment.

1. FULL PAYMENT IS DUE AT TIME OF SERVICE UNLESS PRIOR ARRANGEMENTS ARE MADE.

2. WE MAY ACCEPT ASSIGNMENT ON SOME INSURANCES; ALLOWING A PORTION OF YOUR CARE TO BE PAID BY A THIRD PARTY CARRIER. HOWEVER, PLEASE UNDERSTAND THAT THIS ASSIGNMENT DOES NOT WAIVE YOUR RESPONSIBILITY OF PAYMENT IF WE ARE NOT IN NETWORK WITH YOUR CARRIER.

3. CO-PAYMENTS MUST BE PAID ON EACH VISIT OR BY PRE-PAYMENT WITH ONE CHECK PER WEEK ON MONDAYS.

4. PAYMENT PLANS CAN ONLY BE ACCEPTED WITH PRIOR CREDIT APPROVAL.

5. WE ACCEPT CASH, CHECKS, DEBIT OR CREDIT CARDS.

6. DEDUCTIBLES WILL BE PAID ON A PRE-SCHEDULED FINANCIAL PLAN USING A CREDIT CARD.

7. ANY INSURANCE OR ATTORNEY CORRESPONDENCE REGARDING PAYMENTS MUST BE COPIED TO OUR OFFICE.

8. MIS-ROUTED INSURANCE CHECKS SENT TO YOU MUST BE DELIVERED TO OUR OFFICE WITHIN 2 WORKING DAYS.

9. YOUR INSURANCE IS FILED AS A COURTESY TO YOU. DENIALS, REDUCTIONS AND DELAY IN PAYMENTS MAY BECOME YOUR RESPONSIBILITY IF YOUR CARRIER DOES NOT PAY IF WE ARE NOT IN NETWORK WITH YOUR CARRIER.

10. ALL CHARGES INCURRED ARE YOUR RESPONSIBILITY REGARDLESS OF ASSIGNMENTS, LIENS, SETTLEMENTS, OR IN THE EVENT YOU DISCONTINUE CARE.

Bad checks (NSF, closed accounts, and stopped payment) will be charged back to the patient's account with service fee of $25.00. Checks not redeemed within 10 working days of written notice to the maker will be referred to the prosecutor for collection.

Insurance Assignment

In some cases, we may be able to accept assignment of your insurance benefits. Acceptable insurance identification requires proof of valid insurance coverage, with chiropractic benefits that have not been exhausted. An assignment of benefits simply means that a portion of your charges that are covered by your policy should be paid directly to this office, which will allow you to pay less each visit.

In the event that your carrier does not pay these benefits, you will be held responsible for all charges, if we are not in-network with your carrier. An assignment of benefits does not allow us to become a party to your policy, your insurance is a contract between you and your carrier, and as such you will must still be involved in the settlement of disputed charges. Some carriers habitually discount the doctor’s charges and claim that the amount is not “reasonable and/or necessary” –please be aware that this office takes pride in delivering high quality service at an affordable price. Our fees are not negotiable. If your insurance carrier lowers your benefits that does not change your service fee, if we are not in network with your carrier.

This office does have a contact with the following managed care networks. If you are a member of one of these insurers, please notify us your first visit. A co-insurance or co-pay must be paid each visit. If yourdeductible is not already met, arrangements must be made to pay the ‘allowed’ amount each visit.

List Managed Care Contracts:

I have read the Financial Policy. I understand and agree to this Financial Policy.
Date: ______Signature of Patient: ______
Date: ______Signature of Witness:______

CREDIT CARD PREAUTHORIZATION FORM

I authorized ______to keep my signature on file and to charge myVisa/MasterCard/Discover/American Express Card account for unpaid services/expenses incurred by me at this clinic if not paid as per our financial agreement. I acknowledge that I will be notified in writing of any charges sent to my credit card within two days of processing.
Patient Name: ______

Card Type: VISA MasterCard American Express Discover CareCredit

Account Number: ______Expiration Date:______

Cardholder Name:______

Cardholder Address:______

City: ______State:______Zip:______
Cardholder Signature: ______Date: ______

*This authorization will void one year from date signed.

Financial Agreement

I agree that I am responsible for all charges incurred at ______ (clinic name) beginning on this day: ______of 20____, and ending when my treatment has been completed or I have been discharged.

At my request and as a courtesy to me, after providing a copy of my health insurance I.D. card, a completed original claim form, and my signature on an Assignment of Benefits form, this office agrees to assist me financially by billing my health insurance company and awaiting their direct payment of those amounts allowable under the terms of my policy.

In the event my insurance benefits are terminated or exhausted, I agree to pay all charges in full at the time services are rendered.

I agree to satisfy my deductible, make co-payments, and pay any amount not covered by my insurance company in the following manner:

$ ______will be paid toward my deductible of $ ______until my deductible is met.

This payment is to be made: Each visit Weekly Bi-Monthly Monthly

$ ______co-payment will be made at the conclusion of each office visit.

I also have been informed that the following service(s) is/are not covered by my insurance company and I will pay an additional $ ______for these services.

Not Covered Service(s)

1. ______

2. ______

3. ______

______

Patient Signature Date

______

Witness Signature Date

OFFICE POLICY REGARDING INSURANCE ASSIGNMENT – when Out of Network

Our office will accept your insurance on assignment. However, it must be fully understood that your insurance policy is a contract between you and your insurance company. Our office will not enter into a dispute with your insurance company over policy limitations or issues. This is your responsibility and obligation. All charges incurred are your responsibility. Our office will file your claims for you and assist you in every way possible to ensure benefit recovery.

Please read the following office policy regarding assignments:

1. At the beginning of your treatment our office will make every attempt to verify your policy benefits, however, this office DOES NOT guarantee your insurance policy or payments.

2. Your insurance will be filed as a courtesy to you. We file insurance claims on a weekly basis.

3. You are required to sign an "Assignment of Benefits" form and any other forms required by your insurance company on your first visit.

4. If your insurance company requires their own claim form(s), you are required to bring in the completed form(s) by your second visit and then as needed.

5. You will be responsible for your deductible and co-payment. If your insurance company does not pay something that was anticipated, you will be responsible for the amount as soon as we/you are aware of the denial.

6. Your insurance should pay no later than 60 days from the date in which it was filed.

7. By taking your insurance on assignment, our office agrees to wait for a portion of your bill for an estimated amount of time. In the event that your insurance company does not pay on a timely basis, you may be asked to pay.

8. If your insurance company mails a check directly to you for our services, you must bring the misdirected check to our office within 48 hours.

9. Any overpayments made by your insurance company which credits your account will be refunded to them. However, any overpayments or errors in amounts paid which does not credit your account will be your responsibility.

10. If you discontinue care without the doctor's authorization, the balance on your account is due and payable immediately, even if your insurance has been filed. (If your insurance does pay, after your account has been paid, refunds will be sent to you.)

I have read and understand the policy regarding insurance assignments. I realize that I am responsible for all charges incurred by me at this office.

______

Signature Date

______

Witness

Insurance Plan Summary Form

Employer’s Name: ______

Address: ______

Contact: ______Telephone: ______

Plan Name and/or Group Number: ______

Carrier Name: ______

Claims Address: ______

Contact: ______Telephone: ______

IN-Network: YES NO Pays OUT-OF-NETWORK Benefits : YES NO

Schedule of Fees Requested?______

Deductible?______When another deductible is due? ______

Percentage of Coinsurance? ______

Exclusions? ______

Limitations? ______

Annual Maximum? ______

Accept Assignment? ______

Other Information:

______

______

Date Verified: ______By: ______

If in network/Do we have a current copy of the contract? YES NO

Patient Statements - 10 Tips

1. Make sure your statements are sent on schedule each month. Preferably, around the tenth of the month.

People develop a consistent pattern for paying their bills. If your office does not send out statements on a timely basis, you cannot expect to be paid on a timely basis.

2. Send all statements at once. Do not divide the alphabet.

All patients' statements should have the same due date. This policy makes it easier for everyone in the office to know payment arrangements.

3. Make sure the statements have a "payment due by date." Preferably, due by the 20th of each month.

Statements without due dates can easily be set aside to be paid "later," and then later never comes.

4. Accounts which are not paid by the due date should be called the day after the due date.

Staff members never like to call on past due accounts and may tend to use the argument, "well it's only a couple days past due." When in actuality the patient has had 30 days to pay. Your phone call can be a polite reminder. Remember, the more lenient you are on deadlines, the more likely the patient will expect you to be on making payments.

5. Change the look of your statements after the first 30 days.

Current statements (within 30 days) should be white, then every 30 days thereafter the color of the statement should change to show the patient that they are receiving a different kind of notice. Example: 30-60 blue, 60-90 yellow, 90-120 pink. After 120 days no statement should be sent. Send a personalized, certified letter.

6. Make a payment card or collection calendar.

When a patient signs a payment agreement or makes a promise to pay a certain amount within a certain time frame, you must record the arrangement made on either an index card (filed by patient name) or written on a collection calendar.

7. Set short deadlines for overdue payments.

Patients who fail to pay by the due date should not be given "extra time" to pay. A maximum of no more than five extra days should be given. Time is never on the creditor's side; the longer you wait the less value the payment.

8. Establish a credit policy.

Policies are laws that govern your office's procedures. Policies of all nature should be written, but this is especially true with credit policies since misunderstandings can result.

9. Use return address envelopes.

Statistics show that people are more likely to pay and return bills that come with self addressed envelopes.

10. Keep a positive and professional attitude.

With a positive attitude, your voice will show confidence. Be assertive. Always expect "payment in full."

Collections Calendar

First Day: Financial Counseling; Assignments/Agreements signed; Insurance verified

Second Day: Financial Report of Findings; Payment responsibility set; agreements/assignments signed

Initial Billing:Electronic billing – same day

Paper claims – no later than one week; then once a week

Personal bills – do not “bill” an active patient; collect each visit or once a week minimum