Maintaining the patient’s insurance Information
Maintaining the patient’s insurance company details in the medical facilities software is a simple but tricky one. In most cases, a patient might have single insurance, but it isn’t definite as a patient might have multiple insurances.
A simple such example is if in a couple both the wife and husband are working and have a different insurance provider from each employer and in such cases, the other half can be added to spouse insurance.
In such cases the first insurance the patient is on is called primary, the second one is called secondary and if they have more than two the next one is called Tertiary and quaternary or 4th insurance. There is also a set of rules to define how their kids will be added to these policies and which benefits they can use.
According to the Health insurance portability and accountability Act (HIPAA) EDI 837, the act allows up to a total of 11 insurance policies on a single person.
Now how are all these insurance policies maintained, added, and linked to the patient and which provider to use for a claim is handled by the software with some manual input. When a patient first registers at a medical facility in most cases the front desk people often get confused with the primary and secondary insurance providers and fill in the wrong information but the software provides an option to change this field or more like a swapping option.
There are different methods a software maintains the patient’s insurance information and we are going to talk about a few of them here.
Method 1: Maintaining multiple insurances at the patient level.
In this method, you can maintain multiple insurance providers for a patient in an active state listed as primary, secondary, and so on. The first insurance claim is made to the primary provider and once the amount is received from them its is reported and filed to the secondary insurance provider depending upon the requirement and the individual case.
The main advantage of the method 1 is the records are maintained at the patient level, these are really helpful when there is an error in the data entry and had to resubmit all the claims after the correction.
It also comes with some cons, as the previous insurance providers cannot be deleted from the database, the are simply de-activated and new insurance is added making it primary or secondary and this is troublesome as if the de-activated insurance list piles up it is hard to determine which claim is linked to which provider.
Another con for this you cannot have multiple primary insurances like for example a person walks in with a simple cut on his hand, he is treated and claimed by the first (primary) insurance but if the patient also complains about a stomach ache the services required to treat it are covered by the secondary provider which you cannot claim simultaneously.
Method 2: Maintaining insurance providers at the claim level
The last disadvantage of method 1 is overcome by this method, as the claim is maintained at a different level than the patient. The process this works is whenever a claim is created the software makes a copy of it with all the patient’s demographics and stores it along with the patient’s file, and this claim is the one that is sent to the insurance provider. So multiple claims can be created for each patient and can also be treated for different things at the same time. This claim is the most common one used by medical facilities.
Method 3: Maintaining insurance providers along with the patient template
This itself is not an individual method but rather is used along with either method 1 or 2. This method creates a template for the patient with the required constraints so that the same template can be used for future references saving time and effort to create the same claim from the scratch.
