Claims Reconciliation
Physicians’ ability to provide their communities with quality care is dependent on their ability to keep their practices financially viable. It is therefore important that physician practices pursue appropriate and fair payment that is consistent with legal and community standards for legitimate services provided.
Don’t accept inappropriate reimbursements – Appeal that Claim
The AMA developed the in-depth resource "Appeal that Claim" to equip physician practices with a complete overview of the claims appeal process. View this step-by-step guide to learn more about navigating this complex but vital aspect of the claims revenue cycle.
View the resources below to aid you with the claims reconciliation process.
If your practie receives electronic remittance advice (ERA), the AMA's Claims Workflow Assistant is a free tool to help you secure accurate payments from health insusrers for inappropriately denied claims. You can look up the numbers paters place on the remittance advice to explain how the claim was processed and determine what those numbers mean. Then, you can follow the steps provided to maximize your recovery. The Claims Workflow Assistant also provides numerous template appeal letters that AMA members can easily modify to use in their practices.
Adopting current electronic health care transaction technologies can help your practice lower administrative costs, reduce payment errors and save time. The AMA offers multiple toolkits to ease the process of automating your practice through the use of electronic health care transactions, including claims submission, eligibility requests, claim status and electronic remittance advices.
"What do I need to know about payer and patient credit cards,” helps educate physicians and their practice staff regarding the impact on each practice's bottom line when accepting and processing credit card payments from patients and payers.
For those physician practices which choose not to accept corporate credit cards from payers, a "Sample letter to health insurer or other payer regarding use of an unapproved method of payment for services," is also available for them to customize and send to any payer that is sending a payment in the form of a payment method not agreed to in the underlying contract. This template letter is available at www.ama-assn.org/go/templateletters, and is free to AMA members. Physician practices are also encouraged to file a complaint at www.ama-assn.org/go/clickandcomplain against payers that are requiring a payment method that has not been mutually agreed upon.
You should be paid fairly for both contracted services and those you provide to patients covered by health insurers with which you do not contract. The AMA has developed the educational resource "Holding health insurers accountable for out-of-network services" to help physicians as they seek appropriate payment from health insurers that consider the physician out of network. This resource provides details about what out-of-network physicians might expect when dealing with the health insurer, how these physicians can stay informed about payment laws and issues, and how they can collect fair and accurate payment for their services.
