How MOAs Deal With Insurance Companies

When Lisa Anthony starts to discuss how a Medical Office Administrator (MOA) deals with insurance companies, she begins by injecting a little humor. Perhaps it's to laugh to keep from crying?

"How does the MOA deal with insurance companies?" asks Anthony, Medical Office Administrator instructor at Concorde's campus in Garden Grove, Calif. "By being very patient!"

Anthony said, more and more, insurance companies are overruling physicians' recommended treatment plans in the name of cutting costs. This dynamic is problematic, she said, because in health care, as trained MOAs, the job is to get the doctor paid in a timely manner.

Ways the Medical Office Administrator deals with insurance companies

"Below are many of the tasks and requirements when there is a need to interact directly with the insurance company," Anthony said. "Many times, this interaction can occur by phone and/or off the insurance companies' websites."

1. Checking eligibility and benefits via phone or website.
2. Obtaining authorization for services requiring preauthorization per the insurance contracts.
3. Submitting insurance claims whether it be via paper or electronic submission. Once the claim is processed by the insurance company, the payment received from them is accompanied by an explanation of benefits (EOB). This information is then reconciled into the patient’s accounting record. If there is any patient responsibility such as co-pays and co-insurance, a patient statement is printed and mailed. Adjustments and/or write-offs are made according to the insurance contract or plan.
4. Research, correct and re-submit rejected and denied claims. If the claim is rejected for whatever reason, the Medical Office Administrator follows up to find out why it was rejected, correct the claim and resubmit. An appeal might also need to be written and submitted with supporting information to the insurance company.
5. Understand co-pays, co-insurance, and deductible.

More ways the Medical Office Administrator deals with insurance companies

6. Understand insurance payer contract. The different insurance companies that pay a provider have a variety of plan coverages for their insured clients. The terms of these plans are defined in the payer contract with the health care provider. The MOA should be able to read and understand the requirements of the contract that define:
7. Timely filing - how long after the date of service a provider has to submit a claim.
8. Obtaining clarification on procedures or treatments not covered under the patient's insurance benefits.
9. Updating provider credentialing.
10. Lastly, the Medical Office Administrator should never take no for an answer if the insurance company provides you with information you believe to be inaccurate. Many claims departments are carved out to out-of-country subcontractors, and the communication can be very frustrating, not to mention extremely time-consuming. Learning to navigate the insurance company's websites proficiently can make things much easier.