For a variety of reasons, claims sent to OHIP can be rejected or denied. Over the next few blog entries, we’ll address the common reasons for this and what physicians can do to limit these rejections. In the first part of the series, we look at some of the reasons claims are rejected on an error report.
How does OHIP work?
When a file gets sent to OHIP, OHIP computers will scan the claims for specific types of errors that can be returned to the physician within a day or two. Claims that come back on error reports are no longer in OHIP’s systems at all, and we then have the ability to fix that claim and resubmit it.
By far the most common type of error is a version code error. Each time a health card is renewed, OHIP changes the one or two letter code at the end of the 10 digit OHIP number (which doesn’t change). Patients who do not carry around their most recent card or fail to get their OHIP card updated will have an outdated version code, and any claim submitted under these versions will be rejected. Although this used to be a huge headache for doctors and, obviously, billing agents, there are now systems in place to more easily track down new version codes. Our clients complete an HIC (Health Information Custodian) application and we are then able to find out the correct version code without contacting our physicians. This also means that we are normally able to resubmit these errors within the same billing cycle allowing our physicians to receive payment without delay.
Sometimes patients have allowed their coverage to lapse completely. The number is still valid, but the patient will need to contact the ministry to update their coverage. In these cases, the doctor is at the mercy of the patient to update their coverage, but a private bill can sometimes be the motivator the patient requires.
Beyond problems with version codes and OHIP coverage, claims will also be sent back when the birth date is incorrect, the referral physician’s billing number is incorrect, or sometimes when items like admit dates and diagnostic codes are incorrect.
The easiest way to reduce rejected claims is to make sure the information sent to us is clear and updated. If you work at a clinic or office with repeat patients, please encourage your staff to check the patient’s health card each time he or she comes for an appointment. If you work at a hospital, please provide us with a good contact in ‘Patient Accounts’ who can assist us when necessary, so we can avoid going back to you each time we need information. Over the years we’ve developed good relationships with most of the local hospitals, but the more relationships we have with admin, the better.
Next post I’ll focus on rejected claims that pass through the initial OHIP scan and are denied for other, more complicated reasons.