Sample Billing and Collections Policies and Procedures Manual
Table of Contents

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For printing: Manual - Table of Contents (PDF file - 24 KB)

For downloading: Manual - Table of Contents (Word file - 98 KB)

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Look for links to three sample policies below.

SECTION 1: INTRODUCTION

A. Program/Clinic Description

• Vision, mission, scope of services, future plans

B. Organization Chart – Detailed Structure of Billing and Collections Staff

C. Job Descriptions of Billing and Collections Staff

SECTION 2: BILLING OVERVIEW

A. Requirements for Completing a CMS-1500 and UB-92

• Medicare
• State-specific Medical Assistance
• State-specific S-CHIP
• Blue Cross Blue Shield
• HMO
• Worker’s Compensation
• Other Commercial Payers

B. Billing Flow Chart(s)

• By Clinic
• By Program

SECTION 3: FINANCIAL POLICIES

A. Financial Policy

• Payment due date(s)
• Acceptable form(s) of payment
• Responsibility for completion of explanation of patient responsibility
• Define written agreement with patients for patients with payment plans and when to initiate.
• Patient responsibility for payment if prior authorization is not obtained (if applicable)

B. General Cash Controls – Front Office

• General procedure
• Procedure(s) for payment at time of visit
• Procedure(s) for payments by mail

C. Procedures for Payments by Mail

• Opening/separating mail
• Logging correspondence
• Date stamping correspondence/stamping checks/photocopying
• Making deposits

SECTION 4: PATIENT INFORMATION POLICIES

A. Appointment Scheduling

• Established schedule with physician(s) and other patient care providers
• Scheduling for new patient vs. established patients
• Schedule patients 15-30 minutes before time to see provider to allow for registration time

B. Collection of Patient Information

• Describe data collection process, including method(s), timing and responsibility
• Describe data verification process, including method(s), timing and responsibility
• Establish written checklist that defines each registration task for:
  a. First patient visits
  b. Follow-up visits
  c. Walk-in patients

C. Information to Collect and Disseminate

• Collect from patient:
  a. Patient name, address, phone number(s)
  b. Insurance information – Insurance company, address, member number, group number, guarantor, effective date, phone number, co-pay, mental health benefit, prescription benefit
  c. Referring provider or agency
• Share with patient:
  a. Payment and billing policies
  b. No-show and cancellation policies
  c. Need to bring insurance card and payment to scheduled visit

D. Qualifying/Application Process for Uninsured Patients

E. Standard Preregistration Procedures

F. Physician Responsibilities For Patient Information/Financial Requirements

SECTION 5: BILLING PROCEDURES

A. Encounter Form Development and Management

• Annual review and update process, including diagnosis/procedure codes
• Completion of encounter form
• Flow chart of handling of encounter form

B. Timing of Encounter Form Review and Billing

• Gathering of encounter forms
• Time limit on form processing and data entry
• Charge capture process
• Charge verification/accuracy
• Coding process
• Reconciliation process - patients seen vs. encounter forms generated
• Procedure for “finding” lost/missed charges
• Frequency of billing (daily, 2x/week, etc.)

C Bill Tracking

• Policy for tracking bills submitted to insurers
• Procedure for unprocessed claims
• Frequency of follow-up

D. Payment Due From Patient

• Who to collect payment from
• When to collect payment
• Estimating amount of payment
• Procedure for collecting payments when payment not made at time of visit

E. Payment Processing

• Check processing
• Bank deposits and reconciliation
• Payment posting to billing system
• Reconciliation of daily deposits
• Job descriptions and assignment of duties

SECTION 6: COLLECTION FOLLOW-UP

A. Denial Management Procedures

• Identification of unpaid/denied services, including remittance advice reviews
• Research and correction process
• Time requirement for processing denials
• Payer contact list
• Frequency of re-bills to payers

B. Bad Debt/Uncollectable Account Write-off Policy

• Frequency of review
• Small balance write-off policy
• Number and frequency of patient statements sent before write-off
• Procedure and approval process for account write-off
• Clearly identified staff authorized to write-off accounts

C. Patient Communication

• Collection letters and dunning levels (make sure patient understands that payment is expected throughout process)
• Collection policy signage in clinic and waiting areas
• Collection policy statements in patient brochures

D. Use of Insurance Information Sheets or Index Cards

• Procedures on insurance follow-up
• Summary matrix of insurance company coverage policies and billing requirements

SECTION 7: USE OF OUTSIDE AGENCIES FOR COLLECTION

A. Use of Collection Agencies

• Board policy defining when to use
• Frequency of account write-off and transfer
• Collection agency collection policies
• Collection agency analysis reporting

B. Use of Small Claims Court

C. Use of Attorneys for Collection

SECTION 8: MEASURING OVERALL EFFECTIVENESS

A. Tools and Statistics Useful in Determining Success

• Patient account statistical report
• Financial performance measures; definition of:
  a. Gross collection ratio
  b. Accounts receivable ratio
  c. Days in receivable

B. Reporting

• Collection activity
• Weekly activity
• Total accounts receivable by patient, by payer and by provider 

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