Posting Insurance Payments and Creating Patient Statements 8 Posting Insurance Payments and Creating Patient Statements

Learning Outcomes When you finish this chapter, you will be able to: 8-2 When you finish this chapter, you will be able to: 8.1 Describe how an adjustment is calculated if the payer pays less than the provider’s usual fee. 8.2 List the five steps for processing a remittance advice. 8.3 Demonstrate how to enter insurance payments. 8.4 Demonstrate how to apply insurance payments to charges. 8.5 Demonstrate how to enter capitation payments. 8.6 Demonstrate how to create patient statements.

Learning Outcomes (Continued) 8-3 When you finish this chapter, you will be able to: 8.7 Explain how statements are edited. 8.8 Demonstrate how to print patient statements.

Key Terms capitation payments cycle billing 8-4 capitation payments cycle billing electronic remittance advice (ERA) fee schedule once-a-month billing patient statement payment schedule remainder statements standard statements

8.1 Third-Party Reimbursement Overview 8-5 A fee schedule is a document that specifies the amount the provider bills for provided services List of the provider’s standard fees Not necessarily the amount a provider is paid Difference between amount in fee schedule and amount paid is an adjustment A payment schedule is a document that specifies the amount the payer agrees to pay the provider for a service, based on a contracted rate of reimbursement Learning Outcome: 8.1 Describe how an adjustment is calculated if the payer pays less than the provider’s usual fee. Pages: 248-250 Adjustments must be entered in the billing area of the PMP. Review the examples in the text for each of the different types of insurance plans.

8.2 Remittance Advice (RA) Processing 8-6 An electronic remittance advice (ERA) is an electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier ERA – uses the ASC X12 835 Remittance Advice Transaction (or 835) RA – Paper format Learning Outcome: 8.2 Demonstrate how to enter insurance payments. Pages: 250-252 Insurance carriers usually do not fully pay the amount billed by the provider. Review, check to see that the amount paid is the expected amount, per the provider’s contract with the payer. If a payment is not as expected, then you must determine the reason for the discrepancy. Charges may be denied by insurance carriers for a number of reasons. It will be noted on the RA. Common errors listed in table 8-1.

8.2 Remittance Advice (RA) Processing (Continued) 8-7 Steps for processing Verify all procedures listed on the claim are represented on the RA Review payment amount against expected amount Identify reasons for denials or payment reductions; resubmit claim or appeal if necessary Post payment information in the PMP Bill patient’s secondary health care plan (if appropriate) Learning Outcome: 8.2 Demonstrate how to enter insurance payments. Pages: 250-252

8.3 Entering Insurance Payments 8-8 Payment information is entered in Medisoft through the Enter Deposits/Payments option on the Activities menu Deposits are created within the Deposit List dialog box Learning Outcome: 8.3 Demonstrate how to enter insurance payments. Pages: 253-260 Payment information located on the RA. The Enter Deposits/Payments is very efficient for entering large insurance payments that must be split up and applied to a number of different patients.

8.3 Entering Insurance Payments (Continued) 8-9 The Deposit List dialog box lists deposits for a specific date, or all deposits can be viewed There are several other sorting features as well Learning Outcome: 8.3 Demonstrate how to enter insurance payments. Pages: 253-260

8.3 Entering Insurance Payments (Continued) 8-10 The Deposit List dialog box includes a column where the Payor Type can be identified Capitation payments are made to physicians on a regular basis (such as monthly) for providing services to patients in a managed care insurance plan Flat fee is paid to the physician no matter how many times a patient receives treatment Learning Outcome: 8.3 Demonstrate how to enter insurance payments. Pages: 253-260 Capitation payments are entered differently from regular insurance payments. They will be covered a little later.

8.3 Entering Insurance Payments (Continued) 8-11 To enter a deposit, click the New button in the Deposit List dialog box and the Deposit dialog box appears Deposit dialog box Learning Outcome: 8.3 Demonstrate how to enter insurance payments. Pages: 253-260

8.3 Entering Insurance Payments (Continued) 8-12 The type of payor—patient, insurance, or capitation—is selected from the Payor Type drop-down list Payor Type Learning Outcome: 8.3 Demonstrate how to enter insurance payments. Pages: 253-260

8.3 Entering Insurance Payments (Continued) 8-13 Other information entered about the deposit includes: Deposit date Payment method Check number Description/Bank No. Payment amount Deposit code Insurance Codes for payments, adjustments, withholds, deductibles, and take backs Learning Outcome: 8.3 Demonstrate how to enter insurance payments. Pages: 253-260 Deposit Date The program’s current date is displayed by default and must be changed if it is not the date of the deposit. Payment Method This box lists whether the payment is check, cash, credit card, or electronic. Check Number The number of the check (if a check payment) is entered in this box. Description/Bank No. This box can be used to enter a description of the payment, if desired. Payment Amount The total amount of the payment is entered in this box. Deposit Code This field can be used by practices to sort deposits according to user-defined categories. Insurance The insurance carrier that is making the payment is selected. Payment Code, Adjustment Code, Withhold Code, Deductible Code, and Take Back Code The appropriate codes for the insurance carrier are selected. Check for accuracy before saving.

8.3 Entering Insurance Payments (Continued) 8-14 Once a payment is entered, it appears in the Deposit List window Exercise 8-1 page 258 Learning Outcome: 8.3 Demonstrate how to enter insurance payments. Pages: 253-260

8.4 Applying Insurance Payments to Charges 8-15 Once a deposit is entered, the next step is to apply the payment to patient accounts Highlight the payment in the Deposit List and click the Apply button, opening the Apply Payment/Adjustments to Charges dialog box Apply Payments/ Adjustments to Charges dialog box Learning Outcome: 8.4 Demonstrate how to apply insurance payments to charges. Pages: 260-270 Make sure all entries in the deposit are applied correctly.

8.4 Applying Insurance Payments to Charges (Continued) 8-16 Next, the patient who has a transaction listed on the RA is selected from the drop-down list in the For box The upper-right area of the dialog box lists the amount of the deposit that has not yet been applied Learning Outcome: 8.4 Demonstrate how to apply insurance payments to charges. Pages: 260-270

8.4 Applying Insurance Payments to Charges (Continued) 8-17 The middle section of the Apply Payments to Charges window is where payments are entered and applied Learning Outcome: 8.4 Demonstrate how to apply insurance payments to charges. Pages: 260-270 If a patient is selected who does not have coverage with the insurance carrier that is making the deposit, a Select Payor window opens with the message that the payer does not match any case for the patient. Clicking the Cancel button closes the dialog box. The payments must match the procedure and the date of service.

8.4 Applying Insurance Payments to Charges (Continued) 8-18 The lower third of the Apply Payment/Adjustments to Charges window contains several options that affect claims and statements Exercise 8-2 page 26 Exercise 8-3 page 267 Exercise 8-4 page 268 Learning Outcome: 8.4 Demonstrate how to apply insurance payments to charges. Pages: 260-270 All of the deposit must be applied. The unapplied amount should say 0 at the top of the page.

8.5 Entering Capitation Payments 8-19 Capitation payments are entered in the Deposit List dialog box Capitation is selected from the Payor Type drop-down list in the Deposit window Deposit dialog box for a capitation payment Learning Outcome: 8.5 Demonstrate how to enter capitation payments. Pages: 270-277

8.5 Entering Capitation Payments (Continued) 8-20 Capitation payments are entered but not applied The charges in each patient’s account must be adjusted to a zero balance to indicate that the obligation has been met by the insurance company and patient Learning Outcome: 8.5 Demonstrate how to enter capitation payments. Pages: 270-277

8.5 Entering Capitation Payments (Continued) 8-21 A second deposit is entered with a zero amount to adjust the account Deposit dialog box with a zero payment amount Learning Outcome: 8.5 Demonstrate how to enter capitation payments. Pages: 270-277

8.5 Entering Capitation Payments (Continued) 8-22 When zero amount is saved, the deposit appears in the Deposit List window Payment column lists “EOB Only,” since no payment is associated with zero amount deposit Exercise 8-5 page 274 Exercise 8-6 page 275 Exercise 8-7 page 275 Learning Outcome: 8.5 Demonstrate how to enter capitation payments. Pages: 270-277 The next step is to locate patients who have claims covered by the capitation payment. This is accomplished using the List Only button in the Claim Management dialog box. Once patients have been identified the patient accounts must be adjusted to a zero balance in the Apply Payment/Adjustments to Charges dialog box. To apply the zero payment amount to these patient accounts, select the line for the deposit and click the Apply button. In the Apply Payment/Adjustments to Charges dialog box, select the chart number of each patient covered by the zero payment, and enter an adjustment equal to the outstanding balance. The amount in the Remainder column is the amount that must be entered in the Adjustment column to take the account to a zero balance The amount in the Remainder column is now zero. This procedure must be followed for each patient who has transactions covered by the capitation payment. Complete exercise 8-5, 8-6,8-7