Chapter 9 Receiving Payments and Insurance Problem Solving

Claim Policy Provisions Be aware of insurance policy provisions know your contract Payment time limits vary by payer 4—12 weeks for paper claims 7 – 14 days for electronic claims Prompt pay laws

Explanation of Benefits (EOB) Remittance Advice (RA), check voucher, payment voucher Document issued by the insurance company indicating the status of a claim Paid Adjusted Suspended/pending Rejected Denied Allowed/disallowed/contractual adjustment Provided with payment check

Components of an EOB Subscriber’s/patient’s name and policy number Insurance company’s name/address Service provider Date of service Service or procedure codes Amount billed

Components of an EOB (cont’d) Claim control number Reduction or denial codes, comment codes Patient’s financial responsibility Copayment Coinsurance Deductible Amount paid by the insurance carrier

Interpreting an EOB May have multiple patients, multiple service dates on same EOB One check pays for multiple patients, services Read each transaction, each line item EOB’s vary by provider ERA’s look very different than standard EOB or RA REVIEW FIGURE 9-1

Posting the EOB Compare against the claim submitted codes charges Compare allowed amount against contracted fee schedule Call payer if you don’t understand the processing Keep EOB on file either in an electronic (scanned file) or paper file by posting date

Claims Management Techniques Claims log or register Tickler file Suspense file Follow up file Routinely print aging reports Practice management queues Clearinghouse

Claim Inquiries No response for 45 days Call when…….. No response for 45 days Payment not received within contractual time limit Incorrect payment received Allowed amount or patient’s responsibility not defined or unclear Payment received for incorrect patient

Claim Inquiries (cont’d) Call when…….. EOB/RA show changed code EOB/RA shows a disallowed amount that was a benefit Claim needs revision and resubmission EOB/RA has an error Payment was made out to wrong physician

When NOT to Make an Inquiry Patient believes deductible or out-of-pocket has been met Claim denied for policy termination Claim denied for ineligible dependent Claim denied for policy exclusion

Other Problem Claims Delinquent claim Lost claim Rejected claim Payment is overdue Claim may be in review or suspense Lost claim Claim received by insurance company but not scanned or logged Rejected claim does not follow payers instructions for submission or contains a technical error such as missing or incorrect information

What to do with Denied Claims Denied for non-covered service and write-off is indicated Denied as a bundled service Denied as part of a global period !!!APPEAL!!!! Denied and EOB indicates patient responsibility Transfer balance to patient Encourage them to follow up with insurance Give instructions on what needs to be corrected

Resubmit? Rebill? Don’t refile your claim until you have checked claim status!!!! Results in wasted time, effort Results in denied claims as duplicate submissions Duplicate claims will process and deny faster than one that is in process Still must be posted Skews denial rating / reports

Preventing Denied Claims Verify insurance coverage at the first visit Make sure demographics is current at each visit Include notes and reports as needed Include Letter of Medical Necessity by the physician Use modifiers to further describe and identify the exact service rendered

Underpayments Use the correct fee schedule Call carrier, request review and reprocessing Provide correct allowed amount that should have been applied Call Provider Relations Rep or Contracting Rep Be professional Be intelligent

Overpayments Total amount paid is more than the charge amount Determine where and why the overpayment exists Patient overpayment Incorrect processing Dual coverage

Overpayments (cont’d) Post the payment as indicated by EOB Make notes to indicate overpayment and reason Find out the refund process Submit as soon as possible Indicate to carrier to recoup or take back Patient refunds always process as check or refund on a credit card send check via registered mail to last known address

Review and Appeals Process

Review and Appeals Process Appeal: request for payment by asking for a review of a claim that has been inadequately or incorrectly paid or denied Appeal when Payment is denied or incorrect Physician disagrees with adjudication Unusual medical circumstances prevail Precertification not provided Inadequate payment for a complicated procedure Denied “not medically necessary”

Timely Filing As little as 90 days from initial date of adjudication Up to six months Some allow one year File appeal as soon as possible after EOB is received

How to File an Appeal Know the payer’s requirements Form vs Letter Additional documentation Filing address

Appeals Guidelines Make sure you have sufficient grounds for appeal Complete the required forms in full Be specific in your request Include How the claim was adjudicated The reason why it should be corrected How much reimbursement you are expecting

Attachments Letter of Medical Necessity Operative Report Office Notes CPT / ICD-9 / modifier descriptors NCCI edits Proof of timely filing Proof of eligibility or benefit verification

1st, 2nd, 3rd Level and beyond Don’t give up if your first appeal is denied Fight for what you believe is right Request that Medical Director for your discipline reviews your appeal Peer to peer review

Homework Chapter 9 Workbook – In Class Review on 11/19 Define key terms and key abbreviations Assignment 9-1 Review Questions Workbook – Turn In (due 11/19) Assignment 9-3 Post to a Financial Accounting Record from an EOB Assignment 9-4 Trace an Unpaid Insurance Claim Read Chapter 10 Office and Insurance Collection Strategies

Questions???