1. 17
Refunds, Follow-up, and Appeals

2. Key Terms and Abbreviations
administrative law judge (ALJ) hearing
documentation
Employee Retirement Income Security Act (ERISA) of 1974
follow-up
insurance commissioner
peer review

3. Key Terms and Abbreviations
qualified independent contractor (QIC)
redetermination
SOAP format

4. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
17.1: Understand reimbursement follow-up.
17.2: Know the common problems and solutions for denied or delayed payments.

5. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
17.3: Use problem-solving and communication skills to answer patients' questions about claims.
17.4: Format medical records with proper documentation.
17.5: Understand the appeals process and register a formal appeal.

6. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
17.6: Understand ERISA rules and regulations.
17.7: Write letters of appeal on denied claims.
17.8: Understand refund guidelines.

7. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
17.9: Rebill insurance claims.
17.10: Discuss the three levels of Medicare appeals.
17.11: Calculate and issue refunds.

8. Reimbursement Follow-Up
17.1: Understand reimbursement
follow-up.

9. 17.1: Reimbursement Follow-Up
Follow-up with Insurance Carriers
The majority of a provider's income is generated through the payment of insurance claims, so the medical office specialist must work to obtain prompt reimbursement.

10. 17.1: Reimbursement Follow-Up
Follow-up with Insurance Carriers
Claims that are denied, downcoded, or delayed because more information is needed negatively affect the financial status of a practice and must be dealt with immediately.

11. 17.1: Reimbursement Follow-Up
Follow-up with Insurance Carriers
Follow-up is needed when payments are denied, late, or incorrect.
To ensure timely payment, claim status should be monitored and follow-up done on all claims until they are paid.

12. 17.1: Reimbursement Follow-Up
Follow-up with Insurance Carriers
Depending on the situation and insurance carrier requirements, the follow-up may take place by phone, by , online through the carrier's website, or in written communications.

13. 17.1: Reimbursement Follow-Up
Figure Some reasons to inquire about an insurance claim.>

14. Denied or Delayed Payments
17.2: Know the common problems and solutions for denied or delayed payments.

15. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: The claim is not for a covered benefit.
Solution: Bill the patient, noting that the service/procedure is not covered by the plan or policy.

16. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: The patient's preexisting condition is not covered.
Solution: Bill the patient. If the provider believes the condition was not preexisting, an appeal will need to be filed.

17. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: The patient's coverage has been cancelled.
Solution: Bill the patient, noting the insurance cancellation information.

18. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: Workers' compensation (WC) is involved, and the case is still under consideration.
Solution: Call the employer and ask for the WC case number and address for claim submittal. Contact the patient for additional information, if necessary.

19. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: The carrier considers the procedure or service to be experimental.

20. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Solution: Any new procedure with an unlisted procedure code must include an explanation of the procedure and proof of medical necessity along with the claim. Call the carrier to discuss, if necessary. If still denied, an appeal may be filed or a request made for peer review. Ultimately, the patient may have to be billed.

21. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: The carrier believes there is a need for coordination of benefits with another carrier.
Solution: Call the patient for information on additional health coverage.

22. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: Required preauthorization was not obtained.
Solution: If authorization was obtained, call the carrier and provide the authorization number. If there is a reason why preauthorization was not obtained, an appeal may be filed, but sanctions may apply.

23. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: Services were provided before the patient's health coverage was in effect.
Solution: Bill the patient, noting that no coverage was in place on the date of service.

24. 17.2: Denied or Delayed Payments
Common Problems and Solutions
Problem: The carrier asks for additional information.
Solution: Send the requested information and follow up after 15 days or as needed to obtain payment.

25. Patients' Questions About Claims
17.3: Use problem-solving and communication skills to answer patients' questions about claims.

26. 17.3: Patients' Questions About Claims
Answering Patients' Questions
Good problem-solving and communication skills are essential in communicating with patients about outstanding claims and insurance issues.
The medical office specialist serves as the patient's advocate in dealing with insurance carriers.

27. 17.3: Patients' Questions About Claims
Answering Patients' Questions
Patients may receive bills or EOBs that they are upset about or don't understand.

28. 17.3: Patients' Questions About Claims
Answering Patients' Questions
The first step is to find out the exact nature of the patient's problem.
The medical office specialist can help patients review their insurance benefits to understand which services/procedures are covered and which are not or any limitations of coverage that apply.

29. 17.3: Patients' Questions About Claims
Answering Patients' Questions
It may be necessary to call the insurance carrier to obtain additional information for the patient regarding the claim.

30. 17.3: Patients' Questions About Claims
Techniques to Use in Communicating with Patients About Insurance Questions
Volunteer to explain. Speak slowly and calmly.
Use simple language, avoiding the use of insurance jargon.
Explain more than once when necessary.

31. 17.3: Patients' Questions About Claims
Techniques to Use in Communicating with Patients About Insurance Questions
Ask “Do you understand?” or say “Perhaps I can explain that better.”
Remember that patients may be under stress due to health, financial, or other issues.

32. 17.3: Patients' Questions About Claims
Techniques to Use in Communicating with Patients About Insurance Questions
Communicate with respect and empathy.

33. 17.4: Format medical records with proper documentation.

34. 17.4: Proper Documentation
Documentation Guidelines
Documentation is the chronological recording of pertinent facts and observations regarding a patient's health status and treatment (the medical record).
The structure of the medical record must be consistent.

35. 17.4: Proper Documentation
Documentation Guidelines
Information must be recorded in a format that allows the physician to access it easily and quickly to assist him or her in making a proper diagnosis and creating a treatment plan.

36. 17.4: Proper Documentation
Documentation Guidelines
Documentation must include information on the patient's health history, past and present illnesses, examinations, tests, treatments, and outcomes.

37. 17.4: Proper Documentation
Documentation Guidelines
Insurance carriers may request documentation to verify the place of service, the medical necessity of services provided, or that the services have been accurately reported.

38. 17.4: Proper Documentation
SOAP Format
The most widely used medical record format is the SOAP format, which includes Subjective, Objective, Assessment, and Plan information.
Subjective (E/M history): the patient's chief complaint or reason for the encounter as the patient tells it.

39. 17.4: Proper Documentation
SOAP Format
Objective (E/M examination): objective findings of the physical exam; includes height, weight, vital signs, and other findings

40. 17.4: Proper Documentation
SOAP Format
Assessment (E/M decision making): physician's diagnosis or impression at the time of the encounter
Plan (E/M recommended treatment): recommended treatment, tests, medications, therapies, procedures, or surgeries

41. 17.5: Understand the appeals process and register a formal appeal.

42. 17.5: Appeals The Appeals Process
The first step is to understand the appeals policy and deadlines of each carrier/payer.
The two types of appeals are written and telephone appeals.

43. 17.5: Appeals The Appeals Process
The medical office specialist must differentiate between a denial of charges and a disallowance (partial payment of a claim because the amount was above the maximum allowed charge).

44. 17.5: Appeals The Appeals Process
Standard form letters are used for appeals when the carrier doesn't accept verbal requests.

45. 17.5: Appeals The Appeals Process
Written appeals may be required when a claim is denied as not medically necessary or the carrier has misquoted benefits.
Sometimes when a denial results from an error on the part of the carrier, the provider must still file a written appeal.

46. 17.5: Appeals The Appeals Process
Explanations and clinical information are attached to standard appeal letters to support the appropriateness of the claim.

47. Table 17.2 -- Reason Codes That Require a Formal Appeal
17.5: Appeals
Table Reason Codes That Require a Formal Appeal

48. Table 17.2 -- Reason Codes That Require a Formal Appeal
17.5: Appeals
Table Reason Codes That Require a Formal Appeal

49. 17.6: Understand ERISA rules and regulations.

50. 17.6: ERISA ERISA Rules and Regulations
The Employee Retirement Income Security Act (ERISA) of 1974 is federal legislation enacted to protect the interests of individuals enrolled in pension and health benefit plans sponsored by private employers.
ERISA also regulates private employers' self-funded healthcare plans.

51. 17.6: ERISA ERISA Rules and Regulations
The carrier/plan must respond to a claim within 90 days.

52. 17.6: ERISA ERISA Rules and Regulations
Per ERISA, insured individuals have certain rights if a claim is denied, including the right to appeal.
The provider has at least 60 days (longer with some plans) to file an appeal.
A decision on the appeal must be made within 120 days.

53. 17.7: Write letters of appeal on denied claims.

54. 17.7: Letters of Appeal Writing Effective Appeal Letters
Standard appeal letters can be used, with the specific details of each case inserted at the appropriate locations.
Some circumstances will require an original letter.

55. 17.7: Letters of Appeal Writing Effective Appeal Letters
It is important to understand the federal and state laws that affect the submission of health insurance claims.
To strengthen an appeal, appropriate references to court rulings can be inserted.

56. 17.7: Letters of Appeal Writing Effective Appeal Letters
Effective appeal letters are written in professional language and include:
The patient's name, policy number, and a description of the charges being appealed
Names of people contacted at the insurance company, dates of contact, and details of conversations

57. 17.7: Letters of Appeal Writing Effective Appeal Letters
Effective appeal letters are written in professional language and include:
Concise explanation of what is being requested, along with supporting information
Clear description of the desired result/outcome

58. 17.7: Letters of Appeal Involving the Patient in the Appeal Process
When a provider is willing to file an appeal to attempt to overturn a claim denial, patients appreciate the effort because a successful appeal relieves the patient of a financial burden.

59. 17.7: Letters of Appeal Involving the Patient in the Appeal Process
The patient should be copied on letters of appeal sent to carriers/payers and asked to also appeal on his or her own behalf.
The patient should also be notified by phone when a letter of appeal has been sent.

60. 17.8: Understand refund guidelines.

61. 17.8: Refund Guidelines Refunds to Patients and Carriers
Credit balances and refunds result from overpayments by the patient or insurance carrier. Overpayments are common and can result from:
The patient paying in excess of his/her financial responsibility

62. 17.8: Refund Guidelines Refunds to Patients and Carriers
Credit balances and refunds result from overpayments by the patient or insurance carrier. Overpayments are common and can result from:
The patient having primary and secondary insurance coverage that both pay as primary in error

63. 17.8: Refund Guidelines Refunds to Patients and Carriers
Credit balances and refunds result from overpayments by the patient or insurance carrier. Overpayments are common and can result from:
The insurance company making a duplicate payment on a previously paid claim

64. 17.8: Refund Guidelines Refunds to Patients and Carriers
Carriers must request refunds in writing, clearly stating why a refund is warranted.
The medical office specialist must do research to verify if the refund request is justified.

65. 17.8: Refund Guidelines Refunds to Patients and Carriers
To avoid overpayments, patient copayments, coinsurance, and deductibles should be verified at the time of each visit.

66. Rebill Insurance Claims

67. 17.9: Rebill Insurance Claims
Resubmitting Claims
Before rebilling, the claim status should be checked online if the carrier's website has that capability or by calling the carrier.

68. 17.9: Rebill Insurance Claims
Resubmitting Claims
Some providers automatically rebill if payment hasn't been received within 30 days, but this may be perceived as using aggressive or fraudulent billing practices.

69. 17.9: Rebill Insurance Claims
Resubmitting Claims
Rebilled claims should be clearly identified as “Second Billing” to let the carrier know it is not a duplicate claim and that payment is overdue.

70. 17.9: Rebill Insurance Claims
Table Reasons to Rebill>

71. 17.10: Discuss the three levels of Medicare appeals.

72. 17.10: Medicare Appeals Levels of Medicare Appeals
First Level: Redetermination
A provider has 120 days to file a request for a Medicare review, also known as a redetermination, with a Medicare carrier. Carriers must process redeterminations within 30 days.

73. 17.10: Medicare Appeals Levels of Medicare Appeals Second Level
The second level of the appeal is handled by a qualified independent contractor (QIC) who processes reconsiderations of carriers' initial determinations and redeterminations. Providers have 6 months to file a second-level appeal, and QICs must process their reconsiderations within 30 days.

74. 17.10: Medicare Appeals Levels of Medicare Appeals Third Level
The third level of appeal is an administrative law judge (ALJ). Providers have 60 days to file a third-level appeal, and the value of the claim must be $ or higher. ALJs must make a decision within 90 days.

75. 17.11: Calculate and issue refunds.

76. 17.11: Issue Refunds Calculate and Issue Refunds
Before issuing a refund to a patient, check to see if the patient has an outstanding balance due on his or her account.

77. 17.11: Issue Refunds Calculate and Issue Refunds
If there is an outstanding balance, first apply the refund to the balance and then refund any difference.
Usually an accounting department or office manager handles the actual check writing for refunds.

78. 17.11: Issue Refunds Calculate and Issue Refunds
A patient with both primary and secondary insurance coverage may have a secondary policy that will pay copayments due on the primary policy.
If the patient paid a copay at the time of service and both insurance companies paid their shares, then the patient may be entitled to a refund.

79. 17.11: Issue Refunds Calculate and Issue Refunds
Before processing this refund, check if the patient owes any outstanding balance.

80. 17.11: Issue Refunds Calculate and Issue Refunds
To issue a refund, the medical office specialist makes an adjustment to the balance of a patient's account.
A negative adjustment will increase the balance, and a positive adjustment will decrease it.

81. 17.11: Issue Refunds Calculate and Issue Refunds
When issuing a refund, enter a positive adjustment and make a note in the account to document the reason for the refund.