1. Lesson 6 Topic 2 Claims Problems and Appeals
CBS 115 Medical Billing
Lesson 6 Topic 2
Claims Problems and Appeals

2. Problem Claims Delinquent Suspense (pending)
Payment is overdue
Suspense (pending)
Nonpayment caused by an error or the need for additional information, etc.
Use a tickler file to help you keep on top of delinquent and suspense claims and follow up with the insurance company.
These are some types of problem claims.
The medical office will encounter many types of claims problems.
You should have a procedure or plan to respond so that claims can be settled.

3. Problem Claims (cont’d.)
Lost claims
If you don’t receive a stamped acknowledgment that a claim is received by the insurer with an assigned claim number, then the claim may be lost.
Rejected claims
You can submit a corrected claim to address the problem.
A claim might be rejected if it doesn’t follow all the insurer’s instructions.
For potentially lost claims, sometimes a backlog on the insurer’s part results in a lack of a response. You can send a copy of the original claim to the insurer, but be sure to make it clear that you are not rebilling.

4. Problem Claims (cont’d.)
Denied claims
If a claim is denied, you’ll want to know the reason. Was the diagnosis not covered? Was prior approval for the treatment required? If a claim is denied, inform the patient and work with the physician to address the problem.
Other
Downcoding
Partial payment
Lost payment
Payment to the patient
Underpayment
Overpayment

5. Preventing Denied Claims
Verify insurance coverage at the first visit.
Make sure demographic information is current at each visit.
Include progress notes and orders for tests for extended hospital services.
Submit a letter from the prescribing physician documenting necessity when ambulance transportation is used.
Clarify the type of service.
Use modifiers to further describe and identify the exact service rendered.
Denied claims occur for many reasons, so be proactive to try to prevent or minimize them for your practice.

6. Preventing Denied Claims (cont’d.)
Keep abreast of the latest policies for the Medicare, Medicaid, and TRICARE programs by reading local newsletters.
Obtain the current provider manuals for all contracted payers, including the Blue Plans, Medicaid, Medicare, and TRICARE.
Put bulletins from these programs in the manuals so they’re up to date.

7. Rebilling
Do not rebill a payer without investigating why the claim is still outstanding
rebilling without investigating could create duplicate claims for the same service)
Corrected claims should be resubmitted
A correction notice may be sent with a corrected claim. See Fig. 9-6 (p. 344).
Patient bills should be sent out monthly

8. Appeals
When you can’t address a claim problem using the basic measures, you may have the option to appeal by making a formal request for a review. Consult the physician to see if this is a good idea.
Collect all your documents and call the insurance claims representative or adjuster to find out how to solve the problem.
Appeals are not just to fix minor errors. They are meant to challenge the outcome of the claims process, due to a discrepancy.

9. Appeal Situations Payment is denied Payment is incorrect
Physician disagrees with insurer
Unusual medical circumstances
Precertification not provided
Inadequate payment/complicated procedure
Deemed “not medically necessary”

10. Filing an Official Appeal
Send explanatory letter
explaining the reason why the provider does not agree with the claim denial listed on the EOB/RA
Excerpt coding resource book
Put together excerpts from the coding resource book and attach a photocopy for the article or pertinent information showing the coding resource and date of publication.
Peer review
An evaluation done by a group of unbiased practicing physicians to judge the effectiveness and efficiency of professional care rendered. This can determine the medical necessity and subsequent payment for the case in question

11. Filing an Official Appeal (cont’d.)
Include similar cases
Send copies of similar cases with increased reimbursement from the same insurance company, if available, from your insurance company payment history file.
Call the insurer
Call the insurance company and speak to the person who handles appeals, explaining what you want to accomplish. Send any correspondence to that person also.
Keep copies

12. Medicare Review and Redetermination
Telephone review
The first level of appeal is a simple inquiry. In these cases, you might be able to solve the problem by submitting a corrected claim.
Redetermination
Moving up to a higher level of appeal, a physician may ask for a review of a denial of Medicare Part B claims. This can be done with a letter and government form.
Reconsideration
To progress to the next level of appeal, the physician may feel that the review is unfair and request a hearing on the matter.

13. Medicare Review and Redetermination (cont’d.)
Administrative law judge hearing
Judicial Review
CMS regional offices
Medigap

14. TRICARE Review and Appeal
Reconsideration
Conducted by the claims processor or other TRICARE contractor
Formal review
Conducted by TRICARE headquarters
Hearing
Administered by TRICARE but conducted by an independent hearing officer
TRICARE has its own level of review. Keep in mind that appeals procedures for TRICARE contractors may vary.