1. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 09 Receiving Payments and Insurance Problem- Solving Insurance Handbook for the Medical Office 13 th edition

2. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Receiving Payments and Claims Processing 1. Identify three health insurance payment policy provisions. 2. Indicate time limits for receiving payment for manually (paper claims) versus electronically submitted claims. 3. Interpret and post a patient’s explanation of benefits document. 4. Name three claim management techniques. 2 Lesson 9.1

3. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Receiving Payments and Claims Processing (cont’d) 5. Identify purposes of an insurance company payment history reference file. 6. Explain reasons for claim inquiries. 7. Define terminology pertinent to problem paper and electronic claims. 8. State solutions for denied and rejected paper and electronic claims. 3 Lesson 9.1

4. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Policy Provisions  Differ by insurance companies  Some examples:  Claimant must notify insurance company of a loss within a certain period of time  If a disagreement occurs, suit must being within 3 years after claim was submitted  Insured person cannot bring legal action against insurance company until 60 days after claim was submitted 4

5. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Payment Time Limits  Payment time limits vary by payer  4-12 weeks for paper claims  7 days for electronic claims  Managed care plan can vary in payment schedule 5

6. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Explanation of Benefits  States the status of a claim  Paid  Adjusted  Suspended/Pending  Rejected  Denied  States the allowed and disallowed amounts  Provided with payment check (if applicable) 6

7. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Components of an Explanation of Benefits  Insurance company’s name and address  Provider of services  Dates of services  Service or procedure codes  Amount billed  Reduction or denial codes, comment codes 7

8. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Components of an Explanation of Benefits  Claim control number  Subscriber’s and patient’s name, policy numbers  Patient’s payment responsibility  Copayment  Deductibles  Total paid by insurance carrier 8

9. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Interpretation of an Explanation of Benefits 9

10. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Management Techniques  Insurance claims register  Tickler file  Aging reports 10

11. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Insurance Company Payment History  Insurance company name and regional office addresses  Claims filing procedures  Payment policies  Time limits for claims and payments  Dollar amount for procedural codes  Patient names and policy and group numbers 11

12. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Inquiries  No response for 45 days  Payment was not received within contractual time limit  Incorrect payment was received  Amount allowed/patient’s responsibility are not defined  Payment received for incorrect patient  EOB/RA show changed code  EOB/RA shows a disallowed service that was a benefit  Claim needs revision and resubmission  EOB/RA has an error  Payment was made out to the wrong physician 12

13. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Problem Paper and Electronic Claims  Delinquent  Payment is overdue  Suspense (pending)  Nonpayment caused by an error or the need for additional information, etc. 13

14. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Problem Paper and Electronic Claims  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 14

15. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Problem Paper and Electronic Claims  Denied claims  Downcoding  Payment paid to patient  Two-party check  Underpayment  Overpayment 15

16. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Problem Paper and Electronic Claims  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 16

17. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Problem Paper and Electronic Claims  Preventing denied claims  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. 17

18. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Filing Appeals 9. Identify reasons for rebilling a claim. 10. Describe situations for filing appeals. 11. Name Medicare’s five levels in the redetermination (appeal) process. 12. Determine which forms to use for the Medicare review and redetermination process 18 Lesson 9.2

19. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Filing Appeals (Cont’d) 13. Name three levels of review under the TRICARE appeal process. 14. List four objectives of state insurance commissioners. 15. Mention seven problems to submit to insurance commissioners. 19 Lesson 9.2

20. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Rebilling  Do not rebill a payer without investigating why the claim is still outstanding  Corrected claims should be resubmitted  Patient bills should be sent out monthly 20

21. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Review and Appeal Process  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” 21

22. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Filing an Appeal  Send explanatory letter  Excerpt coding resource book  Peer review 22

23. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Filing an Appeal  Include similar cases  Call the insurer  Keep copies 23

24. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Review and Redetermination Process  Telephone review  Redetermination (Level 1)  Reconsideration (Level 2) 24

25. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Review and Redetermination Process  Administrative Law Judge Hearing (Level 3)  Medicare Appeals Council (Level 4)  Federal District Court (Level 5)  Centers for Medicare and Medicaid Services Regional Offices  Medigap 25

26. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved TRICARE Review and Appeal Process  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 26

27. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Commission Objectives  To make certain that the financial strength of insurance companies is not unduly diminished  To monitor the activities of insurance companies to make sure the interests of the policyholders are protected  To verify that all contracts are carried out in good faith  To make sure that all organizations authorized to transact insurance, including agents and brokers, are in compliance with the insurance laws of the state 27

28. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Commission Objectives  To release information on how many complaints have been filed against a specific insurance company in a year  To help explain correspondence related to insurance company bankruptcies and other financial difficulties  To assist if a company funds its own insurance plan  To help resolve insurance conflicts 28

29. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Types of Problems  Improper denial or underpayment  Delay in claim settlement  Illegal cancellation of policy  Misrepresentation by insurance agent  Misappropriation of premiums  Problems with premium rates  Two companies (which is primary?) 29

30. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Commission Inquiries  Should contain:  Patient’s (policyholder’s) name, address, phone number  Insured’s name  Insurance agent  Complaint  Patient’s signature and date  Insurance company  Policy or claim number  Date of loss 30

31. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 31