1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 15 Refunds and Appeals

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Reimbursement Follow-up  Monitored until payment is received to ensure correct reimbursement

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Reimbursement Follow-up  Reasons for contacting insurance carrier: –Insurance company investigating a claim –Unclear denial of payment –Incorrect payment –Reimbursement received without information regarding the allowable charge or the patient’s responsibility

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Reimbursement Follow-up  Reasons for contacting insurance carrier: –Reimbursement received for an unknown patient –A specialist has provided a service listed as not having a CPT code.

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Denied or Delayed Payments  Problems related to denied or delayed payments  Solutions to common problems  Notification by carrier to provider and patient  Responsibilities of medical office specialist and patient

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient Claim Questions  Identify problem in order to answer patient’s questions.  Identify steps already taken by the patient.  Medical office specialist’s acts in role of advocate by using expertise and objectivity.  Speak slowly and calmly while explaining.

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient Claim Questions  Use simple language without insurance jargon.  Use respect and care.  Verify what the patient understands.

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Record Documentation  Clear and concise  Legal document supporting the diagnosis and procedures  Chronologically documents and contributes to high quality patient care  Required to report pertinent facts

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes SOAP Format  Subjective information told by the patient to the doctor  Objective information gathered from physical exam and therapeutic tests  Assessment includes diagnosis or impression of physician  Plan is recommended treatment, testing ordered, adjustment of medications

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Appeals  Necessary to attempt to collect money due before making patient responsible for charges  Registration of appeal in timely manner  Process in writing or by telephone

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Employee Retirement Income Security Act (ERISA)  Enacted in 1974  Protects interests of participants  Private employee benefit plans  Special codes on insurance cards

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Employee Retirement Income Security Act (ERISA)  Contact information for U.S. Department of Labor  Waiting period is 90 days  Contact plan administrator regarding appeals.

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Appeals Letters  Standardized with specific inserts  Original letter may be necessary  Inclusion of court cases strengthen appeal

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Appeals  Customer service  Require perseverance and attitude regarding insurance carrier’s burden to prove denial is correct  Alternate appeal recipients including legal counsel, Department of Labor, and Department of Insurance

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Refunds  Reasons for overpayment of deductible: Duplicate payments, incorrect payment by carrier  If requested by carrier, must be responded to quickly  Research patient account and EOB  Guidelines for refunds with different payers

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Rebilling  Second billing notation on reprinted paper claim  Carrier requested rebilling due to incorrect or missing information

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Rebilling  Internet research on third-party websites in lieu of telephone calls regarding outstanding claims  PIN: Personal identification number given to participating providers

18. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Appeal Levels  Three levels of appeals: –First level: Redetermination of appeal requested within 120 days –Second level: Provides 6 months to file; handled by QICs –Third level: File with administrative law judge (ALJ); minimum amount $100

19. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Refund Calculations  Credit?  How much?  Adjustments?  Refund due?  How much?