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Insurance Handbook for the Medical Office 13 th edition. Chapter 09 Receiving Payments and Insurance Problem-Solving. Receiving Payments and Claims Processing. Identify three health insurance payment policy provisions. - PowerPoint PPT Presentation
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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
13th edition
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
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
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
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
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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)
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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
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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
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Interpretation of an Explanation of Benefits
9
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Claim Management Techniques
Insurance claims register Tickler file Aging reports
10
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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
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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
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Problem Paper and Electronic Claims
Delinquent Payment is overdue
Suspense (pending) Nonpayment caused by an error or the need
for additional information, etc.
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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
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Problem Paper and Electronic Claims
Denied claims Downcoding Payment paid to patient Two-party check Underpayment Overpayment
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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
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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
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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
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Lesson 9.2
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
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
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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”
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Filing an Appeal
Send explanatory letter Excerpt coding resource book Peer review
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Filing an Appeal
Include similar cases Call the insurer Keep copies
23
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Medicare Review and Redetermination Process
Telephone review Redetermination (Level 1) Reconsideration (Level 2)
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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
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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
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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
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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
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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?)
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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
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Questions?
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