Chapter 09 Receiving Payments and Insurance Problem-Solving

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.

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Lesson 9.1


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.

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Lesson 9.1


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

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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


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


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

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Claim Management Techniques

Insurance claims register Tickler file Aging reports

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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

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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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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

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Denied claims Downcoding Payment paid to patient Two-party check Underpayment Overpayment

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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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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.

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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


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


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

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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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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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Documents

Chapter 09 Receiving Payments and Insurance Problem-Solving