Chapter 9 Receiving Payments and Insurance Problem Solving Elsevier items and derived items © 2010,...

Chapter 9Chapter 9

Receiving Payments and Insurance Receiving Payments and Insurance Problem Solving Problem Solving

Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 22

Learning ObjectivesLearning Objectives Identify three health insurance payment policy Identify three health insurance payment policy

provisions.provisions. Interpret and post a patient’s explanation of Interpret and post a patient’s explanation of

benefits document.benefits document. Indicate time limits for receiving payment for Indicate time limits for receiving payment for

manually versus electronically submitted claims.manually versus electronically submitted claims. Name three claim management techniques.Name three claim management techniques. IIdentify purposes of an insurance company dentify purposes of an insurance company

payment history reference file.payment history reference file. Explain reasons for claim inquiries.Explain reasons for claim inquiries.


Learning Objectives (cont’d.)Learning Objectives (cont’d.)

Define terminology pertinent to problem Define terminology pertinent to problem paper and electronic paper and electronic claims.claims.

State solutions for denied or rejected paper State solutions for denied or rejected paper and electronic claimsand electronic claims..

Identify reasons for rebilling a claim.Identify reasons for rebilling a claim. Describe situations for filing appeals.Describe situations for filing appeals. Name Medicare’s five levels of Name Medicare’s five levels of

redetermination (appeal) process.redetermination (appeal) process.


Learning Objectives (cont’d.)Learning Objectives (cont’d.)

Determine which forms to use for the Determine which forms to use for the Medicare review and Medicare review and redeterminationredetermination process.process.

Name three levels of review under the Name three levels of review under the TRICARE appeal process.TRICARE appeal process.

List four objectives of state insurance List four objectives of state insurance commissioners.commissioners.

Mention seven problems to submit to Mention seven problems to submit to insurance commissioners.insurance commissioners.


Chapter 9Chapter 9

Lesson 9.1 Lesson 9.1


Claim Policy ProvisionsClaim Policy Provisions

Be aware of provisions of insurance policiesBe aware of provisions of insurance policies Payment time limits vary by payerPayment time limits vary by payer

4-12 weeks for paper claims4-12 weeks for paper claims 7 days for electronic claims7 days for electronic claims Managed care plan can vary in payment scheduleManaged care plan can vary in payment schedule


Explanation of BenefitsExplanation of Benefits

States the status of a claimStates the status of a claim PaidPaid AdjustedAdjusted Suspended/PendingSuspended/Pending RejectedRejected DeniedDenied

States the allowed and disallowed amountsStates the allowed and disallowed amounts Provided with payment check (if applicable)Provided with payment check (if applicable)


Components of an EOBComponents of an EOB

Insurance company’s name and addressInsurance company’s name and address Provider of servicesProvider of services Dates of servicesDates of services Service or procedure codesService or procedure codes Amount billedAmount billed Reduction or denial codes, comment codesReduction or denial codes, comment codes


Components of an EOB (cont’d.)Components of an EOB (cont’d.)

Claim control numberClaim control number Subscriber’s and patient’s name, policy Subscriber’s and patient’s name, policy

numbersnumbers Patient’s payment responsibilityPatient’s payment responsibility CopaymentCopayment DeductiblesDeductibles Total paid by insurance carrierTotal paid by insurance carrier


Interpreting an Explanation of Interpreting an Explanation of Benefits (EOB)Benefits (EOB)


Claim Management TechniquesClaim Management Techniques

Insurance claims registerInsurance claims register Tickler fileTickler file Aging reportsAging reports


Insurance Company Insurance Company Payment HistoryPayment History

Insurance company name and regional office Insurance company name and regional office addressesaddresses

Claims filing proceduresClaims filing procedures Payment policiesPayment policies Time limits for claims and paymentsTime limits for claims and payments Dollar amount for procedural codesDollar amount for procedural codes Patient names and policy and group numbersPatient names and policy and group numbers


Claim InquiriesClaim Inquiries No response for 45 daysNo response for 45 days Payment was not received within contractual time limitPayment was not received within contractual time limit Incorrect payment was receivedIncorrect payment was received Amount allowed/patient’s responsibility are not definedAmount allowed/patient’s responsibility are not defined Payment received for incorrect patientPayment received for incorrect patient EOB/RA show changed codeEOB/RA show changed code EOB/RA shows a disallowed service that was a benefitEOB/RA shows a disallowed service that was a benefit Claim needs revision and resubmissionClaim needs revision and resubmission EOB/RA has an errorEOB/RA has an error Payment was made out to the wrong physicianPayment was made out to the wrong physician


Problem ClaimsProblem Claims

DelinquentDelinquent Payment is overduePayment is overdue

Suspense (pending)Suspense (pending) Nonpayment caused by an error or the need for Nonpayment caused by an error or the need for

additional information, etc.additional information, etc.


Problem Claims (cont’d.)Problem Claims (cont’d.)

Lost claimsLost claims If you don’t receive a stamped acknowledgment If you don’t receive a stamped acknowledgment

that a claim is received by the insurer with an that a claim is received by the insurer with an assigned claim number, then the claim may be assigned claim number, then the claim may be lost.lost.

Rejected claimsRejected claims


Problem Claims (cont’d.)Problem Claims (cont’d.)

Denied claimsDenied claims OtherOther

DowncodingDowncoding Partial paymentPartial payment Lost paymentLost payment Payment to the patientPayment to the patient UnderpaymentUnderpayment OverpaymentOverpayment


Preventing Denied ClaimsPreventing Denied Claims Verify insurance coverage at the first visit.Verify insurance coverage at the first visit. Make sure demographic information is current at each Make sure demographic information is current at each

visit.visit. Include progress notes and orders for tests for extended Include progress notes and orders for tests for extended

hospital services.hospital services. Submit a letter from the prescribing physician Submit a letter from the prescribing physician

documenting necessity when ambulance transportation documenting necessity when ambulance transportation is used.is used.

Clarify the type of service.Clarify the type of service. Use modifiers to further describe and identify the exact Use modifiers to further describe and identify the exact

service rendered.service rendered.


Preventing Denied Claims Preventing Denied Claims (cont’d.)(cont’d.)

Keep abreast of the latest policies for the Keep abreast of the latest policies for the Medicare, Medicaid, and TRICARE programs Medicare, Medicaid, and TRICARE programs by reading local newsletters.by reading local newsletters.

Obtain the current provider manuals for all Obtain the current provider manuals for all contracted payers, including the Blue Plans, contracted payers, including the Blue Plans, Medicaid, Medicare, and TRICARE.Medicaid, Medicare, and TRICARE. Put bulletins from these programs in the manuals Put bulletins from these programs in the manuals

so they’re up-to-date.so they’re up-to-date.


Chapter 9Chapter 9

Lesson 9.2 Lesson 9.2


RebillingRebilling

Do not rebill a payer without investigating why Do not rebill a payer without investigating why the claim is still outstandingthe claim is still outstanding

Corrected claims should be resubmittedCorrected claims should be resubmitted Patient bills should be sent out monthlyPatient bills should be sent out monthly


Appeal SituationsAppeal Situations

Payment is deniedPayment is denied Payment is incorrectPayment is incorrect Physician disagrees with insurerPhysician disagrees with insurer Unusual medical circumstancesUnusual medical circumstances Precertification not providedPrecertification not provided Inadequate payment/complicated procedureInadequate payment/complicated procedure Deemed “not medically necessary”Deemed “not medically necessary”


Filing an Official AppealFiling an Official Appeal

Send explanatory letterSend explanatory letter Excerpt coding resource bookExcerpt coding resource book Peer reviewPeer review


Filing an Official Appeal (cont’d.)Filing an Official Appeal (cont’d.)

Include similar casesInclude similar cases Call the insurerCall the insurer Keep copies Keep copies


Medicare Review and Medicare Review and RedeterminationRedetermination

Telephone reviewTelephone review Redetermination Redetermination Reconsideration Reconsideration


Medicare Review and Medicare Review and Redetermination (cont’d.)Redetermination (cont’d.)

Administrative law judge hearingAdministrative law judge hearing Judicial ReviewJudicial Review CMS regional officesCMS regional offices MedigapMedigap


TRICARE Review and AppealTRICARE Review and Appeal

ReconsiderationReconsideration Conducted by the claims processor or other Conducted by the claims processor or other

TRICARE contractorTRICARE contractor Formal reviewFormal review

Conducted by TRICARE headquartersConducted by TRICARE headquarters HearingHearing

Administered by TRICARE but conducted by an Administered by TRICARE but conducted by an independent hearing officer independent hearing officer


State Insurance Commissioner State Insurance Commissioner ObjectivesObjectives

To make certain that the financial strength of To make certain that the financial strength of insurance companies is not unduly diminishedinsurance companies is not unduly diminished

To monitor the activities of insurance companies to To monitor the activities of insurance companies to make sure the interests of the policyholders are make sure the interests of the policyholders are protectedprotected

To verify that all contracts are carried out in good faithTo verify that all contracts are carried out in good faith To make sure that all organizations authorized to To make sure that all organizations authorized to

transact insurance, including agents and brokers, are transact insurance, including agents and brokers, are in compliance with the insurance laws of the statein compliance with the insurance laws of the state


State Insurance Commissioner State Insurance Commissioner Objectives (cont’d.)Objectives (cont’d.)

To release information on how many To release information on how many complaints have been filed against a specific complaints have been filed against a specific insurance company in a yearinsurance company in a year

To help explain correspondence related to To help explain correspondence related to insurance company bankruptcies and other insurance company bankruptcies and other financial difficultiesfinancial difficulties

To assist if a company funds its own To assist if a company funds its own insurance planinsurance plan

To help resolve insurance conflictsTo help resolve insurance conflicts


Problems Submitted to Problems Submitted to CommissionerCommissioner

Improper denial or underpaymentImproper denial or underpayment Delay in claim settlementDelay in claim settlement Illegal cancellation of policyIllegal cancellation of policy Misrepresentation by insurance agentMisrepresentation by insurance agent Misappropriation of premiumsMisappropriation of premiums Problems with premium ratesProblems with premium rates Two companies (which is primary?)Two companies (which is primary?)


Commission Inquiries Commission Inquiries

Should Contain:Should Contain: Patient’s (policyholder’s) name, address, phone Patient’s (policyholder’s) name, address, phone

numbernumber Insured’s nameInsured’s name Insurance agentInsurance agent ComplaintComplaint Patient’s signature and datePatient’s signature and date Insurance companyInsurance company Policy or claim numberPolicy or claim number Date of lossDate of loss

Chapter 9 Receiving Payments and Insurance Problem Solving Elsevier items and derived items © 2010,...

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