Billing 101B Series Part IIBilling 101B Series Part II
Introduction
Router / Billing Cycle
Follow-Up Terminology Acronyms
MGBS Follow-Up Process
Appeals Process
Questions
TRANSACTION WITHIN THE UCSF BILLING SYSTEMS
Nancy Baird Router
TES (Edit Checking)
Pre-Bill (Edits)
IDX BAR
(Edits)
SMS (Edits)
Payor
Payor
(Electronic/Paper) Claims
(Electronic/Paper) Claims
(Electronic) Payments Rejections
(Electronic) Payments Rejections
(Manual) Payments Rejections
(Manual) Payments Rejections
Encounter Entry
THE BILLING CYCLE
Client Relations/ Services
A/R Analysis and Reporting
Billing Inquires (Customer Services)
QA and Training
1. Appointment Scheduling and Registration – The process of scheduling an appointment and obtaining and/or updating all current demographic, financial and insurance information.
2. Arrival/Check-In – The process of arriving patients, verify information and updating as necessary.
4. Coding and Batching the Encounter forms – The process of coding a visit completing an encounter form and batching encounter forms.
5. Charge Entry – The process of entering charges, CPT codes, and ICD-9 codes into a billing system.
3. Patient Care
6. Edit Resolution – The process of data verification encompasses TES, Z-Claim and Pre-Bill editing systems (in this order).
7. Claims Submission and Patient Billing – The process of submitting claims to third-party payors and mailing patient statements (bills).
8. Payment Posting – The process of posting payments and adjustments to open accounts.
9. A/R Follow-Up – The process of resolving outstanding accounts (non zero balance).
The billing cycle includes nine major steps and is supported by ongoing quality assurance and training, customer service, analysis and reporting and client relations
TerminologyTerminology
What is FSC?What is IMF?Edits (TES, Z-Claim, Pre-Bill)What is an EOB, EOMB & ERA?
Explanation of BenefitsExplanation of Medicare BenefitsElectronic Remittance Advice
What is POS?What is DRQ?What is A/R?
MGBS Follow Up ProcessMGBS Follow Up Process
Myth:Having insurance = paid services/automated
payment
Fact:
MGBS Follow-Up ProtocolMGBS Follow-Up Protocol
Follow-Up Phones, FAX, & Internet
PCS Workfile
Modified Account Balance
Example of PCS Workfile
Modified Account Balance Modified Account Balance CriteriaCriteria
1. FSC Category
2. Initial Claim Date
3. Tickle Code Assignment
4. Dunning Level (Self-Pay Only)
5. Sum of Invoice(s) Balance
PCS Workfile - examplePCS Workfile - example
Myth:Myth:Everything that we bill for gets paidEverything that we bill for gets paid
Fact:Fact:
Possible Actions on an Possible Actions on an Adjudicated ClaimAdjudicated Claim
AdjustmentsContractual Adjustments
Coding Adjustments
Risk Management Adjustments
Bad Debt
AdjustmentsAdjustments
Date of Service Contractual
Adjustment Amount
Billed Amount Allowed Amount
Possible Actions on an Possible Actions on an Adjudicated ClaimAdjudicated Claim
Rejections/Denials
Rejection/DenialRejection/Denial
Appeals ProcessAppeals Process
ManualWhen does MGBS file an appeal?
What process does MGBS use for appeal?
How do I know if a claim is being appealed?
Are appeals always paid?
What happens when an appeal is denied?
Appeals ProcessAppeals Process
Automated (EOB Resolve)Criteria:
Electronic payors for claims and payments
What payors are included?
Results since implementation (October 2007)?
Aetna (Appealing underpayments and clinical edits of $125k)
Blue Shield (Appealing underpayments and clinical edits of $68k)
Questions?
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