CHAPTER 10

Remittance Advice (RA) and Electronic Remittance Advice (ERA) include:

. Identifying info for all parties: patient, medical provider insurance carrier . Claim amounts - amount charged, amount paid, adjustments applied, claim total . Claim status - paid, denied, pending . Explanation of decision

Any refund due a Medicare recipient must be made to the beneficiary within

30 days

Which statement is correct regarding accounts receivable?

A low number of days in A/R typically indicates successful revenue cycle management.

Advance Beneficiary Notice

An ABN must be signed prior to providing a Medicare service or test to document that the patient is willing to assume responsibility for payment of services that Medicare may not cover when subject to either National or Local Coverage Determinations (NCD) or (LCD).

Lower Level of Care is a denial that applies when the following occurs:

Care provided on an inpatient basis is typically provided on an outpatient basis Outpatient procedure could have been done in the providers office Skilled nursing care could have been performed by a home health agency

Which Bankruptcy Chapter combines the debt of the debtor and reduces the monthly payments allowing a potential for a provider to receive a portion of what is owed?

Chapter 13 - Adjustment of Debts of an Individual With Regular Income. The debts owed by the debtor are combined and the monthly payment is potentially reduced for the debtor. Under this filing, a provider or facility has the potential to receive a portion of the debt owed. Instructions for filing a claim against the bankruptcy are found on the back of the bankruptcy notice.

Which are the two main types of Bankruptcy seen in medical practices and facilities?

Chapter 7 and Chapter 13 Chapter 7 - Liquidation. Assets are sold and the payment is made to debtors. Chapter 13 - Adjustment of Debts of an Individual with Regular Income. Debts owed by the debtor are combined and the monthly payment is reduced.

A claim was resubmitted to Medicare through a clearinghouse 60 days after the date of service and the claim was denied. The biller checked the clearinghouse claim status system and determined Medicare did not receive the claim. What action should the biller take?

Check the clearinghouse reports and appeal the denial with proof of claims submission. If a claim is submitted after the filing deadline the claim is denied. This type of denial can be appealed if you have documentation that supports the claim was originally filed within the timely filing limit. When a claim is denied because it was not filed timely, and there is no documentation for an appeal, the balance must be written off by the participating provider and cannot be billed to the patient.

A patient is seen for a preventative office visit. The provider receives a denial stating it is a non-covered service. What action should the biller take?

Check the patient's benefits to determine whether the patient's policy covers preventive medicine. If not transfer to patient balance.

A provider removes a skin lesion in an ASC and receives a denial from the insurance carrier that states "Lower level of care." What steps should the biller take?

Check with the provider and write an appeal explaining why the service required the ASC. "Lower level of care" is a denial that applies when the following occurs: o Care provided on an inpatient basis is typically provided on an outpatient basis o Outpatient procedure could have been done in the provider's office o Skilled nursing care could have been performed by a home health agency When this type of denial occurs a letter should be written explaining the reason why the higher level of care was required. Along with the appeal letter the documentation from the patient's chart that supports the level of care should also be submitted.

What is the best way to handle a denial for incorrect information.

Contact the insurance and the patient to figure out where the error is and get it corrected. When a denial for incorrect information is received, it is important to review the information to see if an error was made. If the information submitted matches the information that you have then there is a problem somewhere. Contact the insurance payer and/or the patient for updated information

When a patient's claim is denied because they are covered under another insurance?

Coordination of benefits - If a patient is covered under more than one insurance plan one plan will be primary and the other is secondary

Appeal - formal request to reconsider a decision about a denied claim - documents needed to submit an appeal

Copy of remittance advice Copy of medical record Copy of original claim Letter detailing why claim should be paid

Which statement is TRUE regarding denials?

Denials should be reviewed to determine whether additional information is needed, if errors need to be corrected, or if the denial should be appealed. Denials or reimbursement problems should be worked as soon as they are received from the insurance carriers. Each denied claim should be reviewed to determine whether additional information is needed, if errors need to be corrected, or if the denial should be appealed. These denials will be identified when posting the payments, reviewing remittance advice, and on aging reports.

Which document is sent to the patient and typically has the statement "this is not a bill" written on top?

EOB - Explanation of benefits

When accepting debit cards in a medical practice, which act requires the office to disclose specific information before completing a transaction?

Electronic Funds Transfer Act. When allowing payments via a debit card, the office must also be familiar with the Electronic Funds Transfer Act. This act requires the office or facility to disclose specific information before completing a transaction.

Electronic Remittance Advice (ERA)

Electronic statement sent by an insurance carrier to the medical provider which explains the adjudication decisions on those claims submitted by the provider.

Consumer Credit Protection Act (CCPA)

Equal Credit Opportunity Act - prohibits discrimination Fair Credit Reporting Act - protects collected information Truth in Lending Act - Lenders to disclose credit terms Fair Credit Billing Act - creditor promptly credit your payments Fair Credit and Charge Card Disclosure Act - creditor disclose terms on credit APR and annual fees

Statement sent to the patient from the insurance carrier explaining services paid for on their behalf

Explanation of benefits - An Explanation of Benefits (EOB) is a statement sent by an insurance carrier to the covered individuals explaining what medical treatments and/or services were paid for on their behalf.

Which Act protects information collected by the consumer reporting agencies such as the credit bureaus, medical information companies and tenant screening services?

Fair Credit Reporting Act -

Which federal act states that third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collect of the debt?

Fair Debt Collection Practices Act (FDCPA) States that third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family, or household purposes.

Failure to refund an over-payment to an insurance carrier violates what law?

False Claims Act

Which statement is TRUE regarding the Prompt Payment Act?

Federal agencies are required to pay all claims within 30 days of receipt. The Prompt Payment Act is a federal law that ensures that federal agencies pay their bills within 30 days of receipt and acceptance of material and/or services.

Steps to Working the A/R

Financial policy Verify insurance Registration process Collection Submit claims correctly Monitor Denials Invoices Write-offs

A claim has been denied as not medically necessary. The biller has checked the medical record and the medical policy and verified it is not covered according to the carrier's medical policy. No ABN was signed. What is the next action the biller should take?

I. Write-off the balance II. Check with the provider to appeal the claim The carrier has determined based on information (procedure and diagnosis code(s)) submitted on the claim that the procedure was not medically necessary. When a claim is denied due to medical necessity, if the information was reported correctly, the provider can either appeal the claim or write off the amount. Depending on the insurance carrier contract, if the patient has signed an ABN prior to the procedure, the balance may be transferred to patient responsibility.

Common Claim Denials are:

Incorrect information Coordination of Benefits Timely filing Missing referral Non-covered service Prior Authorization Coverage termination Not medically necessary Pre-existing condition Lower Level of Care

On a billing statement, write-off amounts is indicated on

Insurance adjustments section

Which of the following information is the highest level of the appeals process of Medicare?

Judicial Review. The final level of appeal for Medicare is to request a Judicial Review in Federal District Court. The threshold for review in federal district court in 2016 is $1,460.00 and is calculated each year and may change. A request must be made within 60 days of receipt of the Medicare Appeals Council's decision.

What is a lower level of care denial?

Lower level of care" is a denial that applies when the following occurs: • Care provided on an inpatient basis is typically provided on an outpatient basis • Outpatient procedure could have been done in the provider's office • Skilled nursing care could have been performed by a home health agency

Common Claim Statuses

No record of claim Claim denied Claim pending Claim paid

What steps should be taken when a medical office receives notice that a patient has filed bankruptcy?

Obtain the case number, verify the case filing, and verify the provider is listed as a creditor, stop all collection efforts for balances filed under the bankruptcy. When a medical provider or facility receives notice a patient has filed for bankruptcy, the following steps should be taken: If notice is received from the patient, ask for the case number. If a notice is received from the bankruptcy court, the case number will be on the notice. Verify the case filing with the bankruptcy course. Verify the medical provider or facility is listed as a creditor. For providers listed as a creditor, stop all collection efforts on balances incurred prior to the filing of bankruptcy. The provider or facility may continue to collected balances due from the insurance companies.

What is prompt pay discount?

Patient covered by insurance is offered a discount at the time of service. Note: insurance company must be offered the same discount

Medicare Appeal Process for Parts A and B - 5 levels to the appeal - all request must be in writing

Redetermination - filed 120 days, form CMS-2007 Reconsideration - filed 180 days, form CMS-2003Irm Administrative Law Judge - filed 60 days, CMS-20034 A/B Appeals Council - filed 60 days, form DAB-101 Judicial Review - filed 60 days

Accounts Receivable (A/R)

Represents money owed to the healthcare practice by patients and/or insurance carriers.

Electronic Funds Transfer Act

Requires office to disclose specific information before completing a transaction.

Once a credit balance for an insurance carrier has been identified, what action should the biller take?

Research to determine if it is a true overpayment, then submit a refund to the insurance carrier for the overpayment. When it is determined an insurance carrier has overpaid for a service, or paid a service in error, the amount of the overpayment should be refunded as soon as discovered and verified. Failure to refund an overpayment to an insurance carrier violates the False Claims Act.

When a denial is received for a procedure that is determined to not be medically necessary by the insurance carrier what steps should the biller take?

Review the medical records and codes reported and the payers medical policy for that procedure.

Explanation of Benefits (EOB)

Statement sent by an insurance carrier to the covered individuals explaining what medical treatments and/or services were paid for on their behalf.

Remittance Advice (RA)

Statement sent by an insurance carrier to the medical provider which explains the adjudication decisions on those claims submitted by the provider.

Steps taken when a request for medical records is:

Submit copy of medical record for specific date of service. Review medical record - services billed are accurate. Attach a copy of the claim and remittance advice.

Accounts Receivable Management

System that assists providers in the collection of the reimbursement for services rendered.

How often should the patient's insurance be verified?

The patients insurance should be verified every time a patient is seen. The patient may present an insurance card but that does not mean that they are insured. Coverage changes are common. A patient may change insurance plans or the copayments and deductibles may change. Prior to treatment, the insurance carrier should be contacted to confirm coverage and the amount to be collected from the patient. This can be done through phone calls, the insurance carrier's website, or through the clearinghouse.

Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)?

Third party debt collectors are prohibited from employing deceptive or abusive conduct of consumer debts incurred for personal, family or household purposes.

Fair Debt Collection Practices Act (FDCPA)

Third party debt collectors prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family, or household purposes.

A biller received a request for medical records for Patient A for DOS 05/15/20XX. Patient A's entire medical record (multiple dates of service) was copied and sent to the insurance carrier. Which statement below is TRUE?

This is a violation of HIPAA. HIPAA has a clause called 'minimum necessary.' This means only the records requested to support the submitted charges are the ones that should be copied and sent. Additional dates of service not requested should not be sent.

Which statement is TRUE regarding discounts given to patients?

When a prompt payment discount is offered to a patient, the same discount should be reported on the claim to the insurance carrier. (referred to as prompt pay discount)

Can a patient be refused treatment due to inability to pay for the service?

Yes a provider can refuse to see a patient when it is not an emergency situation. According to the Federal Emergency Medical Treatment and Active Labor Act - mandates minimum standards for emergency care. A patient cannot be refused treatment for emergency care, however a physician can refuse patients for non-emergency, routine care.

When should patient invoices (statements) be sent to the patient?

as soon as the RA is posted and a balance is transferred to the patient. Patient invoices should be sent as the remittance advice has been posted. The sooner the invoice is received by the patient, the sooner it is likely to be paid. Patient invoices should detail the date of service, services performed, insurance reimbursement received, payments collected at the time of service, and reason the patient balance is due.

Collection Agency

business that pursues payments of debts owed by individuals for a percentage of the amount collected.

When all means of collecting payment form patient have been exhausted, account is considered

delinquent

The first step in working a denied claim is to

determine and understand why the claim was denied. Insurance carriers will use different denial codes on the remittance advice.

How to work a denied clam

determine why the claim was denied contact insurance carrier with questions correct information resubmit or appeal claim track the details and stay organized

Pre-existing condition - as of January 2014 PPACA - Patient Protection and Affordable Care Act

eliminates pre-existing conditions clauses. A person cannot be denied coverage, charged higher premiums or denied treatment based on their health status. A payer can no longer deny payment based on pre-existing conditions.

Prompt Payment Act

federal law that ensures federal agencies pay their bills within 30 days of receipt and acceptance of material and/or services. When payments not made in timely manner interest should be automatically paid.

Functions of Accounts Receivable Management are:

insurance verification insurance eligibility prior authorization billing and claims submission posting payments, collections

Problem in revenue cycle can be indicated by:

measured in A/R days. Days should be low.