Exploring Healthcare Reimbursement- Life Cycle of a Claim

There are several ways that electronic submissions can be made:

-A provider may complete the claim using specialized software and submit it to the third-party payer -A provider may enter essential data into a database and have a clearinghouse (see below) complete and submit the claim -A provider may hire a company to complete and file the claim based on the information gathered at the office

Electronic claims have a number of advantages:

-Administrative costs are lower because fewer personnel hours are needed to prepare forms, and supply and postage costs are lower -Fewer claims are rejected because technical errors are detected and corrected before the claim arrives at the payer -Processing is faster with fewer errors. The payer receives an electronic claim in minutes. The payer does not have to perform data entry, so there is less opportunity for errors to be introduced. In addition, the computer, rather than being processed by a claims analyst can automatically adjudicate most claims -Errors can be corrected faster. If the payer finds any errors on claims or the claim is denied, the office/facility is notified immediately and employees can begin work on resolving the issue -Payment is faster. Payment can be transferred electronically to the provider's bank, eliminating delays in cash flow. These payments are referred to as electronic remittances. Medicare is require by law to process electronic claims in 14 days, and is prohibited from processing paper claims for at least 28 days after receipt

Tracing Claims

-Any claims that have not been processed within that time frame are subject to interest in the amount allowed by state law. As a general rule, any claim that has not been paid or denied within 45 days of submission on paper, or 20 days of submission electronically, may be considered past due and warrants a telephone call to the health insurance payer. Most medical office software can print a list of past due claims, making it easy to identify the claims that require further investigation. Also note that Medicare and other payers may have specific guidelines regarding time frames for claims submission as well as payments. -The insurance analysis report will allow you to, at a glance, ensure that all payers are on track with payments. By grouping payments by health insurance payer, this can easily identify an issue with credentialing, slow insurance processing, or issues with your clearinghouse. -When a claim is past due, you should call the payer to follow up on or trace the claim. During this call, you may be told that the health insurance payer does not have the claim on file. If this is the case, you can request a fax number to send the claim to the customer service representative for processing personally. You may also be told that there was an error on the claim. Sometimes you may be able to clarify the error over the phone. Other times the claim will need to be resubmitted. You should always document any phone call made to a health insurance payer, noting the date and time of the call, the name of the person spoken to, and the results of the call.

Electronic claims also have disadvantages:

-Claims transmission can be disrupted occasionally due to power failures, or computer hardware or software problems that might require claims to be resubmitted -Many patient billing programs cannot create an electronic attachment, so when a claim attachment is required, the electronic claim must be sent separately from mailed attachments, which sometimes causes problems for the payer in matching up the two. In some cases, the claim must instead be submitted on paper when it must be accompanied by a claim attachment

outpatient physician visit submission:

-Patient registration -Receipted copayment from patient -Correctly coded encounter form. Charges will be totaled for all services performed. These same codes should be verified against the patient's medical record before the claim is filed -Charges should be entered into patient's account -Claim form should be completed -Supporting documentation (as needed) should be attached to the claim. (This is needed for certain codes that require further information or to review and verify past payments.) -A copy of the claim should be made and stored in the facility -Claim form to be submitted to third-party payer

Paper-based claims processing looks like this:

-Third-party payers receive mailed forms and date them (date received). -They are organized by payer or they are scanned electronically. -Third-party payers enter the information into their own claims software. -Claim is reviewed by claims examiner for validation of information.

Medicare claim must also be submitted within the timely filing requirement. This requirement is within one year:

-from the date of service on a provider claim -the date the services were through on an institutional claim

An EOB statement has three sections that explain how a claim was processed:

1) Service Information. Identifies the provider (hospital or other facility, doctor, specialist, or clinic), dates of service, and charges from the provider. 2) Coverage Determination. Summarizes the total deductions, charges not covered by the plan, and the amount the patient may owe the provider. 3) Benefit Payment Information. Indicates who was paid, how much, and when.

Each patient record has two components that may or may not be stored together:

1) The medical record documentation component records the details of the healthcare visit. 2) The financial record component includes the patient's contact information, billing information, payment history, insurance cards, and financial liability form.

the format of EOB forms can vary greatly between different health insurance payers, but in no time they will be second nature to your job duties. You may receive these notices in both paper and electronic form. Regardless of the method, they all contain the same basic information.

1. Account name: company name 2. Date the EOB statement was finalized 3. Member's or insured's name and ID number 4. Patient's identification number as it appears on his or her ID card 5. Number assigned to the claim 6. Name of the person who received the service (the patient) 7. Provider's name 8. Service description column, indicating: -Dates of the services provided (DOS) -Procedures performed (CPT codes) -Total charge for each procedure -The portion of the bill not covered by the plan (adjustment) -The contractual allowed amount -Patient's copay -Patient's deductible or non-covered procedures or amounts -Patient's coinsurance 9. Total payment to the provider 10. The total amount that is the patient's responsibility to the provider of services. This will include copays, deductibles, coinsurance, and non-covered services.

referral

A formal request or recommendation from a patients' primary care physician to be seen by another physician, usually a specialist.

Claim Submission - Third-Party Payer Information

A medical claim cannot even begin correctly if the correct health insurance and billing information is not collected and kept up to date. First- and third-party billing information (along with other demographic information) is usually collected when the patient comes in for treatment. Patient information is re-verified at each visit to ensure records are up to date. This information allows the submission to go to the correct place with the correct identifiers.

Inquiries

A patient or provider need not wait until the EOB is received to find out what is happening with a claim. The status of a claim can be accessed any time during or after the claim process by making an inquiry. An inquiry can be made via a written request, but technology has made inquiries quicker and more up-to-date. Most healthcare providers will have electronic access to a claim's status, allowing them to see where in the process that particular claim is.

utilization review

A process conducted by the third-party payer to ensure the patient is receiving appropriate care. Utilization reviews include determination of medical necessity as well as analysis of the provider, setting, and proposed techniques of procedures or services.

Which of the following is NOT a reason to make an inquiry about a claim? -A payment is made but not for the correct amount -A claim is not processed on time -A remittance advice is sent to the healthcare provider -The codes on the RA do not match those on the claim

A remittance advice is sent to the healthcare provider

Managing Claims

According to the CMS, any claims filed to Medicare, Medicaid, or any other government entity must be kept for at least 5 years. If the claim was made electronically, the superbill, or encounter form used to create the claim and the remittance advice, must be kept for the same amount of time.

Posting Payments

After posting the payment to the specific date and procedure, an adjustment may be needed. An adjustment is a positive or negative change to a patient's account balance. Corrections, changes, and write-offs to patients' accounts are made by means of adjustments to the existing transaction.

The Four Steps in a Medical Claim

All medical claims going through third-party payers follow the same cycle. The cycle begins when a patient with medical benefits receives medical services and a medical insurance claim is created. The cycle ends when the claim is paid. What happens in between is essentially universal, with minor exceptions depending upon the third-party payer. In its most basic form, the life cycle of a claim looks like this: -Submission -The healthcare provider sends the claim to the third-party payer, requesting payment. Submissions are made electronically (or occasionally by mail). -Processing -The third-party payer receives the claim and gathers information related to the case (specifics about the patient, the case, and the coverage). -Adjudication -The third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits. This process also checks for completeness of the claim, bundling issues for CPT® codes, medical necessity, and recent claims (to avoid unnecessary service or duplicate claims). -Payment -A financial payment is made by the third-party payer and received by the provider. The payment may be a lump sum for multiple claims or a single payment for one claim depending. The third-party payer also submits a remittance advice to the healthcare provider and an explanation of benefits (EOB) is sent to the patient. These forms explain what was covered by the third-party payer, what was not, and why. These forms contain patient and facility information, types and dates of services, charges, type of bill, and reason and remark codes, which will be discussed later. *Reconciliation -This is the process where the healthcare provider analyzes received payment information in comparison to submitted claim information for accuracy. If the provider believes a claim was in appropriately denied by the payer, the dispute process begins the cycle again until satisfactory reconciliation is achieved by both the provider and the third-party payer.

The claim itself must be filed on the _____.

CMS-1500

What form would be used for the reading of the x-ray charges?

CMS-1500

What form would be used to charge for the doctor's professional services for casting Jim's wrist?

CMS-1500

Back Side of Insurance Card

Claims Submission - Indicates where paper claims are to be mailed (if permitted) and how electronic claims are to be processed. There is other important information on this side of the card that pertains to verification of benefits, prior approval for services, and prescription coverage.

Submitting a Claim

Claims are prepared for submission after healthcare services are rendered. Care is then documented and charges are entered according to the provider's process. All claims must contain diagnosis and procedure codes that are assigned based on the provider's documentation. Code assignment process varies according to the provider. Diagnoses and procedures may be selected by a physician in an electronic health record system. Inpatient admissions have codes assigned after discharge by a certified medical coder. Other settings have their own processes. Regardless of the process, all the diagnosis and procedure codes are selected based on the physician's documentation.

examples of EOBs and how they are used to explain benefits and payments:

Example 1 -Alice, the patient, is the 6-year-old daughter of an employee at the local grocery store. The grocery store's insurance company, Acme Insurance, receives a claim for Alice's visit to her family physician. Because this is Alice's first claim, Acme Insurance contacts the grocery store to make sure that Alice has been added as a dependent to the employee's policy prior to processing the claim. If the employer verifies Alice has been added as a dependent, the insurance company will continue processing the claim. If the grocery store does not show Alice has been added to her parent's policy, the claim will not be processed -In the instance where Acme insurance checked with the grocery store and found Alice was not added to the employee's policy, an explanation of benefits would be sent to the family physician showing Acme's determination that no payment is made because Alice is not covered by the policy. Example 2 -Hartford Medical has received a claim for a routine office visit for Emily. Hartford has determined that Emily is covered and the claim is medically appropriate. The reviewer looks up the details of Emily's policy. The policy states Emily must pay the first $200 in medical expenses each calendar year, and then the charges are paid 80% by the insurance company and 20% by the patient. The reviewer determines Emily has already paid $200 this year, so the insurance company pays 80% of the allowed amount to the doctor's office. Emily receives a statement from her insurance coverage showing their benefit determination and a bill from her physician for the remaining 20% -An explanation of benefits would be sent to Emily's physician's office and to Emily. The explanation of benefits would show the date of visit, the provider, the total charge, the amount covered by the insurance, and the amount Emily is responsible to pay based on Hartford's 80/20 determination of benefits.

All medical visits produce a third-party medical claim.

False

All third-party payers use the exact same methods of processing claims.

False

In a physician's office the financial responsibility form should be kept in a separate billing file.

False

It is the patient's responsibility to make sure all up-to-date demographic and insurance information is on file at the healthcare provider.

False

Medical claims are always printed on paper.

False

Preauthorization is the process of calling the patient's specialist to obtain permission for them to receive prescribed procedures.

False

You may not use the Internet to arrange specialist referrals.

False

Managed Care Organizations (MCOs)

HMOs and PPOs require preauthorization for many procedures and services. By contrast, many MCOs recommend predetermination, a similar process to preauthorization without the requirement.

Front Side of Insurance Card:

I.D. Number - This identifies the patient and the patient's family members to the third-party payer. Name - The subscriber name (employee) is typically shown here. Care Type - Indicates the type of plan the patient has with the third-party payer.

Information is collected from the patient regarding financial responsibility for the administered healthcare services.

In many cases, this financial responsible person is the patient; however, a parent or legal guardian would be responsible for a minor or ward. Even when third-party payer information is provided, most healthcare providers require the patient or legal guardian to accept financial responsibility in the event the third-party payer only pays a portion of the charges or denies the claim.

patients may be covered by more than one insurance plan.

Insurance companies and state insurance commissioners have established specific rules that determine which coverage is billed first, called primary, and which is billed second, called the secondary policy. These types of claims are called crossover claims and the coverage determination process on these claims is coordination of benefits (COB).

Managed Care Organization (MCO)

MCOs offer health plans that feature a high measure of control and administration to minimize cost and increase overall quality of care. HMOs and PPOs are subtypes of managed care organizations.

Claims will be kept in two files:

Open/Pending claims -claims that have not yet completed the claims processing cycle. Open claims may have been recently submitted, re-submitted, or appealed; whatever the case, they have not been completed. Closed/Paid claims -claims for which the entire process has been completed. Open and closed claims may be organized and filed by date and/or the third-party payer to whom they were submitted.

Medicare administrative contractors (MACs)

Organizations that process Medicare claims under contracts with the CMS

Constant awareness of denials, or even low payments, is necessary

Physicians rely on medical billers to keep a close eye on incorrect claim processing. Full adjustments of services should never be done without research and communication with the appropriate staff. Often times, payment can easily be obtained with simple coding corrections or a phone call.

The Birthday Rule Example: Mary and Josiah Banks have a son, Ian. Mary has an insurance policy through Aetna U.S. Health Care that provides family coverage. Josiah has an insurance policy through Premera Blue Cross that also provides family coverage. Mary's birthday is January 10, 1977, and Josiah's birthday is April 15, 1968.

Primary Coverage Mary= Aetna U.S. Healthcare Josiah= Premera Blue Cross Ian= Aetna U.S. Healthcare Secondary Coverage Mary= Premera Blue Cross Josiah= Aetna U.S. Healthcare Ian= Premera Blue Cross

Reconciling a Claim

Providers may make inquiries via mail, computer, or phone for several reasons. Perhaps the payer has not responded to a claim in a timely manner (it usually takes 4 to 6 weeks for paper-based submissions, less for electronic submissions). Or maybe the claim was completed but payment was not made. Maybe there was a discrepancy in the amount paid and the amount indicated on the completed claim. It could be that there is a difference in the codes that were submitted and the codes that were listed on the remittance advice. This happens when an insurance company's coverage policies exclude coverage for an appropriately submitted procedure code. The remittance advice sent by the insurance company may list the code for the procedure that they will cover in lieu of the originally submitted code. It is important to remember to submit the appropriate code for the actual procedure performed and not the code that the provider knows the insurance company will cover. Coding based on insurance company coverage policy is inappropriate reporting and may be viewed as fraud.

electronic submissions

Recently, have become a staple of many healthcare providers and a requirement of many third-party payers. Because of new Medicare regulations, a reduced operating cost, and updated HIPAA mandates, electronic submissions are used by nearly all healthcare providers.

Each EOB form is different, depending on the insurance company. Some may be easy to decipher, while others are not. Keep in mind the differences and try not to let the different formats overwhelm you.

Step 1Identify the first insurance payment. On this particular form, the first insurance payment is located in the first row under the first column from the right, labeled "Amount Paid." The first insurance payment is 132.00. Step 2Identify the first adjustment for Sally Adams. The adjustment is located in the first row, the sixth column from the left, labeled "Adjustment." The first adjustment is 20.00. Step 3Identify the second insurance payment. Just like in step 1, the second insurance payment is located in the first column from the right, labeled "Amount Allowed," but this time in the second row. The second insurance payment is 13.42. Step 4Identify the second adjustment for Sally Adams. The second adjustment is found in the second row, sixth column from the left under the heading "Adjustment." The second adjustment is 10.48. Step 5Identify the patient responsibility for Sally Adams. To find the patient responsibility, find the box on the right-side of the form. The number to the right of the label "Total Patient Responsibility" is the patient responsibilty: 30.00.

Claims Adjudication Process

Step 1The adjudication process begins by comparing the patient information and demographics on the claim to the information and demographics on the policy. This verifies that the correct person is identified on the claim and that person is eligible for benefits. If the identifying information is not the same, the claim is rejected. Step 2The next step in the process is a check of the diagnostic and procedure codes. The codes listed on the claim are compared against those on the list of covered codes for that particular policy. The procedure codes are checked to make sure they correspond to the diagnosis codes and represent a necessary medical procedure. At this point in the process, the claim is also checked to ensure proper authorization (or preauthorization) was obtained for any procedure that the policy states requires such. The claim may be rejected if there are codes on the claim that are not covered by the policy, if a procedure is deemed medically unnecessary, or if proper authorization was not obtained. Step 3The adjudication process continues with a check of the common data file. The common data file is an overview of claims recently filed on the patient. It is reviewed to make sure there are no duplicate claims and to check to see if the claim is related to other procedures performed recently. Step 4Next, the payer determines what the allowed charges are for each service on the claim. The allowed charge is simply the amount the policy states is payable for a particular procedure. Using this payment figure, the payer can then determine the deductible (the amount the insured must pay yearly before benefits begin) and the coinsurance (the percentage of the bill the patient pays once the deductible is met). Step 5This next step is optional. Before submission, over half of all medical facilities choose to use an electronic software to edit bills before they are submitted. This is called claim scrubbing and is the basic act of checking for human error. Claim scrubbers will check the bill for specific rules or set guidelines, as programmed into the software, and point out which areas need reevaluating. These rules are called programmed edits. Claim scrubbers help reduce the possibility of bills being rejected. Step 6The adjudication process is now complete. All payment determinations have been made regarding third-party payer obligations and policyholder obligations. The next step is to inform the medical service provider and the policyholder of the determinations made.

The steps for obtaining authorization from an insurance company, such as for a surgical procedure, may vary. Some precertifications may be authorized via the payer website or electronically. Listed below are typical steps when obtaining precertification via phone:

Step 1Write down the date and time of the call, the name of the insurance company, and the name of the insurance company representative on the phone. Step 2Give the insurance company representative your name and your office's/physician's name. Step 3Give the insurance company representative the name of the patient, the name of the insured, and the insured's ID number. Step 4Let the representative know what the procedure is your doctor has prescribed for the patient and the date by which the procedure must be performed. Step 5Provide the representative any other requested information (e.g., procedure code, diagnosis code, and place where the procedure is to be performed). Step 6Write down the authorization number the representative provides. Step 7Ask the representative if any supporting documentation (e.g., chart notes, operative report, laboratory report, or pathology report) will be needed with the CMS-1500 billing form. If so, write down the required documentation. Step 8Keep all preceding information in the patient's file for reference in case the insurance carrier does not pay the claim.

birthday rule

The guidelines that determines which of two married parents with medical coverage from different employers has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary

Claims Processing

The way a claim is processed depends very much upon the way the submission was made. In the past claims were traditionally submitted by mail. If you end up working in an office that still uses a paper-based system, you must carefully review the CMS-1500 for errors or omissions. Approximately 1/3 of all paper-based submissions are initially rejected due to incorrect or incomplete claim forms. These rejections will result in resubmissions that will take up valuable time and delay payment. We will work through the CMS-1500 form in great detail in the next unit.

preauthorization

This is the process of contacting an insurance carrier to obtain permission for a patient to receive prescribed services and/or procedures. For many insurance carriers, preauthorization is a requirement for a claimed service to be reimbursed.

predetermination

This is the same concept and process as a preauthorization without the "requirement." Some services may not require precertification, but predetermination is recommended by the insurance carrier.

Coverage should also be verified with the insurance company so you have the most current and accurate information possible

This is usually done by a phone call to the insurance company or via electronic verification. Some companies have a separate phone number for verification. The process may be completely automated or may include personally speaking with a representative. Many companies also offer the option of verifying benefits online through a secure website.

A financial responsibility form signed by the patient assigns the patient or guardian responsibility of any part of a claim that is unpaid by the third-party payer.

True

An insurance policy indicated on a single insurance card can cover more than one person.

True

Explanations of payments or non-payments are sent to both the healthcare provider and the patient.

True

The submission of a claim begins with the healthcare provider.

True

You should always make note of precertification numbers in a patient's file.

True

Claim Forms

Two different claim forms, UB-04 and CMS-1500, are used to bill healthcare services regardless of the third party payer.

Jim falls on his wrist while skateboarding and goes to the emergency room where he has an x-ray. What form would be used for the x-ray charges?

UB-04

Jim's wrist is put in a cast. Which form would be used to charge for the casting materials?

UB-04

CLAIM FORM EXAMPLE 2: Henry's orthopedist, Dr. Lewis, recommends rotator cuff surgery since all of the conservative treatments for shoulder pain and immobility have failed. Dr. Lewis schedules Henry's surgery at the Chugach Surgery Clinic. Henry undergoes successful same-day surgery rotator cuff repair at the Chugach Surgery Clinic.

UB-04: Chugach Surgery Clinic bills the surgery and recovery room care charges, supplies, drugs, and surgical equipment because Chugach Surgery Clinic owns the facility and the equipment and supplies used to perform the surgery. CMS-1500: Dr. Lewis bills professional services for performance of the rotator cuff surgery. The anesthesiologist for the surgery also bills his professional services separately on CMS-1500.

CLAIM FORM EXAMPLE 1: Dorothy cuts her finger preparing Sunday dinner and goes to the Valley Emergency Room. The ER doctor, Dr. Ross, examines her and requests an x-ray of the finger. An x-ray is performed and read by the radiologist, Dr. Greene. With no apparent bone or tendon involvement, Dr. Ross stitches the laceration and discharges Dorothy.

UB-04: Hospital Emergency Room facility charges, suture kit, x-ray, bandages, anesthetic, and other supplies are billed on the UB-04 as outpatient charges by Valley Hospital. The hospital bills for the facility, equipment, and supplies. CMS-1500: Emergency room physician charges, professional services for emergency care and suturing by Dr. Ross are billed on CMS-1500. Radiologist professional charges for Dr. Greene's reading of the x-ray are billed on CMS-1500. The professional services are billed by the professional provider who provides services at the outpatient facility.

Claim Notices

Upon completion of the adjudication process, the third-party payer will send out a remittance advice (RA) or an explanation of benefits (EOB) to the healthcare provider, though they differ.

write-off

a balance that has been removed from a patient's account the difference between total charge and the allowable amount by the insurance. The patient's bill might also be adjusted as a result of any discounts given. If the provider is a PAR (participating) provider, the difference between the billed amount and the allowed amount is adjusted from the amount the patient owes. Also note whether a balance is due from the patient, or whether a refund is due the patient or payer.

clearinghouse

a company contracted by the third-party payers to handle and format submissions, screen claims, and make data available to providers. The clearinghouse has pre-edits built in so claims that do not meet the clean claim requirements are sent back to the providers to be reviewed, to have errors corrected, and to be resubmitted once they are correct.

remittance advice

a copy of the sales invoice returned with a customer's payment that indicates the invoices, statements, or other items being paid

remittance advice (RA)

a document that lists the amount that has been paid on each claim as well as the reasons for nonpayment or partial payment

payor number

a number that identifies an insurance company, allows medical offices to submit claims electronically.

For a claim to be submitted properly

all information must be accurate, up-to-date, and clearly documented. Documentation is the foundation for tracking patient treatment, proving appropriateness of medical care, compliance with regulations imposed by various agencies, and supports the billed services. While all health care providers typically have their own unique business processes, a common practice is to have one system for patient accounts and another system for medical record documentation. For a document accuracy, pre-billing software scrubbers pre-edit the content prior to reaching the biller. We will discuss this more later.

An advantage of the electronic claim is _____. -increased speed -decreased errors -decreased cost -all of the above

all of the above

How can inquiries pertaining to a claim be made? -by mail -electronically -by phone -all the above

all the above

Medicare, Medicaid, TRICARE, and many private health insurance payers

allow providers to submit insurance claims directly to them with no "middle man."

To maintain an accurate record of claims and payments, many healthcare providers will use what?

an aging report

common data file

an overview of claims recently filed on the patient

Dirty claims

are claims that are not completed properly or have errors that would result in denial. The goal is to submit a clean claim. A clean claim is a complete and accurate claim form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to enable the payer to process the claim.

Clean claims

are free from common errors that require resubmission.

electronic media claims (EMCs) or electronic data interchange (EDI)

are submitted to the payer via a central processing unit (CPU), direct data entry, direct wire, telephone or fast-access line via modem, or computer. Each facility will have its own method of claims submission. Electronic claims are never printed on paper. When claims are sent electronically to the payer for processing, an electronic signature is used to verify that the information received is true and correct. Medicare requires electronic transmission of claims for providers with 10 or more employees or facilities with 25 or more employees. Paper claims will not be processed for these submitters.

Who typically needs to review EOBs and RAs sent by the third-party payers? -the policyholder -the healthcare provider -both A and B -neither A nor B

both A and B

misreading and interpreting an explanation of benefits

can cause your physicians, hospital, or healthcare providers to lose out on appropriate reimbursement.

Most claims today are filed _____.

electronically

Every outpatient visit

from a complicated trip to the emergency room to a routine physician office followup, is tied to a specific patient and documented in a paper or electronic record (or some combination of both called a hybrid record).

explanation of benefits (EOB)

insurance report that is sent with claim payments explaining the reimbursement of the insurance carrier

The manner of the claim submission will depend upon the medical provider's system

it is common for electronic submissions, though some may be paper-based. Claims submitted electronically (via the Internet or a private network) have the advantage of being received quickly, making the entire processing time quicker.

Claims are sometimes denied or rejected

many times for errors the medical office, hospital, or similar provider made. Incorrect identification numbers, incorrect birthdates, missing diagnosis codes, missing CPT/HCPCS codes, and missing supporting documentation can all delay payment of insurance claims. Attention to detail in the claim submission process saves time and effort in the end. A rejected claim never entered the payer's system due to an incorrect identification number or similar technical problem, though a claim can be rejected for a variety of other reasons. These are often returned to the provider during the electronic media claims (EMCs) or electronic data interchange (EDI) process. Rejected claims should be corrected and resubmitted as a new claim. A denied claim is one the health insurance payer received and processed but did not pay due to benefits or coverage issues. The reason for denial is usually listed on the EOB.

the patient's registration form

needs to be updated at a minimum annually. Before releasing private patient information to insurance carriers, patients must give signed authorization as to not violate HIPAA regulations for patient confidentiality. In addition, a copy of both sides of the patients' insurance identification cards needs to be part of the financial records. Each provider must have a system in place to maintain all documentation related to the patient's financial responsibility.

Audits

performed to make sure that all billable services are appropriately coded.

a medical billers' extensive financial duties at the end of each month

post all charges and deposits and make sure that all aging reports are up to date and all invoices have been sent. The exact way in which this is done will depend upon the type of office in which you work, your individual duties in regard to billing, your employer's preferences, and the billing software/system used. Of course, one of the most time-consuming parts of medical billing will be following up on claims that have been denied, rejected, or paid at a reduced rate. The physician and his/her staff may question the validity of the rejection or reduced payment and decide to follow up on the claim. In this case, before filing an appeal, a polite phone call should be made to see if the issue can be resolved. If it cannot, a letter should be sent to the payer stating that, in the physician's judgment, there has been an incorrect payment of the claim.

One of the duties of the clearinghouse is to _____.

pre-edit claims for errors

A billing clerk or billing specialist in the provider's office

responsible for keeping track of paid and unpaid claims and remainders. There are a couple of ways that this can be done. Most offices will run an aging report that reconciles claims by date (current, 30 days unpaid, 60 days unpaid, etc.). The biller can then look into the unpaid claims and take appropriate action. Some offices may use a claims log or claims register into which all claims are entered. They are first put into the log when the claims are filed and all applicable information is included. When payments are received, they are reviewed for accuracy and entered into the log. Any notes needed regarding the payment, patient billing, or status of the claim may be entered.

those dealing with large government insurance entities, such as Medicaid or the Public Employees Health Program (PEHP)

tend to experience the highest wait times because of the call volume these groups must deal with. To alleviate such problems, companies like Blue Cross have implemented policies instructing customers to visit their websites to find answers before placing a call to an agent.

deductible

the amount the insured must pay yearly before benefits begin

allowed charge

the amount the policy states is payable for a particular procedure

UB-04

the claim form used to bill inpatient and outpatient facility charges: surgery centers, freestanding radiology clinics, laboratories, hospitals, skilled nursing, and emergency rooms. The electronic version of the UB-04 claim form is the 837-I (institution).

CMS-1500

the claim form used to bill professional services: surgeon's fees for a surgery performed at an outpatient surgery center or an emergency physician's fee for professional services provided in the emergency room. The electronic version of the CMS-1500 claim form is the 837-P (provider).

clean claim date

the date on which all such necessary information has been received. Only clean claims are then submitted from the clearinghouse to the third-party payer; however, this does not mean the provider will still not receive rejections on the claims that were sent on by the clearinghouse.

A clearinghouse acts as a liaison between _____.

the healthcare provider and the third-party payer

coinsurance

the percentage of the bill the patient pays once the deductible is met

In a physician's office who is ultimately the person in charge of deciding whether or not to follow up on a denied claim?

the physician

adjudication

the process of reviewing a claim and deciding what claims are to be paid

In order for claims to be reimbursed efficiently and accurately

the submission process must be completed in an exacting manner. There have been some excellent advances in this process in recent years that have made the entire claims process much simpler, quicker, and more accurate.