Receiving Payments and

1
Chapter 9

• Receiving Payments and
• Insurance Problem Solving

2
Claims Provisions

• Claimant obligation to notify carrier of loss
  within certain period of time or insurer has
  right to deny benefits
• Insurer has obligation to pay benefits promptly
  when claim submitted
• Specific time limits will be stated in either the
  insurance contract or payers manual

3
Exceeding Time Line

• If payment from insurer is slow, denied, ignored,
  or exceeds time lines as stated in contract, the
  office needs to
• Contact the insurance company by letter asking
  why the claim has not been paid
• If problem persists,
• Contact the state insurance commission

4
Explanation of Benefits

• EOB/remittance advice (RA) document stating the
  status of the claim
• If benefits has been assigned, the physician
  receives a copy of the EOB with the payment
• If benefits have not been assigned, the physician
  does not receive payment and may not receive an
  EOB

5
EOB Components

• Insurance companys name and address
• Provider of service
• Dates of service
• Service or procedure numbers
• Amounts billed by the providers
• Reduction or denial codes
• Claim control number

6
Components

• Subscribers and patients name and policy number
• Analysis of patients total payment
  responsibility
• Copayment amount due from patient
• Deductible amount subtracted from billed amount
• Total amount paid by insurance carrier

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8
Posting an EOB

• Upon receipt of EOB, check each line against the
  charges for each patient.
• Record the payment and adjustment.

9
Claims Management Techniques

• Insurance Claims Register
• Tickler File
• Aging Reports

10
Insurance Company Payment History

• Either with software or manually keep information
  about insurance companies
• Insurance company name and address
• Claims filing procedures
• Payment policies
• Time limits to submit claims
• Time limit for receiving payments
• Dollar amount for each procedure code

11
Claim Inquiries

• An inquiry or tracer is used to find the status
  of a claim or to inquiry about payment
  determination shown on the EOB
• Reasons for making inquiries
• No response to submitted claim
• Payment not received within time limit
• Amount is incorrect
• Amount allowed and patient responsibility not
  defined
• Payment received for patient not seen

12
Reasons continued

• EOB shows code was changed from submitted code
• EOB shows service was disallowed
• Error on EOB
• Check received made out to wrong physician

13
Problem claims in office

• To prevent repeated errors, identify the source
  of the errors
• Collecting registration information
• Posting charges to accounts
• Wrong CPT and ICD-9-CM codes
• Incorrect provider numbers
• Wrong gender and birth year
• Improve accuracy

14
Problem Claims

• Delinquent, Pending, or Suspense
• Lost Claims
• Rejected Claims
• Denied Claims
• Prevention measures
• Downcoding

15

• Payment Paid to Patient
• Two-party Check
• Overpayment
• Rebilling

16
Review and Appeal Process

• An appeal is a request for payment by asking for
  a review of an insurance claims that has been
  inadequately or incorrectly paid or denied.
• Base the appeal on billing guidelines, state and
  federal insurance laws and regulations
• There is sufficient information to back up claim
• Amount of money should be sufficient
• Decision to appeal rests in physicians hands

17
Medicare Review and Appeal Process

• Inquiry
• Review
• Fair hearing
• Administrative law judge
• Appeals council review
• Federal district court hearing