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Presentation on theme: "BILLING, REIMBURSEMENT, AND COLLECTIONS Chapter 9."— Presentation transcript:


2 2 Billing, Reimbursement, and Collections Learning Objectives Compute charges for medical services and create patient statements based on the patient encounter form and the physician's fee schedule. Explain the process of completing and transmitting insurance claims. Discuss the advantages of using electronic claims. Describe the different types of billing options used by medical practices for billing patients. Discuss the procedures and options available for collecting delinquent accounts.

3 Chapter 93 Key Terms Clearinghouse CMS-1500 claim form Collection agency Collection at the time of service Cycle billing Dependent Electronic claims EOB ERA Fee adjustment Fee schedule Guarantor Monthly billing Patient information form Patient statement Terminated account Third-party liability Write-off

4 Chapter 94 Patient Encounter Form Facilitates billing process Used to record details of each patient encounter for billing and insurance Includes Patient information Date Diagnosis for current visit Procedure information Financial information

5 Chapter 95 Patient Encounter Form (cont’d) Usually preprinted with common diagnoses/procedures New form attached to medical record for each visit Physician fills in form as visit/procedures progress Form is returned to administrative medical assistant for use in billing

6 Chapter 96 Fee Schedule Lists the usual procedures performed in the office and corresponding charges There may be more than one fee schedule, depending on insurance plan participation Administrative medical assistant must be familiar with office policy regarding financial arrangements for payment

7 Chapter 97 Patient Statements All transaction data stored in patient ledger Statement shows Services rendered Charges Payments made Balance owed Statement is sent to patient or guarantor

8 Chapter 98 Computerized Billing Used to print patient statements and blank patient encounter forms Also used to produce reports such as Day sheets Monthly reports Aging reports Departmental income Physician income Procedure code usage

9 Chapter 99 Insurance Claims Most practices complete the insurance form for the patient Form captures both clinical and financial information Transmitted to patient’s insurance carrier Partial or full reimbursement

10 Chapter 910 The CMS-1500 Claim Form Most common paper claim form Prepared by medical insurance specialist Data is collected from Patient information form Patient encounter form Transmitted via mail

11 Chapter 911 The HIPAA Claim Form Standard format for electronic claims Accepted by government and private carriers Prepared on computer by medical insurance specialist Transmitted via a modem to insurance company Faster and easier to track

12 Chapter 912 Third-Party Payers Insurance carriers Review claim for accuracy and completeness Evaluate treatment received Decide what benefits are due to the insured Carrier may Pay the claim Deny the claim Pay less than the full amount

13 Chapter 913 ERA/EOB ERA is electronic EOB is paper Explains reimbursement decision Amount of benefit Benefits paid to Paid on behalf of How determined May include check or record of EFT

14 Chapter 914 ERA/EOB (cont’d) Administrative medical assistant checks report against original claim Files with patient’s financial records Updates patient’s ledger Deposits check or records EFT

15 Chapter 915 Patient Billing After insurance claim process has been completed Patient may be billed for amounts not fully reimbursed by the carrier Administrative medical assistant acts as go-between for carrier and patient

16 Chapter 916 Completing the Claim Form Verify insurance information Use phone, fax, or Web to verify coverage Accuracy of data Contract numbers Patient’s identification information Insured’s information Secondary carriers, if any Illness or injury related to work or accident Diagnosis codes Procedure codes and charges Provider information

17 Chapter 917 Using Computers to Create Claims Computerized billing and claims Most practices use software programs, such as NDCMediSoft, to store information about patients and insurance plans Claims created by billing programs may be printed or submitted electronically The stored information is called a database

18 Chapter 918 Electronic vs. Paper Claims Electronic claims Transmitted via modem Receive immediate feedback Faster reimbursement Greater accuracy Less expensive Paper claims Sent through mail Must be keyed or scanned by insurance company into its computer system Possibility of errors

19 Chapter 919 Clearinghouses Service bureau Acts as an intermediary between provider and payer Reformats data from provider to a form accepted by the payer

20 Chapter 920 Follow-up ERA/EOB checked Procedures listed on ERA/EOB match claim Unpaid charges explained Codes on ERA/EOB match claim Payment listed for each procedure is correct

21 Chapter 921 Follow-up (cont’d) Tracer Contains basic billing information and asks carrier about status Paper or electronic Some providers automatically rebill after 30 days

22 Chapter 922 Follow-up (cont’d) Denied or late claims Unclear denial or incorrect payment should be followed up to determine cause Carrier asks for more information to process claim Claims investigated for preexisting conditions

23 Chapter 923 Follow-up (cont’d) Provider resubmits claims on own Mistake in billing Claim overlooked Insurance carrier asks for resubmission Incorrect codes have been submitted Information is incomplete or missing Charges do not total properly Appeal process

24 Chapter 924 Patient Payments Cash flow Payment methods Collection at the time of service Monthly billing Fixed weekly or monthly payments Bill health insurance carriers Cash-only basis

25 Chapter 925 Cash Payments Each payment is entered in Patient’s ledger Daily record Payments given to assistant, not physician Receipt must be given Safeguard money Endorse checks for deposit only Daily bank deposits

26 Chapter 926 Patient Statements Monthly billing Bills sent once a month Timed near end of month to coincide with patient’s other bills Cycle billing Avoids once-a-month billing workload Stabilizes cash flow Accounts divided into equal groups Each group billed on a different date

27 Chapter 927 Payment Plans and Adjustments Payment plans Patients unable to pay bill in one lump sum Agreement in writing Fee adjustment Write-offs—PAR provider not permitted to bill for difference between amount charged and amount reimbursed Physician may choose to reduce or cancel a bill Written evidence; don’t delete transactions

28 Chapter 928 Health Insurance Provides payment for a portion of medical expenses Participating (PAR) providers usually file claims for patients Patients responsible for copayments Non-participating (nonPAR) providers expect payment at time of service Receipt given to patient for payment Patient may file claim

29 Chapter 929 Third-Party Liability Person other than patient is responsible for charges Assistant must obtain verification from third party Must be in writing; can not be oral Guarantor Person who is the policyholder for the patient Dependent children

30 Chapter 930 Collections Effective communication with patients is first step in collections process Notify patient in advance of probable costs not covered by insurance plans Have patient agree in writing to pay for noncovered services Advance Notice for Noncovered Services Make payment arrangements before services are performed

31 Chapter 931 Collections (cont’d) Collection ratio At least 1/3 of the outstanding accounts should be collected each day Aging accounts Status: 30, 60, or 90 days past due Laws regulating collections Fair Debt Collection Practices Act of 1977 Telephone Consumer Protection Act of 1991

32 Chapter 932 Collections (cont’d) Collection methods Office policies Federal laws and state laws Telephone Letter Terminated accounts Physician may terminate the relationship due to lack of payment Collection agencies

33 Chapter 933 Collections (cont’d) Statute of Limitations Set by each state Truth in Lending Act of 1960 For payment plans over 4 payments in length, with finance charges Regulation Z requires a disclosure form to be completed and signed by practice manager and patient

34 Chapter 934 Collections (cont’d) Uncollectable accounts All collection attempts have been exhausted Would cost more to continue collection attempts than the amount due Written off as bad debt

35 Chapter 935 Quiz False, collections are begun after the bill is more than 30 days overdue. False, the insurance carrier uses ERA/EOB to inform the patient/provider of the status of claims. The ERA/EOB is submitted to the insurance carrier as part of the claim. (T/F) An appeal is a formal method of asking for reconsideration of a denied claim. (T/F) Collections are made on current bills. (T/F) True, the appeal is done in writing.

36 Chapter 936 Critical Thinking List some advantages of electronic claims. Advantages of electronic claims: lower costs, reduced rejection, greater accuracy, faster payment, access to status reports.


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