Lesson 6: Payments Topic 1: EOBs and Claim Tracking CBS 115 Medical Billing Lesson 6: Payments Topic 1: EOBs and Claim Tracking

Claim Policy Provisions Be aware of provisions of insurance policies Payment time limits vary by payer 4-12 weeks for paper claims 7 days for electronic claims Managed care plan can vary in payment schedule Contact the insurance company if payment is not received in a reasonable amount of time. State insurance commissioners can help obtain late payments from different carriers

Explanation of Benefits remittance advice, check voucher, or payment voucher. States the status of a claim Paid Adjusted Suspended/Pending Rejected Denied States the allowed and disallowed amounts Provided with payment check (if applicable)

Suspended claim a claim that is processed by a third-party payer but is held in an indeterminate/pending state about payment either because of an error of their need for additional information from the provider of service or the patient.

Components of an EOB Insurance company’s name and address Provider of services Dates of services Service or procedure codes Amount billed Reduction or denial codes, comment codes Ask for more information to determine coverage and benefits, or state amounts of adjustment because of payments by other insurers. The explanation of benefits (EOB) is the starting point to understanding and addressing outstanding or problem claims. You’ll want to study the details of the EOB line by line. Reduction or denial codes include comment codes with reasons, remarks, or notes indicating reasons payments were denied.

Components of an EOB (cont’d.) Claim control number Subscriber’s and patient’s name, policy numbers Patient’s payment responsibility Copayment Deductibles Total paid by insurance carrier An analysis of the patient’s total payment responsibility could include the amount not covered, copayment, deductible, coinsurance, and other insurance payment.

Interpreting an Explanation of Benefits (EOB) Fig. 9-1 (p. 330) Time limits for receiving payment from electronic claims are much shorter than for manual claims for all types of insurance coverage. See Chapter 3 for instructions on posting an EOB to a patient’s account.

Claim Management Techniques Insurance claims registe A spreadsheet software program can help generate an insurance claims register that is easy to update. Tickler file suspense file, follow-up file Aging reports Electronic practice management system can run a monthly “aging report” to identify which claims are still outstanding.

Insurance Company Payment History To track the payment history of insurance companies, use software or a manual system. Include the information listed in this slide. Insurance company name and regional office addresses Claims filing procedures Payment policies Time limits for claims and payments Dollar amount for procedural codes Patient names and policy and group numbers Be sure to keep names of patients and their policy and group numbers current. Discuss the value of an insurance company payment history. (it is easy to see which companies pay slowly or pay less for certain services, and provides reports for tax purposes or to determine financial trends) Explain when the payment history will come in handy and save the administrator time in claims follow-up. (all the information is on one report, which makes follow-up easier and more efficient)

Reasons for Claim Inquiries No response for 45 days Payment was not received within contractual time limit Incorrect payment was received Amount allowed/patient’s responsibility are not defined Payment received for incorrect patient EOB/RA show changed code EOB/RA shows a disallowed service that was a benefit Claim needs revision and resubmission EOB/RA has an error Payment was made out to the wrong physician Inquiries should be submitted in writing, whenever possible. See Fig. 6-3 (p. 334) and Fig. 6-4 (pp. 335) for sample inquiry letters. When calling to inquire about a claim, document the date, time of call, and the name of the person spoken to, along with an outline of the conversation.