1. Chapter 9
Receiving Payments and Insurance Problem Solving

2. Claim Policy Provisions
Be aware of insurance policy provisions
know your contract
Payment time limits vary by payer
4—12 weeks for paper claims
7 – 14 days for electronic claims
Prompt pay laws

3. Explanation of Benefits (EOB)
Remittance Advice (RA), check voucher, payment voucher
Document issued by the insurance company indicating the status of a claim
Paid
Adjusted
Suspended/pending
Rejected
Denied
Allowed/disallowed/contractual adjustment
Provided with payment check

4. Components of an EOB Subscriber’s/patient’s name and policy number
Insurance company’s name/address
Service provider
Date of service
Service or procedure codes
Amount billed

5. Components of an EOB (cont’d)
Claim control number
Reduction or denial codes, comment codes
Patient’s financial responsibility
Copayment
Coinsurance
Deductible
Amount paid by the insurance carrier

6. Interpreting an EOB
May have multiple patients, multiple service dates on same EOB
One check pays for multiple patients, services
Read each transaction, each line item
EOB’s vary by provider
ERA’s look very different than standard EOB or RA
REVIEW FIGURE 9-1

7. Posting the EOB Compare against the claim submitted
codes
charges
Compare allowed amount against contracted fee schedule
Call payer if you don’t understand the processing
Keep EOB on file either in an electronic (scanned file) or paper file by posting date

8. Claims Management Techniques
Claims log or register
Tickler file
Suspense file
Follow up file
Routinely print aging reports
Practice management queues
Clearinghouse

9. Claim Inquiries No response for 45 days
Call when……..
No response for 45 days
Payment not received within contractual time limit
Incorrect payment received
Allowed amount or patient’s responsibility not defined or unclear
Payment received for incorrect patient

10. Claim Inquiries (cont’d)
Call when……..
EOB/RA show changed code
EOB/RA shows a disallowed amount that was a benefit
Claim needs revision and resubmission
EOB/RA has an error
Payment was made out to wrong physician

11. When NOT to Make an Inquiry
Patient believes deductible or out-of-pocket has been met
Claim denied for policy termination
Claim denied for ineligible dependent
Claim denied for policy exclusion

12. Other Problem Claims Delinquent claim Lost claim Rejected claim
Payment is overdue
Claim may be in review or suspense
Lost claim
Claim received by insurance company but not scanned or logged
Rejected claim
does not follow payers instructions for submission or contains a technical error such as missing or incorrect information

13. What to do with Denied Claims
Denied for non-covered service and write-off is indicated
Denied as a bundled service
Denied as part of a global period
!!!APPEAL!!!!
Denied and EOB indicates patient responsibility
Transfer balance to patient
Encourage them to follow up with insurance
Give instructions on what needs to be corrected

14. Resubmit? Rebill?
Don’t refile your claim until you have checked claim status!!!!
Results in wasted time, effort
Results in denied claims as duplicate submissions
Duplicate claims will process and deny faster than one that is in process
Still must be posted
Skews denial rating / reports

15. Preventing Denied Claims
Verify insurance coverage at the first visit
Make sure demographics is current at each visit
Include notes and reports as needed
Include Letter of Medical Necessity by the physician
Use modifiers to further describe and identify the exact service rendered

16. Underpayments Use the correct fee schedule
Call carrier, request review and reprocessing
Provide correct allowed amount that should have been applied
Call Provider Relations Rep or Contracting Rep
Be professional
Be intelligent

17. Overpayments Total amount paid is more than the charge amount
Determine where and why the overpayment exists
Patient overpayment
Incorrect processing
Dual coverage

18. Overpayments (cont’d)
Post the payment as indicated by EOB
Make notes to indicate overpayment and reason
Find out the refund process
Submit as soon as possible
Indicate to carrier to recoup or take back
Patient refunds
always process as check or refund on a credit card
send check via registered mail to last known address

19. Review and Appeals Process

20. Review and Appeals Process
Appeal: request for payment by asking for a review of a claim that has been inadequately or incorrectly paid or denied
Appeal when
Payment is denied or incorrect
Physician disagrees with adjudication
Unusual medical circumstances prevail
Precertification not provided
Inadequate payment for a complicated procedure
Denied “not medically necessary”

21. Timely Filing As little as 90 days from initial date of adjudication
Up to six months
Some allow one year
File appeal as soon as possible after EOB is received

22. How to File an Appeal Know the payer’s requirements Form vs Letter
Additional documentation
Filing address

23. Appeals Guidelines Make sure you have sufficient grounds for appeal
Complete the required forms in full
Be specific in your request
Include
How the claim was adjudicated
The reason why it should be corrected
How much reimbursement you are expecting

24. Attachments Letter of Medical Necessity Operative Report Office Notes
CPT / ICD-9 / modifier descriptors
NCCI edits
Proof of timely filing
Proof of eligibility or benefit verification

25. 1st, 2nd, 3rd Level and beyond
Don’t give up if your first appeal is denied
Fight for what you believe is right
Request that Medical Director for your discipline reviews your appeal
Peer to peer review

26. Homework Chapter 9 Workbook – In Class Review on 11/19
Define key terms and key abbreviations
Assignment 9-1 Review Questions
Workbook – Turn In (due 11/19)
Assignment 9-3 Post to a Financial Accounting Record from an EOB
Assignment 9-4 Trace an Unpaid Insurance Claim
Read Chapter 10 Office and Insurance Collection Strategies

27. Questions???