1. Receiving Payments and Insurance Problem Solving
Chapter 9
Receiving Payments and Insurance Problem Solving
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2. Learning Objectives
Identify three health insurance payment policy provisions.
Interpret and post a patient’s explanation of benefits document.
Indicate time limits for receiving payment for manually versus electronically submitted claims.
Name three claim management techniques.
Identify purposes of an insurance company payment history reference file.
Explain reasons for claim inquiries.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

3. Learning Objectives (cont’d.)
Define terminology pertinent to problem paper and electronic claims.
State solutions for denied or rejected paper and electronic claims.
Identify reasons for rebilling a claim.
Describe situations for filing appeals.
Name Medicare’s five levels of redetermination (appeal) process.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

4. Learning Objectives (cont’d.)
Determine which forms to use for the Medicare review and redetermination process.
Name three levels of review under the TRICARE appeal process.
List four objectives of state insurance commissioners.
Mention seven problems to submit to insurance commissioners.
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5. Chapter 9
Lesson 9.1
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6. 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, depending on the state.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

7. Explanation of Benefits
States the status of a claim
Paid
Adjusted
Suspended/Pending
Rejected
Denied
States the allowed and disallowed amounts
Provided with payment check (if applicable)
Also referred to as a remittance advice, check voucher, or payment voucher.
What is a “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.)
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8. 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
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.
Explain the purpose of reduction or denial codes. (Ask for more information to determine coverage and benefits, or state amounts of adjustment because of payments by other insurers.)
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9. 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.
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10. Interpreting an Explanation of Benefits (EOB)
Fig. 9-1 (p. 318)
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.
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11. Claim Management Techniques
Insurance claims register
Tickler file
Aging reports
A spreadsheet software program can help generate an insurance claims register that is easy to update.
What is another name for a “tickler file?” (Suspense file, follow-up file)
Electronic practice management system can run a monthly “aging report” to identify which claims are still outstanding.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

12. Insurance Company Payment History
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
To track the payment history of insurance companies, use software or a manual system. Include the information listed in this slide.
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.)
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13. 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. 9-3 (p. 321) and Fig. 9-4 (pp. 322) 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.
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14. Problem Claims Delinquent Suspense (pending) Payment is overdue
Nonpayment caused by an error or the need for additional information, etc.
These are some types of problem claims.
The medical office will encounter many types of claims problems.
You should have a procedure or plan to respond so that claims can be settled.
Use a tickler file to help you keep on top of delinquent and suspense claims and follow up with the insurance company.
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15. Problem Claims (cont’d.)
Lost claims
If you don’t receive a stamped acknowledgment that a claim is received by the insurer with an assigned claim number, then the claim may be lost.
Rejected claims
For potentially lost claims, sometimes a backlog on the insurer’s part results in a lack of a response. You can send a copy of the original claim to the insurer, but be sure to make it clear that you are not rebilling.
A claim might be rejected if it doesn’t follow all the insurer’s instructions.
You can submit a corrected claim to address the problem.
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16. Problem Claims (cont’d.)
Denied claims
Other
Downcoding
Partial payment
Lost payment
Payment to the patient
Underpayment
Overpayment
If a claim is denied, you’ll want to know the reason. Was the diagnosis not covered? Was prior approval for the treatment required? If a claim is denied, inform the patient and work with the physician to address the problem.
Explain some reasons why an insurance claim may be denied. (Answers will vary. See p. 326 for a short list.)
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17. Preventing Denied Claims
Verify insurance coverage at the first visit.
Make sure demographic information is current at each visit.
Include progress notes and orders for tests for extended hospital services.
Submit a letter from the prescribing physician documenting necessity when ambulance transportation is used.
Clarify the type of service.
Use modifiers to further describe and identify the exact service rendered.
Denied claims occur for many reasons, so be proactive to try to prevent or minimize them for your practice.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

18. Preventing Denied Claims (cont’d.)
Keep abreast of the latest policies for the Medicare, Medicaid, and TRICARE programs by reading local newsletters.
Obtain the current provider manuals for all contracted payers, including the Blue Plans, Medicaid, Medicare, and TRICARE.
Put bulletins from these programs in the manuals so they’re up-to-date.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

19. Chapter 9
Lesson 9.2
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20. Rebilling
Do not rebill a payer without investigating why the claim is still outstanding
Corrected claims should be resubmitted
Patient bills should be sent out monthly
Why should you always investigate an outstanding claim before rebilling? (Rebilling without investigating could create duplicate claims for the same service.)
A correction notice may be sent with a corrected claim. See Fig. 9-6 (p. 331).
Clams with minor errors (missing identification numbers, etc.) can be rebilled, instead of having to go through the appeal process.
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21. Appeal Situations Payment is denied Payment is incorrect
Physician disagrees with insurer
Unusual medical circumstances
Precertification not provided
Inadequate payment/complicated procedure
Deemed “not medically necessary”
When you can’t address a claim problem using the basic measures, you may have the option to appeal by making a formal request for a review. Consult the physician to see if this is a good idea.
If you appeal, you must follow the laws and regulations surrounding an appeal and also the insurer’s procedures.
Collect all your documents and call the insurance claims representative or adjuster to find out how to solve the problem.
Explain how appeals differ from standard administrative efforts to solve claims problems. (Appeals are not just to fix minor errors. They are meant to challenge the outcome of the claims process, due to a discrepancy.)
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22. Filing an Official Appeal
Send explanatory letter
Excerpt coding resource book
Peer review
Send a letter explaining the reason why the provider does not agree with the claim denial listed on the EOB/RA (explanation of benefits/remittance advice).
Put together excerpts from the coding resource book and attach a photocopy for the article or pertinent information showing the coding resource and date of publication.
What is a “peer review?” (An evaluation done by a group of unbiased practicing physicians to judge the effectiveness and efficiency of professional care rendered. This can determine the medical necessity and subsequent payment for the case in question.)
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

23. Filing an Official Appeal (cont’d.)
Include similar cases
Call the insurer
Keep copies
Send copies of similar cases with increased reimbursement from the same insurance company, if available, from your insurance company payment history file.
Call the insurance company and speak to the person who handles appeals, explaining what you want to accomplish. Send any correspondence to that person also.
Discuss why it is a good idea to keep all copies of data sent for the physician’s files.
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24. Medicare Review and Redetermination
Telephone review
Redetermination
Reconsideration
Each insurer may have its own appeals process. Because Medicare covers so many patients, become familiar with its appeals process.
The first level of appeal is a simple inquiry. In these cases, you might be able to solve the problem by submitting a corrected claim.
Moving up to a higher level of appeal, a physician may ask for a review of a denial of Medicare Part B claims. This can be done with a letter and government form.
To progress to the next level of appeal, the physician may feel that the review is unfair and request a hearing on the matter.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

25. Medicare Review and Redetermination (cont’d.)
Administrative law judge hearing
Judicial Review
CMS regional offices
Medigap
Some hearings, depending on the amount in question, may be requested from an administrative law judge.
The Social Security Administration also has an appeals council if you feel the judgment was not lawful.
Finally, in costly and controversial cases, you might appeal all the way to a federal district court.
Explain why the appeals system progresses in levels. Discuss the advantages of this administrative/judicial approach for the insurer, the physician, and the patient.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

26. TRICARE Review and Appeal
Reconsideration
Conducted by the claims processor or other TRICARE contractor
Formal review
Conducted by TRICARE headquarters
Hearing
Administered by TRICARE but conducted by an independent hearing officer
TRICARE has its own level of review. Keep in mind that appeals procedures for TRICARE contractors may vary.
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27. State Insurance Commissioner Objectives
To make certain that the financial strength of insurance companies is not unduly diminished
To monitor the activities of insurance companies to make sure the interests of the policyholders are protected
To verify that all contracts are carried out in good faith
To make sure that all organizations authorized to transact insurance, including agents and brokers, are in compliance with the insurance laws of the state
Regulations vary widely from state to state.
Insurance commissioner will review policies to determine whether the denial of a claim was legal or not.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

28. State Insurance Commissioner Objectives (cont’d.)
To release information on how many complaints have been filed against a specific insurance company in a year
To help explain correspondence related to insurance company bankruptcies and other financial difficulties
To assist if a company funds its own insurance plan
To help resolve insurance conflicts
Insurance commissioners do not have the legal authority to order an insurance carrier to make a payment.
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29. Problems Submitted to Commissioner
Improper denial or underpayment
Delay in claim settlement
Illegal cancellation of policy
Misrepresentation by insurance agent
Misappropriation of premiums
Problems with premium rates
Two companies (which is primary?)
This slide lists the types of problems that should be submitted to your state’s insurance commissioner.
Discuss the state’s insurance commission or department, its structure, and its regulatory function. (Answers will vary, based on state.)
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30. Commission Inquiries Should Contain:
Patient’s (policyholder’s) name, address, phone number
Insured’s name
Insurance agent
Complaint
Patient’s signature and date
Insurance company
Policy or claim number
Date of loss
Everything related to insurance claims and filings has to be done according to procedures.
If you submit a request to the insurance commissioner, it should include all the information provided in this slide.
Suggest some methods that could be used to speed up payment from a continually slow-paying insurance company. (Copying the carrier on letters to the insurance commissioner, rating the carrier with the commissioner’s office. Answers will vary.)
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.