14 Payments (RAs/EOBs), Appeals, and Secondary Claims
Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>14.1  Describe the steps pa...
Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>14.7  Discuss h...
Key Terms <ul><li>aging </li></ul><ul><li>appeal </li></ul><ul><li>appellant </li></ul><ul><li>autoposting </li></ul><ul><...
Key Terms (Continued) <ul><li>HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277) </li></ul><ul><l...
14.1 Claim Adjudication <ul><li>Payers follow five steps in order to adjudicate claims: </li></ul><ul><ul><li>Initial proc...
14.1 Claim Adjudication (Continued) <ul><li>Concurrent care— situation in which a patient receives independent care from t...
14.1 Claim Adjudication (Continued) <ul><li>Medical necessity denial— refusal by a plan to pay for a procedure that does n...
14.1 Claim Adjudication (Continued) <ul><li>RA/EOB— document detailing the results of claim adjudication and payment </li>...
14.2 Monitoring Claim Status  <ul><li>Medical insurance specialists monitor claims by reviewing the insurance aging report...
14.2 Monitoring Claim Status (Continued) <ul><li>Monitoring claims (continued): </li></ul><ul><ul><li>Aging— classificatio...
14.2 Monitoring Claim Status (Continued) <ul><li>The HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (276/277)...
14.2 Monitoring Claim Status (Continued) <ul><li>The HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (276/277)...
14.3 The Remittance Advice/Explanation of Benefits (RA/EOB) <ul><li>Electronic and paper RAs/EOBs contain the same essenti...
14.3 The Remittance Advice/Explanation of Benefits (RA/EOB) (Continued) <ul><li>To explain the determination to the provid...
14.4 Reviewing RAs/EOBs <ul><li>The unique claim control number reported on the RA/EOB is first used to match up claims se...
14.5 Procedures for Posting <ul><li>The process for posting payments and managing denials: </li></ul><ul><ul><li>Payments ...
14.5 Procedures for Posting (Continued) <ul><li>Electronic funds transfer   (EFT)— electronic routing of funds between ban...
14.6 Appeals <ul><li>An appeal process is used to challenge a payer’s decision to deny, reduce, or otherwise downcode a cl...
14.6 Appeals (Continued) <ul><li>Medicare participating providers have appeal rights, that involve five steps: </li></ul><...
14.7 Postpayment Audits, Refunds, and Grievances <ul><li>Filing an appeal may result in payment of a denied or reduced cla...
14.8 Billing Secondary Payers <ul><li>Claims are sent to patient’s additional insurance plans after the primary payer has ...
14.9 The Medicare Secondary Payer  (MSP) Program, Claims, and Payments <ul><li>Medicare Secondary Payer (MSP)— federal law...
14.9 The Medicare Secondary Payer  (MSP) Program, Claims, and Payments (Cont.) <ul><li>Under the MSP program, Medicare is ...
Upcoming SlideShare
Loading in...5
×

Survey of Medical Insurance pp ch14

1,411

Published on

Published in: Economy & Finance, Business
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,411
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
0
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 14.1 Describe the steps payers follow to adjudicate claims. Pages: 520-523 Teaching Notes:   Examine the details of each step of the claim adjudication process with the class. Ask your students to describe the importance of monitoring a payer’s claim adjudication process, in their own words.
  • Learning Outcome: 14.1 Describe the steps payers follow to adjudicate claims. Pages: 520-523 Teaching Notes:   Ask your students to recite the three options that can result from a payer determination. (A payer’s payment determination is a decision whether to (1) pay a claim, (2) deny a claim, or (3) pay a claim at a reduced level.)
  • Learning Outcome: 14.1 Describe the steps payers follow to adjudicate claims. Pages: 520-523 Teaching Notes:   Have your students create some examples that could result in a medical necessity denial.
  • Learning Outcome: 14.1 Describe the steps payers follow to adjudicate claims. Pages: 520-523
  • Learning Outcome: 14.2 Describe the procedures for following up on claims after they are sent to payers. Pages: 523-527 Teaching Notes:   Review the example of an insurance aging report in Figure 14.1 with the class.
  • Learning Outcome: 14.2 Describe the procedures for following up on claims after they are sent to payers. Pages: 523-527 Teaching Notes:   Have your students explain, in their own words, the concept of claim turnaround time.
  • Learning Outcome: 14.2 Describe the procedures for following up on claims after they are sent to payers. Pages: 523-527 Teaching Notes:   Review the main types of claim status category codes that payers use on the HIPAA 277 transaction. (A codes; P codes; F codes; R codes; E codes.)
  • Learning Outcome: 14.2 Describe the procedures for following up on claims after they are sent to payers. Pages: 523-527 Teaching Notes:   Review the main types of claim status category codes that payers use on the HIPAA 277 transaction. (A codes; P codes; F codes; R codes; E codes.)
  • Learning Outcome: 14.3 Identify the types of codes and other information contained on an RA/EOB. Pages: 527-533 Teaching Notes:   Review the contents of Figure 14.3 with your class.
  • Learning Outcome: 14.3 Identify the types of codes and other information contained on an RA/EOB. Pages: 527-533 Teaching Notes:   Review the different types of codes used by payers, and have your students create flash cards of them.
  • Learning Outcome: 14.4 List the points that are reviewed on an RA/EOB. Page: 534 Teaching Notes:   Ask your class to describe the procedure that is followed to double-check the remittance data on an RA/EOB. (Refer to the numbered list on page 534.)
  • Learning Outcome: 14.5 Explain the process for posting payments and managing denials. Pages: 534-536 Teaching Notes:   Have your students list the types of data entry that are included when payment and adjustment transactions are entered in the PMP. (Date of deposit; payer name and type; check or EFT number; total payment amount; amount to be applied to each patient’s account, including type of payment.)
  • Learning Outcome: 14.5 Explain the process for posting payments and managing denials. Pages: 534-536 Teaching Notes:   Create examples of the process of claim reconciliation to review with your class. (See the example on page 535 for a reference.)
  • Learning Outcome: 14.6 Describe the purpose and general steps of the appeal process. Pages: 536-540 Teaching Notes:   Ask your students to explain some ways that events that follow the review and processing of an RA/EOB can alter the amount of the payment.
  • Learning Outcome: 14.6 Describe the purpose and general steps of the appeal process. Pages: 536-540 Teaching Notes:   Review the contents of the Medicare Redetermination Notice in Figure 14.6 with your students.
  • Learning Outcome: 14.7 Discuss how appeals, postpayment audits, and overpayments may affect claim payments. Pages: 540-541 Teaching Notes:   Ask students to describe what they think would be a good method for making a refund payment to a patient.
  • Learning Outcome: 14.8 Describe the procedures for filing secondary claims. Pages: 541-543 Teaching Notes:   Review the two models in Figure 14.7 (a) and (b) to highlight the chain of events for your class.
  • Learning Outcome: 14.9 Discuss procedures for complying with the Medicare Secondary Payer (MSP) program. Pages: 543-551 Teaching Notes:   Ask your students why they think medical insurance specialists are responsible for identifying the situations where Medicare is the secondary payer and for preparing appropriate primary and secondary claims.
  • Learning Outcome: 14.9 Discuss procedures for complying with the Medicare Secondary Payer (MSP) program. Pages: 543-551 Teaching Notes:   Review the details for completing the Medicare Secondary Payer (MSP) CMS-1500 (08/05) claim with your class. (See Table 14.4 for these details.)
  • Survey of Medical Insurance pp ch14

    1. 1. 14 Payments (RAs/EOBs), Appeals, and Secondary Claims
    2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>14.1 Describe the steps payers follow to adjudicate claims. </li></ul><ul><li>14.2 Describe the procedures for following up on claims after they are sent to payers. </li></ul><ul><li>14.3 Identify the types of codes and other information contained on an RA/EOB. </li></ul><ul><li>14.4 List the points that are reviewed on an RA/EOB. </li></ul><ul><li>14.5 Explain the process for posting payments and managing denials. </li></ul><ul><li>14.6 Describe the purpose and general steps of the appeal process. </li></ul>14-2
    3. 3. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>14.7 Discuss how appeals, postpayment audits, and overpayments may affect claim payments. </li></ul><ul><li>14.8 Describe the procedures for filing secondary claims. </li></ul><ul><li>14.9 Discuss procedures for complying with the Medicare Secondary Payer (MSP) program. </li></ul>14-3
    4. 4. Key Terms <ul><li>aging </li></ul><ul><li>appeal </li></ul><ul><li>appellant </li></ul><ul><li>autoposting </li></ul><ul><li>claim adjustment group code (CAGC) </li></ul><ul><li>claim adjustment reason code (CARC) </li></ul><ul><li>claimant </li></ul><ul><li>claim status category codes </li></ul><ul><li>claim status codes </li></ul>14-4 <ul><li>claim turnaround time </li></ul><ul><li>concurrent care </li></ul><ul><li>determination </li></ul><ul><li>development </li></ul><ul><li>electronic funds transfer (EFT) </li></ul><ul><li>explanation of benefits (EOB) </li></ul><ul><li>grievance </li></ul><ul><li>HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835) </li></ul>
    5. 5. Key Terms (Continued) <ul><li>HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277) </li></ul><ul><li>insurance aging report </li></ul><ul><li>medical necessity denial </li></ul><ul><li>Medicare Outpatient Adjudication (MOA) remark codes </li></ul><ul><li>Medicare Redetermination Notice (MRN) </li></ul>14-5 <ul><li>Medicare Secondary Payer (MSP) </li></ul><ul><li>overpayments </li></ul><ul><li>pending </li></ul><ul><li>prompt-pay laws </li></ul><ul><li>RA/EOB </li></ul><ul><li>reconciliation </li></ul><ul><li>redetermination </li></ul><ul><li>remittance advice (RA) </li></ul><ul><li>remittance advice remark code (RARC) </li></ul><ul><li>suspended </li></ul>
    6. 6. 14.1 Claim Adjudication <ul><li>Payers follow five steps in order to adjudicate claims: </li></ul><ul><ul><li>Initial processing – payers first perform initial processing checks on claims, rejecting those with missing or clearly incorrect information </li></ul></ul><ul><ul><li>Automated review – claims are processed through the payer’s automated medical edits </li></ul></ul><ul><ul><li>Manual review – a manual review is done if required </li></ul></ul><ul><ul><li>Determination – the payer makes a determination of whether to pay, deny, or reduce the claim </li></ul></ul><ul><ul><li>Payment – payment is sent with a remittance advice/explanation of benefits (RA/EOB) </li></ul></ul>14-6
    7. 7. 14.1 Claim Adjudication (Continued) <ul><li>Concurrent care— situation in which a patient receives independent care from two or more physicians on the same date </li></ul><ul><li>Suspended— claim status when the payer is developing the claim </li></ul><ul><li>Development— process of gathering information to adjudicate a claim </li></ul><ul><li>Determination— payer’s decision about the benefits due for a claim </li></ul>14-7
    8. 8. 14.1 Claim Adjudication (Continued) <ul><li>Medical necessity denial— refusal by a plan to pay for a procedure that does not meet its medical necessity criteria </li></ul><ul><li>Remittance advice (RA)— document describing a payment resulting from a claim adjudication </li></ul><ul><li>Explanation of benefits (EOB)— document showing how the amount of a benefit was determined </li></ul>14-8
    9. 9. 14.1 Claim Adjudication (Continued) <ul><li>RA/EOB— document detailing the results of claim adjudication and payment </li></ul><ul><li>HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835)— electronic transaction for payment explanation </li></ul>14-9
    10. 10. 14.2 Monitoring Claim Status <ul><li>Medical insurance specialists monitor claims by reviewing the insurance aging report and following up at properly timed intervals based on the payer’s promised turnaround time </li></ul><ul><ul><li>Insurance aging report— report grouping unpaid claims transmitted to payers by the length of time they remain due </li></ul></ul><ul><ul><li>Prompt-pay laws— states’ laws obligating carriers to pay clean claims within a certain time period </li></ul></ul>14-10
    11. 11. 14.2 Monitoring Claim Status (Continued) <ul><li>Monitoring claims (continued): </li></ul><ul><ul><li>Aging— classification of accounts receivable by length of time </li></ul></ul><ul><ul><li>Claim turnaround time— time period in which a health plan must process a claim </li></ul></ul>14-11
    12. 12. 14.2 Monitoring Claim Status (Continued) <ul><li>The HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (276/277) is used to track the claim progress through the adjudication process </li></ul><ul><ul><li>HIPAA X12 276/277 Health Care Claim Status Inquiry/Response— standard electronic transaction to obtain information on the status of a claim </li></ul></ul><ul><ul><li>The inquiry is the HIPAA 276 </li></ul></ul><ul><ul><li>The payer’s response is the HIPAA 277 </li></ul></ul>14-12
    13. 13. 14.2 Monitoring Claim Status (Continued) <ul><li>The HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (276/277) (continued) </li></ul><ul><ul><li>Claim status category codes— used on a HIPAA 277 to report the status group for a claim </li></ul></ul><ul><ul><li>Pending— claim status when the payer is waiting for information </li></ul></ul><ul><ul><li>Claim status codes— Used on a HIPAA 277 to provide a detailed answer to a claim status inquiry </li></ul></ul>14-13
    14. 14. 14.3 The Remittance Advice/Explanation of Benefits (RA/EOB) <ul><li>Electronic and paper RAs/EOBs contain the same essential data: </li></ul><ul><ul><li>A heading with payer and provider information </li></ul></ul><ul><ul><li>Payment information for each claim, including adjustment codes </li></ul></ul><ul><ul><li>Total amounts paid for all claims </li></ul></ul><ul><ul><li>A glossary that defines the adjustment codes that appear on the document </li></ul></ul>14-14
    15. 15. 14.3 The Remittance Advice/Explanation of Benefits (RA/EOB) (Continued) <ul><li>To explain the determination to the provider, payers use a combination of codes: </li></ul><ul><ul><li>Claim adjustment group codes (CAGC)— used on an RA/EOB to indicate the general type of reason code for an adjustment </li></ul></ul><ul><ul><li>Claim adjustment reason codes (CARC)— used on an RA/EOB to explain why a payment does not match the amount billed </li></ul></ul><ul><ul><li>Remittance advice remark codes (RARC)— explain payers’ payment decisions </li></ul></ul><ul><ul><li>Medicare Outpatient Adjudication remark codes (MOA)— explain Medicare payment decisions </li></ul></ul>14-15
    16. 16. 14.4 Reviewing RAs/EOBs <ul><li>The unique claim control number reported on the RA/EOB is first used to match up claims sent and payments received, and then: </li></ul><ul><ul><li>Basic data are checked against the claim </li></ul></ul><ul><ul><li>Billed procedures are verified </li></ul></ul><ul><ul><li>The payment for each CPT is checked against the expected amount </li></ul></ul><ul><ul><li>Adjustment codes are reviewed to locate all unpaid, downcoded, or denied claims </li></ul></ul><ul><ul><li>Items are identified for follow-up </li></ul></ul>14-16
    17. 17. 14.5 Procedures for Posting <ul><li>The process for posting payments and managing denials: </li></ul><ul><ul><li>Payments are deposited in the practice’s bank account, posted in the practice management program, and applied to patients’ accounts </li></ul></ul><ul><ul><li>Rejected claims must be corrected and re-sent </li></ul></ul><ul><ul><li>Missed procedures are billed again </li></ul></ul><ul><ul><li>Partially paid, denied, or downcoded claims are analyzed and appealed, billed to the patient, or written off </li></ul></ul>14-17
    18. 18. 14.5 Procedures for Posting (Continued) <ul><li>Electronic funds transfer (EFT)— electronic routing of funds between banks </li></ul><ul><li>Autoposting— software feature enabling automatic entry of payments on a remittance advice </li></ul><ul><li>Reconciliation— process of verifying that the totals on the RA/EOB check out mathematically </li></ul>14-18
    19. 19. 14.6 Appeals <ul><li>An appeal process is used to challenge a payer’s decision to deny, reduce, or otherwise downcode a claim </li></ul><ul><ul><li>Appeal— request for reconsideration of a claim adjudication </li></ul></ul><ul><ul><li>Claimant— person/entity exercising the right to receive benefits </li></ul></ul><ul><ul><li>Appellant— one who appeals a claim decision </li></ul></ul><ul><ul><li>Each payer has a graduated level of appeals, deadlines for requesting them, and medical review programs to answer them </li></ul></ul>14-19
    20. 20. 14.6 Appeals (Continued) <ul><li>Medicare participating providers have appeal rights, that involve five steps: </li></ul><ul><ul><li>Redetermination— first level of Medicare appeal processing </li></ul></ul><ul><ul><li>Medicare Redetermination Notice (MRN)— resolution of a first appeal for Medicare fee-for-service claims </li></ul></ul><ul><ul><li>2. Reconsideration </li></ul></ul><ul><ul><li>3. Administrative law judge </li></ul></ul><ul><ul><li>4. Medicare appeals council </li></ul></ul><ul><ul><li>5. Federal court (judicial review) </li></ul></ul>14-20
    21. 21. 14.7 Postpayment Audits, Refunds, and Grievances <ul><li>Filing an appeal may result in payment of a denied or reduced claim </li></ul><ul><ul><li>Postpayment audits are usually used to gather information about treatment outcomes, but they may also be used to find overpayments, which must be refunded to payers </li></ul></ul><ul><ul><li>Overpayments— improper or excessive payments resulting from billing errors </li></ul></ul><ul><ul><li>Refunds to patients may also be requested </li></ul></ul><ul><li>Grievance— complaint against a payer filed with the state insurance commission by a practice </li></ul>14-21
    22. 22. 14.8 Billing Secondary Payers <ul><li>Claims are sent to patient’s additional insurance plans after the primary payer has adjudicated claims </li></ul><ul><li>Sometimes, the medical office prepares and sends the claims </li></ul><ul><ul><li>In other cases, the primary payer has a coordination of benefits (COB) program that automatically sends the necessary data to secondary payers </li></ul></ul><ul><li>If a paper RA/EOB is received, the CMS-1500 is used to bill the secondary health plan </li></ul>14-22
    23. 23. 14.9 The Medicare Secondary Payer (MSP) Program, Claims, and Payments <ul><li>Medicare Secondary Payer (MSP)— federal law requiring private payers to be the primary payers for Medicare beneficiaries’ claims </li></ul><ul><li>The medical insurance specialist is responsible for identifying the situations in which Medicare is the secondary payer and for preparing appropriate primary and secondary claims </li></ul>14-23
    24. 24. 14.9 The Medicare Secondary Payer (MSP) Program, Claims, and Payments (Cont.) <ul><li>Under the MSP program, Medicare is the secondary payer in any of these instances: </li></ul><ul><ul><li>Patient is covered by an employer group health insurance plan or is covered through an employed spouse’s plan </li></ul></ul><ul><ul><li>Patient is disabled, under age sixty-five, and covered by an employee group health plan </li></ul></ul><ul><ul><li>Services are covered by workers’ compensation insurance </li></ul></ul><ul><ul><li>Services are for injuries in an automobile accident </li></ul></ul><ul><ul><li>Patient is a veteran who chooses to receive services through the Department of Veterans Affairs </li></ul></ul>14-24

    ×