• Save
Survey of Medical Insurance pp ch14
Upcoming SlideShare
Loading in...5
×
 

Survey of Medical Insurance pp ch14

on

  • 1,760 views

 

Statistics

Views

Total Views
1,760
Views on SlideShare
1,059
Embed Views
701

Actions

Likes
1
Downloads
0
Comments
0

1 Embed 701

http://moodle.richmondcc.edu 701

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • 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 Survey of Medical Insurance pp ch14 Presentation Transcript

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