• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Issues and Trends in HBI Ch 13
 

Issues and Trends in HBI Ch 13

on

  • 398 views

 

Statistics

Views

Total Views
398
Views on SlideShare
228
Embed Views
170

Actions

Likes
0
Downloads
2
Comments
0

1 Embed 170

http://moodle.richmondcc.edu 170

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: <br />  Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material. <br />   <br />
  • Learning Outcome: 13.1 Explain the claim adjudication process. <br /> Teaching Notes: <br />   <br /> Examine and discuss with students how each of the five steps of the claim adjudication process ensures that the claim is processed accurately. <br /> Discuss possible errors and adjustments during the adjudication process. <br />
  • Learning Outcome: 13.1 Explain the claim adjudication process. <br /> Teaching Notes: <br />   <br /> Ask students to define and provide an example of each term on this slide (concurrent care, suspended, development, and determination). <br /> Identify and discuss with students strategies to ensure accuracy during the development process of adjudication. <br />
  • Learning Outcome: 13.1 Explain the claim adjudication process. <br /> Teaching Notes: <br />   <br /> Provide some examples that could result in a medical necessity denial and discuss with students the reason for the denial. <br /> Identify and discuss with students the differences between the RA and EOB. <br />
  • Learning Outcome: 13.1 Explain the claim adjudication process. <br /> Teaching Notes: <br /> Identify and discuss with students how the RA and EOB assist in the medical claims reimbursement process. <br /> Examine and discuss with students the advantages of using the HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835). <br />
  • Learning Outcome: 13.2 Describe the procedures for following up on claims after they are sent to payers. <br /> Teaching Notes: <br />   <br /> Identify and discuss the components of the insurance aging report in Figure 13.1. <br /> Examine and discuss with students the advantages of prompt-pay laws as they relate to both the patient and the provider. <br />
  • Learning Outcome: 13.2 Describe the procedures for following up on claims after they are sent to payers. <br /> Teaching Notes: <br />   <br /> Examine and discuss with students the relationship between aging and claim turnaround time. <br />
  • Learning Outcome: 13.2 Describe the procedures for following up on claims after they are sent to payers. <br /> Teaching Notes: <br />   <br /> Ask students to explain the differences between 276 and 277. <br />
  • Learning Outcome: 13.2 Describe the procedures for following up on claims after they are sent to payers. <br /> Teaching Notes: <br />   <br /> Identify and discuss with students the main types of claim status category codes that payers use on the HIPAA 277 transaction (A codes, P codes, F codes, R codes, and E codes). <br />
  • Learning Outcome: 13.3 Interpret a remittance advice (RA). <br /> Teaching Notes: <br />   <br /> Identify and discuss with students the contents of Figure 13.3. <br /> Ask students to explain the differences between electronic and paper RA formats. <br />
  • Learning Outcome: 13.3 Interpret a remittance advice (RA). <br /> Teaching Notes: <br />   <br /> Identify and discuss with students how the codes CAGC, CARC, and RARC help the provider understand the claim’s reimbursement. <br /> Ask students to explain how the MOA remark codes help with Medicare claims. <br />
  • Learning Outcome: 13.4 Identify the points that are reviewed on an RA. <br /> Teaching Notes: <br />   <br /> Ask your class to describe the advantages of double-checking the remittance data on an RA/EOB. <br /> Identify and discuss with students how the adjustment codes help identify how claims are paid. <br />
  • Learning Outcome: 13.5 Explain the process for posting payments and managing denials. <br /> Teaching Notes: <br />   <br /> Identify and discuss with students 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; and amount to be applied to each patient’s account, including type of payment). <br /> Provide an example of a partially paid claim and discuss with students why some claims get partially denied and what can be done to ensure full payment. <br />
  • Learning Outcome: 13.5 Explain the process for posting payments and managing denials. <br /> Teaching Notes: <br />   <br /> Ask students to explain why EFT and RA reconciliation is more efficient than paper transfer between banks. <br /> Identify and discuss with students the advantages of using autoposting and provide examples of strategies to ensure accuracy. <br />
  • Learning Outcome: 13.6 Describe the purpose and general steps of the appeal process. <br /> Teaching Notes: <br />   <br /> Ask students to describe the advantages of the general appeal and review process to both patients and providers. <br /> Identify and discuss with students the differences between the claimant and the appellant (provide an example of each). <br />
  • Learning Outcome: 13.6 Describe the purpose and general steps of the appeal process. <br /> Teaching Notes: <br />   <br /> Identify and discuss with students each step of the general appeal and review process. <br /> Ask students to identify and describe the differences between an administrative law judge, Medicare appeals council, and federal court (judicial review). <br />
  • Learning Outcome: 13.7 Assess how appeals, postpayment audits, and overpayments may affect claim payments. <br /> Teaching Notes: <br />   <br /> Ask students to describe how postpayment audits can find overpayments to the patient and provider. <br /> Identify and discuss the advantages of a grievance process to both the patient and provider. <br />
  • Learning Outcome: 13.8 Describe the procedures for filing secondary claims. <br /> Teaching Notes: <br />   <br /> Refer to Figure 13.7. Ask students to describe how secondary insurance protect patients and providers. <br /> Identify and discuss the steps involved in processing secondary insurance claims. Why is the RA required to receive payment from the secondary payer? <br />
  • Learning Outcome: 13.9 Discuss procedures for complying with the Medicare Secondary Payer (MSP) program. <br /> Teaching Notes: <br />   <br /> Identify and discuss with students the steps that medical insurance specialists are responsible for in identifying the situations where Medicare is the secondary payer and for preparing appropriate primary and secondary claims. <br /> Ask students to explain how the MSP federal law regulates primary and secondary insurance carriers. <br />
  • Learning Outcome: 13.9 Discuss procedures for complying with the Medicare Secondary Payer (MSP) program. <br /> Teaching Notes: <br />   <br /> Ask students to explain how the MSP program is coordinated with Workers’ Compensation. <br />

Issues and Trends in HBI Ch 13 Issues and Trends in HBI Ch 13 Presentation Transcript

  • CHAPTER 13 Payments (RAs), Appeals, and Secondary Claims © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
  • Learning Outcomes 13-2 When you finish this chapter, you will be able to: 13.1 13.2 Explain the claim adjudication process. Describe the procedures for following up on claims after they are sent to payers. 13.3 Interpret a remittance advice (RA). 13.4 Identify the points that are reviewed on an RA. 13.5 Explain the process for posting payments and managing denials. 13.6 Describe the purpose and general steps of the appeal process.
  • Learning Outcomes (continued) 13-3 When you finish this chapter, you will be able to: 13.7 Assess how appeals, postpayment audits, and overpayments may affect claim payments. 13.8 Describe the procedures for filing secondary claims. 13.9 Discuss procedures for complying with the Medicare Secondary Payer (MSP) program.
  • 13-4 Key Terms • • • • • • • • • aging appeal appellant autoposting claim adjustment group code claim adjustment reason code (CARC) claimant claim status category codes claim status codes • • • • • 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)
  • 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) 13-5 • Medicare Secondary Payer (MSP) • overpayments • pending • prompt-pay laws • RA/EOB • reconciliation • redetermination • remittance advice (RA) • remittance advice remark code (RARC) • suspended
  • 13.1 Claim Adjudication 13-6 • Payers follow five steps in order to adjudicate claims: 1. Initial processing – payers first perform initial processing checks on claims, rejecting those with missing or clearly incorrect information 2. Automated review – claims are processed through the payer’s automated medical edits 3. Manual review – a manual review is done if required 4. Determination – the payer makes a determination of whether to pay, deny, or reduce the claim 5. Payment – payment is sent with a remittance advice/explanation of benefits (RA/EOB)
  • 13.1 Claim Adjudication (continued) 13-7 • 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
  • 13.1 Claim Adjudication (continued) 13-8 • 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
  • 13.1 Claim Adjudication (continued) • RA/EOB—document detailing results of claim adjudication and payment • HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835)—electronic transaction for payment explanation 13-9
  • 13.2 Monitoring Claim Status 13-10 • 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
  • 13.2 Monitoring Claim Status (continued) 13-11 • 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
  • 13.2 Monitoring Claim Status (continued) 13-12 • 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
  • 13.2 Monitoring Claim Status (continued) 13-13 • 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
  • 13.3 The Remittance Advice (RA) • Electronic and paper RA 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 13-14
  • 13.3 The Remittance Advice (RA) (continued) 13-15 • 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 (MOA) remark codes—explain Medicare payment decisions
  • 13.4 Reviewing RAs 13-16 • 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
  • 13.5 Procedures for Posting 13-17 • 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
  • 13.5 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 check out mathematically 13-18
  • 13.6 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 13-19
  • 13.6 Appeals (continued) • Medicare participating providers have appeal rights that involve five steps: 1. Redetermination—first level of Medicare appeal processing Medicare Redetermination Notice (MRN)— resolution of a first appeal for Medicare fee-forservice claims 2. Reconsideration 3. Administrative law judge 4. Medicare appeals council 5. Federal court (judicial review) 13-20
  • 13.7 Postpayment Audits, Refunds, and Grievances 13-21 • 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
  • 13.8 Billing Secondary Payers 13-22 • 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 is received, CMS-1500 is used to bill the secondary health plan
  • 13.9 The Medicare Secondary Payer (MSP) Program, Claims, and Payments 13-23 • Medicare Secondary Payer (MSP)—federal law requiring private payers to be primary payers for Medicare beneficiaries’ claims • The medical insurance specialist is responsible for identifying situations in which Medicare is the secondary payer and for preparing appropriate primary and secondary claims
  • 13.9 The Medicare Secondary Payer 13-24 (MSP) Program, Claims, and Payments (continued) • 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 covered through an employed spouse’s plan – Patient is disabled, under age 65, and covered by an employee group health plan – Services are covered by workers’ compensation insurance – Services are for injuries of an automobile accident – Patient is a veteran choosing to receive services through the Department of Veterans Affairs
  • Summary
  • Summary
  • Summary
  • Summary