Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 0
Chapter 9
Receiving Payments
and Insurance
Problem Solving
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 1
Learning Objectives
 Identify three health insurance
payment policy provisions.
 Interpret and post a patient’s
explanation of benefits document.
 Name three claim management
techniques.
 Identify purposes of an insurance
company history reference file.
 Indicate time limits for receiving
payment for manually versus
electronically submitted claims.
 Explain reasons for claim inquiries.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 2
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.
 List four objectives of state insurance
commissioners.
 Mention seven problems to submit to
insurance commissioners.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 3
Learning Objectives
(cont’d.)
 Describe situations for filing appeals.
 Name three levels of review under the
TRICARE appeal process.
 State the levels of review and
redetermination in the Medicare
program.
 Determine which forms to use for the
Medicare review and redetermination
process.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 4
Chapter 9
Lesson 9.1
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 5
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 6
Explanation of Benefits
 States the status of a claim
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Paid
Adjusted
Suspended/Pending
Rejected
Denied
 States the allowed and disallowed
amounts
 Provided with payment check (if
applicable)
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 7
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 8
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 9
Interpretin
g an
Explanatio
n of
Benefits
(EOB)
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 10
Claim Management
Techniques
 Insurance claims register
 Tickler file
 Aging reports
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 11
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 12
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 13
Problem Claims
 Delinquent
 Payment is overdue
 Suspense (pending)
 Nonpayment caused by an error or
the need for additional information,
etc.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 14
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 15
Problem Claims (cont’d.)
 Denied claims
 Other
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Downcoding
Partial payment
Lost payment
Payment to the patient
Underpayment
Overpayment
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 16
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.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 17
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.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 18
Chapter 9
Lesson 9.2
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 19
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 20
Appeal Situations
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Payment is denied
Payment is incorrect
Physician disagrees with insurer
Unusual medical circumstances
Precertification not provided
Inadequate payment/complicated
procedure
 Deemed “not medically necessary”
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 21
Filing an Official Appeal
 Send explanatory letter
 Excerpt coding resource book
 Peer review
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 22
Filing an Official Appeal
(cont’d.)
 Include similar cases
 Call the insurer
 Keep copies
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 23
Medicare Review and
Redetermination
 Telephone review
 Redetermination
 Reconsideration
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 24
Medicare Review and
Redetermination (cont’d.)
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Administrative law judge hearing
Judicial Review
CMS regional offices
Medigap
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 25
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 26
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 27
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 28
Problems Submitted
to Commissioner
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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?)
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 29
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
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 30