Solved by a verified expert:The purpose of the Claims s ection of this course is to cl ose the gap of information aboutwha t happens after a cl aim is s ubmitted. In this s ection, you will l earn a bout the 3 possibleoutcomes a fter cl aim s ubmission, a s well a s some follow-up methods. It will provide yougeneral knowledge but i t is i mportant for you to remember that most topics covered in thiscours e a re payer specific. Pa yer s pecific means that the policies a nd procedures that will have to be followed will beva ri ed depending on which third party payer you a re submitting to. These processes won’trea lly be refined until you a re on the job. The physician’s office that you work for will mostl i kely have their own policies and procedures in place, however know that every a nswer isa s i mple phone call away. Don’t hesitate to pick up the phone and call the payer to getcl a ri fication about a nything you may be unsure of. You s hould begin your s tudies in this section of the course by giving yourself a refresher onthe two pri mary types of claims that you will be submitting. Refer to your InsuranceHa ndbook for the Medical Office textbook a nd reference chapter 7 – The cl aims process.Then utilize the Chapter 10 – Cl a i m Forms chapter i n your understanding Hospital Billingtext book. The CMS-1500 i s the cl aim that is used i n the outpatient office setting. You will report a lls ervi ces and diagnostics done in the physician’s office on this claim as well as theprofessional s ervices performed in the hospital s etting. The UB-04 i s the cl aim form that hospitals use to submit their charges to third party payers.Thes e contain all charges regardless of the patient’s status, (inpatient or outpatient). There a re two ways to submit a claim, electronically or by ma iling or faxing in a papercl a im.• A paper claim i s one that is submitted on paper i ncluding optically s canned claims thata re converted to electronic form by i nsurance companies. Pa per cl aims may be typed orgenerated vi a computer.• An electronic claim i s one that is s ubmitted to the i nsurance ca rrier via dial-up modem(tel ephone l ine or computer modem), direct data entry, or over the Internet by way ofdi gital subscriber line (DSL) or file tra nsfer protocol (FTP). El ectronic cl aims are digital filestha t a re not printed on paper cl aim forms when submitted to the payer. Once a cl aim is submitted to the third party payer there a re three possible outcomes. Thecl a im will be paid, the cl aim will be pended, or the claim will be denied. You will s ome formof a remi ttance a dvice from the third party payer explaining which outcome was rendered.Ea ch remit will be payer s pecific, meaning a remit from Insurance company “A” ma y l ookdi fferent from a remit from Insurance Company “B.” Al l of the i nformation that is containedi n a remit will be pretty s imilar but you will have to learn to read each payer’s differencesonce you get on the job. Let’s break down a s ample of a remittance a dvice. The next few slides will define thedi fferent pieces of i nformation that a re contained. You will see portions of the above remitbl own up for ease of reading a long with descriptors of what you are s eeing.8 Thi s is zoomed in to highlight the top portion of the RA (remittance a dvice.) The middlea reas s hows which s pecific payer this remit if from. Notice that it is dated on the top. Thel eft s hows the practice/hospital that the payer is s ending payment to. And the ri ght hands i de lists the payee ID number, the NPI i d number, the EFT number, a nd the i ssue date. Thepa yee ID is a unique number assigned to the practice that submitted the claim forms. TheNPI i s the National Provi der Identification number that is a unique number assigned to thephys ician. No two physicians will s hare an NPI number. EFT s tands for El ectronic FundsTra ns fer, this number will change on every remit.9 Thi s is the Mi d-Left s ection that we zoomed in on. The ICN is the Item Control Number. Thes ervi ce dates will s how the date the patient was admitted and discharged or the dates ofs ervi ce that this payment is for. Below is the patient name and the identification number.Thi s RA is reading that this patient was admitted on Ja n 20, 2009 a nd discharged January24, 2009.10 Thi s is the upper ri ght hand side that i s zoomed i n on. This is the financial portion of thisRA. It s hows the Deductible a mount, the co-insurance amount, the billed a mount, the TPLor Thi rd Pa rty Li ability Amount, and the Paid Amount.Jus t a s a refresher…• The deductible is an annual a mount that must be paid to the provider beforerei mbursement from the payer will take effect. It is a one ti me a nnual fee.• The Co-Insurance is a percentage based fee that is a lso patient responsibility. The mostcommon example of this is the 80% that the payer reimburses and the 20% that thepa ti ent is responsible for.• Thi rd Pa rty Liability is generally noted when there is a n injury i nvolved (based ondi a gnosis codes 800-999). Any ti me a patient gets i njured there i s a ri sk that there will bes ome sort of legal involvement. Third party payers will need to know if the case is beingpurs ued from a l egal standpoint before they wi ll a gree to pay the cl aim.11 Thi s is the charge a rea of the RA enlarged. It l ists the REV codes, HCPCS, Service Dates,Modi fiers, Units Billed, Billed Amount, and Allowed amount.Jus t a refresher…• The revenue codes or “rev” codes a re categories of services that are grouped together tocombi ne a like charges. You originally l earned this i n Chapter 10 of your UnderstandingHos pital Billing text book.• The HCPCS a re the CPT codes or Medicare National Codes that were s ubmitted on thecl a im form.• The Uni ts a re the amount of ti mes each listed HCPCS code was billed.• There is generally a big difference between the billed a mount a nd the a llowed a mount.The bi lled amount is the fee that the physician s ubmitted on his/her cl aim form. Thea l lowed a mount is the a mount the i nsurance has agreed to pay for. This will va rys i gnificantly based on the physician’s contract wi th the third party pa yer.12 Thi s section of the RA s hows samples of denial codes. Denial codes explain the reason thatea ch line item on the RA was paid, pended or denied. Take a moment to read the s ample infront of you. The next s lides will go over the most common reasons for denial. When a claim gets paid you will need to verify that the a ppropriate payment was madeba s ed on the contractual a greement between the physician a nd the i nsurance company.You wi ll also need to see i f the payer “dropped” any pa rt of the balance to patientres ponsibility. “Dropping” would mean that the i nsurance company has designated aporti on of the payment should be made directly from the patient to the physician.Exa mples would include Co-insurance, deductibles, a nd non-covered s ervices.14 When a remittance advice indicates that the cl aim is pending, that means that thei ns urance company mostly l ikely is depending on your follow-up to proceed withprocessing. This usually means that more documentation and or the entire medical recordi s needed for the medical review portion of processing to be completed. When thisha ppened you will make copies of the entire record, or portions requested and submitthem to the review department along with a copy of the claim form. When documentationi s requested, processing is usually delayed depending on the payer. When a claim i s denied it means that the i nsurance has s ent back $0.00 for pa yment. Adenial isn’t the end of the world, nor does it mean that the physician will never get paid forthe s ervices rendered. It just means that a s a biller or a medical collector you get to playdetective to find out why it was denied a nd what it will take to get paid.Let’s s tart by l ooking a t some of the more common denial reasons, and then we will discusspos sible ways to have the cl aim reprocessed. We a re now going to review the top 10 most popular reasons that a health insurance claimi s denied.(1) Incorrect patient’s information (insurance ID# , date of birth): If you a re s ubmittingel ectronic cl aims, AVOID entering patient’s i nsurance number wi th characters like a na s terisk (*) a nd dash (-) in between the alphanumeric numbers because thesecha ra cters ca n be recognize by electronic as unrecognizable. Just check on this issuewi th the clearinghouse or your s ervice provider. Always ma ke a copy of your patient’spri ma ry & s econdary i nsurance ca rd on file (copy front and back!). Ma ke s ure to get acopy of their new ca rd (if there is a change).(2) Patient’s non-coverage or terminated coverage at the time of service: Tha t i s why it is,very i mportant that you check on your patient’s benefits and eligibility before see thepa ti ent. When you don’t verify i n advance, you run the risk not receivi ng payment forthe s ervice rendered to the patient.(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)— be careful also withyour secondary code! Claims may be denied even if the problem was just because ofthe secondary CPT/ICD9 code: Di s cuss solvi ng the coding error rather than how muchyou wa nt to get reimbursed. Most of the i nsurance companies will help you with codes(i n fairness!!) and they a lso i nform you on outdated codes, or codes that requires a 5thdi git. Be nice with the claims department! Also, under no circumstances ca n youa uthorize a code change UNLESS you a re the coder. Stay confined within thepa ra meters of your job description even though you may be a ware of the necessarys ol ution. (4) Incorrect use of modifiers! (be ca reful with bilateral procedures!, modifiers forprofessional a nd technical component, modifiers for multiple procedures, postoperativeperi od, etc.).(5) No precertification or preauthorization obtained (if required): It i s s o hard to file a na ppeal when the claim or s ervice was non-pre-certified. Avoid i t from happening!(6) No referral on file (if required) Note: HMOs a lways requires a referral! (remembertha t!)18 (7) The patient has other primary insurance or the patient’s claim is for workman’s compor auto accident claim! It i s the responsibility of your front desk staff to get all thenecessary i nformation before the patient can be s een. Remember that i f this is aworkma n’s comp or an auto accident cl aim, you need a claim number a nd the adjustor’sna me. Services a re always preauthorized!(8) Claim requires documentation & notes to support medical necessity A wel ldocumented medical records is a good practice! (9) Claim requires referring physician’s info to include a NPI or national provideridentifier.(10) Untimely filing: Thi s means that the cl aim was received by the i nsurance companypa s t their a llotted time limit for s ubmission. Unfortunately most of the i nsurances does nota ccept your billing records on your office computer that s hows that date(s) you billed thei ns urance! If you are s ubmitting cl aims by electronic, make s ure you generate transmissionreports/receipts. Your reports must read "accepted" a nd not "rejected". File all thesetra ns mittal reports/ a nd receipts and a very s afe place! If you are s ending claims by paperor pos tal mail, i t is a good i dea to send your cl aims as certified mail with tra cking number,keep your receipts! Now tha t we know s ome reasons that claims get denied, what ca n we do a bout it? You willneed to research each individual third party payers requirements when it comes toa ppealing a decision made on a cl aim. However, i t is required that all appeals come in theform of a l etter with s upporting documentation. It is i mperative that this l etters a recomposed in the utmost professional manner. Spelling errors a nd grammatical errors willnot be received well a nd will reflect poorly on the physician who employs you. Pay s peciala ttention to details as all correspondence i s considered part of the medical record andtherefore a l egal document.
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