Transcript BLUE CROSS/BLUE SHIELD

Chapter 7
REIMBURSEMENT
FOLLOW-UP AND
COLLECTIONS
Reimbursement Follow-up
and Collections
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Learning Objectives
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Describe the claim determination process used by
health plans.
Follow five steps to process reimbursement advices
(RAs) from health plans.
Discuss common reasons for and appeals of reduced
or denied payments.
Describe the patient billing and collections process.
Handle patients’ inquiries about insurance and
billing problems.
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Key Terms
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Accounts receivable
Adjustments
Appeal
Determination
Downcoding
Electronic funds
transfer (EFT)
Insurance aging report
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Patient aging report
Patient ledger
Patient statement
Preexisting condition
Uncollectible account
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Health Plan Claim Processing
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Medical Insurance Specialist
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Prepare & Transmit clean claims that will be
paid in full and on time
Claims that payer pay late, decide not to pay, or
pay at a reduced level have a negative effect on
“account receivable”, (the practice’s cash flow)
The Medical Insurance Specialist must
understand the process that payer follow to
examine claims and determine payments
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Claim
Processing
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Payer receives complete claim
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Claims department determines:
1. Whether benefits are due as per patient’s policy
2. Whether services provided were medically necessary
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Occasionally, additional clinical
information is requested
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Payment
Determination
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Payer decides to
1. Pay the claim
2. Deny the claim
3. Reduce the payment for the claim
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Reduced Payments
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Carriers will reduce payment when:
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The procedure does not link correctly to the
diagnosis
Documentation fails to support the level of
service claimed
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Denied Payments
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Carriers will deny payment when:
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The claim is not for a covered benefit
Patient’s preexisting condition is not covered
Patient’s coverage has been cancelled
In these instances, patient is billed
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Overdue Claims
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Claims must be monitored until payments are
received.
Follow-up period for most offices is 7-14 days after claims
are transmitted.
 To avoid late payment the medical Insurance Specialist
regularly review the insurance the “Aging Report”.
Aging Report – A report that shows the time span
between issuing an invoice and receiving payment;
used in medical office to determine late payments and
collect them.
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Overdue Claims
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Insurance aging report
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HIPAA Transaction
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Shows the ages of unpaid claims
Claim status inquiry is used to follow up with
payers electronically
Most offices follow up 7-14 days after
claim is transmitted
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Processing the
Remittance Advice (RA)
RA is usually received electronically.
 Sent by the payer to the medical office
summarizes the determinations for a number of
claims.
 RA lists the following:
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Claim control number
Patient’s name
Dates of Service
Charges
How payment amount is determined
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Five Steps for
Processing RAs
Step 1
Step 2
Step 3
Step 4
Step 5
Match claim control number, patient’s name,
date of service with payer’s payments
Check patient data, plan, procedures against
claim
Compare each payment with expected amount
Read carrier’s explanations for unpaid, reduced,
or denied claims; decide if resubmission or
appeal is warranted
Determine any write-offs (adjustments) and note
balance due from patient
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Appeals
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Written request asking carrier to review
reimbursement on a claim
Usually filed when:
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Physician did not file for preauthorization in a timely
manner
Physician thinks payment received is inadequate
Physician disagrees with the carrier’s preexisting
condition decision
Patient has unusual circumstances affecting treatment
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Other Options
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If appeal is denied
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Physician may request peer review
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Objective, unbiased group of physicians
determines what payment is adequate for
services provided.
State Insurance Commissioners
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Regulatory agency; serves as liaison
Physician, patient or carrier may appeal
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Patient Billing
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Patient usually pays at time of
service if physician has not accepted
assignment
Medical billing program used to create
walkout receipt for patient
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Summarizes patient’s services, charges,
payments for that visit
Patient pays copayment only if
physician has accepted assignment
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Patient Billing
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Patient Statements
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(cont’d)
Usually created and mailed monthly
Medical billing software used to create bills
Billing Statements Show:
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Dates of service and services provided
Payments from patient and insurance carrier
Balance due
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Collections
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The collection process begins with effective
communication with patients about their
responsibility to pay for services
Patient aging report shows which patients have
overdue balances
 A reminder is usually sent at 30 days
 More stringent collection letters sent subsequently
 Small claims court or collection agencies
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Uncollectible Accounts
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No payment has been made after the
collection process has been exhausted
It would be more costly to continue the
collection process
Amount owed is written off
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Complaints and Problems
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Medical insurance specialist acts as gobetween with patients and health plans
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To help answer patient inquiries, ask if patient
has:
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Contacted the health plan
Spoken with the service representative
Reviewed the policy
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Complaints and Problems
(cont’d)
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If the patient has already contacted the health
plan:
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Medical insurance specialist may contact the health
plan again to get a detailed explanation
Volunteer to explain to patient
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Speak slowly and calmly; use simple language
Explain more than once, if necessary
Ask questions to be sure patient understands explanation
Use respect and care
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Quiz
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Collections are done on current bills. (T/F)
False, collections are begun after the bill is more
than 30 days overdue.
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An appeal is a formal method of asking for
reconsideration of a denied claim. (T/F)
True, the appeal is done in writing.
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RAs are usually received on paper. (T/F)
False, RAs are usually received electronically.
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Critical Thinking
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What is the importance of prompt
collection?
Collection directly affects cash flow. Slow
payments by health plans or patients may cause
delays in the practice’s ability to meet the
financial responsibilities of running a business.
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