Transcript CHAPTER Posting Insurance Payments and Creating Patient Statements © 2011 The McGraw-Hill Companies, Inc. All rights reserved.

CHAPTER
8
Posting Insurance
Payments and
Creating Patient
Statements
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8-2
Learning Outcomes
When you finish this chapter, you will be able to:
8.1
8.2
8.3
8.4
8.5
8.6
Describe how an adjustment is calculated if the
payer pays less than the provider’s usual fee.
List the five steps for processing a remittance
advice.
Demonstrate how to enter insurance payments.
Demonstrate how to apply insurance payments to
charges.
Demonstrate how to enter capitation payments.
Demonstrate how to create patient statements.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8-3
Learning Outcomes (Continued)
When you finish this chapter, you will be able to:
8.7
8.8
Explain how statements are edited.
Demonstrate how to print patient statements.
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Key Terms
8-4
• capitation payments
• cycle billing
• electronic remittance
advice (ERA)
• fee schedule
• once-a-month billing
• patient statement
• payment schedule
• remainder statements
• standard statements
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8.1 Third-Party Reimbursement Overview
8-5
• A fee schedule is a document that specifies the
amount the provider bills for provided services
– List of the provider’s standard fees
– Not necessarily the amount a provider is paid
– Difference between amount in fee schedule and
amount paid is an adjustment
• A payment schedule is a document that
specifies the amount the payer agrees to pay the
provider for a service, based on a contracted
rate of reimbursement
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8.2 Remittance Advice (RA) Processing
8-6
• An electronic remittance advice (ERA) is an
electronic document that lists patients, dates of
service, charges, and the amount paid or denied
by the insurance carrier
• ERA – uses the ASC X12 835 Remittance
Advice Transaction (or 835)
• RA – Paper format
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8.2 Remittance Advice (RA) Processing
(Continued)
8-7
• Steps for processing
1. Verify all procedures listed on the claim are
represented on the RA
2. Review payment amount against expected amount
3. Identify reasons for denials or payment reductions;
resubmit claim or appeal if necessary
4. Post payment information in the PMP
5. Bill patient’s secondary health care plan (if
appropriate)
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8.3 Entering Insurance Payments
8-8
• Payment information is entered in Medisoft
through the Enter Deposits/Payments option on
the Activities menu
• Deposits are created within the Deposit List
dialog box
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8.3 Entering Insurance Payments
(Continued)
8-9
• The Deposit List dialog box lists deposits for a
specific date, or all deposits can be viewed
– There are several other sorting features as well
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8.3 Entering Insurance Payments
(Continued)
8-10
• The Deposit List dialog box includes a column
where the Payor Type can be identified
• Capitation payments are made to physicians
on a regular basis (such as monthly) for
providing services to patients in a managed care
insurance plan
– Flat fee is paid to the physician no matter how many
times a patient receives treatment
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8.3 Entering Insurance Payments
(Continued)
8-11
• To enter a deposit, click the New button in the
Deposit List dialog box and the Deposit dialog
box appears
Deposit dialog box
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8.3 Entering Insurance Payments
(Continued)
8-12
• The type of payor—patient, insurance, or
capitation—is selected from the Payor Type
drop-down list
Payor Type
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8.3 Entering Insurance Payments
(Continued)
8-13
• Other information entered about the deposit
includes:
–
–
–
–
–
–
–
–
Deposit date
Payment method
Check number
Description/Bank No.
Payment amount
Deposit code
Insurance
Codes for payments, adjustments, withholds,
deductibles, and take backs
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8.3 Entering Insurance Payments
(Continued)
8-14
• Once a payment is entered, it appears in the
Deposit List window
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8.4 Applying Insurance Payments
to Charges
8-15
• Once a deposit is entered, the next step is to
apply the payment to patient accounts
– Highlight the payment in the Deposit List and click the
Apply button, opening the Apply Payment/Adjustments
to Charges dialog box
Apply Payments/
Adjustments to
Charges dialog box
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Applying Insurance Payments
to Charges (Continued)
8-16
• Next, the patient who has a transaction listed on
the RA is selected from the drop-down list in the
For box
– The upper-right area of the dialog box lists the
amount of the deposit that has not yet been applied
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Applying Insurance Payments
to Charges (Continued)
8-17
• The middle section of the Apply Payments to
Charges window is where payments are entered
and applied
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8.4 Applying Insurance Payments
to Charges (Continued)
8-18
• The lower third of the Apply Payment/Adjustments
to Charges window contains several options that
affect claims and statements
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8.5 Entering Capitation Payments
8-19
• Capitation payments are entered in the Deposit
List dialog box
– Capitation is selected from the Payor Type drop-down
list in the Deposit window
Deposit dialog box
for a capitation
payment
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8.5 Entering Capitation Payments
(Continued)
8-20
• Capitation payments are entered but not applied
• The charges in each patient’s account must be
adjusted to a zero balance to indicate that the
obligation has been met by the insurance
company and patient
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8.5 Entering Capitation Payments
(Continued)
8-21
• A second deposit is entered with a zero amount
to adjust the account
Deposit dialog box
with a zero payment
amount
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8.5 Entering Capitation Payments
(Continued)
8-22
• When zero amount is saved, the deposit appears
in the Deposit List window
• Payment column lists “EOB Only,” since no
payment is associated with zero amount deposit
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
8-23
8.6 Creating Statements
• Patient statements are a list of the amount of
money a patient owes, organized by the amount
of time the money has been owed, the
procedures performed, and the dates the
procedures were performed
– Created after an insurance claim has been filed and
RA has been received
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8.6 Creating Statements (Continued)
8-24
• Statements are created in the Statement
Management area of Medisoft
Statement
Management
dialog box
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8.6 Creating Statements (Continued)
8-25
• When the Create Statements button is clicked,
the Create Statements dialog box opens
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8.6 Creating Statements (Continued)
8-26
• The Create Statements dialog box contains
several filters, including:
–
–
–
–
–
–
–
–
Transaction Dates
Chart Numbers
Billing Codes
Case Indicator
Location
Provider
Amount
Statement Type
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8.6 Creating Statements (Continued)
8-27
• Standard statements show all charges
regardless of whether the insurance has paid on
the transactions
• Remainder statements list only those charges
that are not paid in full after all insurance carrier
payments have been received
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8.6 Creating Statements (Continued)
8-28
• Once statements have been created, they are
listed in the Statement Dialog box with a status
of Ready To Send
Ready To
Send status
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8-29
8.7 Editing Statements
• If changes are necessary, highlight the
statement in the Statement Management dialog
box and click the Edit button
Edit button
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8.7 Editing Statements (Continued)
8-30
• The Statement dialog box has three tabs that
contain important information that can be edited:
– General Tab
– Transactions Tab
– Comment Tab
Three tabs of
the Statement
diaolg box
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8.8 Printing Statements
8-31
• The Print/Send button in the Statement
Management dialog box is used to print
statements that are then sent out to patients and
guarantors
Print/Send
button
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8.8 Printing Statements (Continued)
8-32
• When the Print/Send button is clicked, a
statement method (paper or electronic) is
chosen from the Print/Send Statements dialog
box
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8.8 Printing Statements (Continued)
8-33
• Next, the type of statement is chosen from the
list provided in the Open Report dialog box
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8.8 Printing Statements (Continued)
8-34
• When the
Print/Send button
is clicked, paper
statements are
printed and mailed
by the office
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8.8 Printing Statements (Continued)
8-35
• Practices uses different methods to send
statements to patients
– In once-a-month billing, statements are mailed to all
patients at the same time each month
– In cycle billing, patients are divided into groups and
statement printing/mailing is staggered throughout the
month
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.