Chapter 9 Flashcards
Yo puedo… Yo puedo… Yo puedo…
Yo Soy una Mujersona triple E!
Excelente!l
Eficiente!
Exitosa!
La Inteligencia Q hace girar los planetas en el inmenso espacio…. vive dentro de mi…
entrelazada en el doble helice de mi ADN
envuelta en mis genes… y es por eso Q yo puedo HTS todo lo Q mi corazon desea.
The data entry process is critical in the claims billing cycle. Data entry is used to capture demographic information, CPT®, HCPCS Level II, and ICD-10-CM codes necessary to report the services for patient encounters. Payments and adjustments from insurance carriers are also entered into the practice management system through data entry.
Even the smallest mistake can result in a denied claim. For example, when a number is transposed, which is a simple mistake, the result can be a denied claim for an invalid ID number, or invalid ICD-10-CM/CPT® code, depending on the number transposed.
Reduce Payment Delay
Verify insurance.
Submit Clean Claims.
Submit Claims Electronically
Check Status Reports
Submit Documentation
Post Contractual Adjustments
Section Review 9.1
Cost-based fee schedules are developed using which of the following?
C. Total cost of all the procedures the physician will perform.
What is the physician payment schedule determined by?
Answer: B. The insurance payer
Given the following information:
National conversion factor $33.89
RVU value of 3.26
What is the provider’s fee schedule for 99203 (new patient office visit) using the above values?
Answer: A. $110.00
Rationale: The correct fee would be $108.00. Multiply $33.89 (national CF) x 3.26 (RVU value) = $110.48. This calculation is rounded to the nearest whole dollar, which would set the fee for 99203 at $110.00.
What will happen if there is failure to post a contractual adjustment to a patient’s account?
Answer: C. It will leave a balance on the patient’s account that should not be there.
Which of the following tasks is the most basic element of the billing process?
Answer: C. Data entry
Prior Authorization
Prior authorization is a requirement imposed by insurance payers to determine the medical necessity and benefit coverage eligibility before the patient receives a service or undergoes a procedure.
Typical information required for prior authorization is the following:
Patient’s name (as it appears on the insurance card)
Patient’s date of birth
Insured’s ID number
CPT®/HCPCS Level II code(s)
ICD-10-CM code(s)
Location where service is performed
Ordering physician
Date of service for the procedure if scheduled
Insurance contracts and policies should be reviewed to determine when prior authorization is required.
If one is required and was not obtained, the service will not be covered by the insurance company. Furthermore, the patient is not responsible for payment of this service if the prior authorization was not obtained.
BILLING TIP
Many facilities will have an authorizations department.
If authorization is not obtained prior to the procedure, some insurance carriers will allow for a retroactive authorization under special circumstances.
Claim Scrubbers
A claim scrubber is a software program that reviews claims for key components and flags any detected errors before claims are sent to an insurance company.
The claim scrubber verifies CPT®/HCPCS Level II codes and ICD-10-CM codes.
The scrubber looks at the procedure code and diagnosis code to justify the medical necessity of the procedure.
Some practice management systems can build in medical necessity policies based on the insurance carrier. This can be cumbersome to maintain.
A more manageable process is to have the NCDs, LCDs, and Billing and Coding Articles for your area loaded in the system and maintained as many insurance carriers will follow CMS guidelines.
Claims may be scrubbed within the medical billing department prior to submitting to the clearinghouse,
and then again by the clearinghouse before submitting to the payer.
Applying their knowledge of coding concepts and payer policies will increase the professional medical biller’s value to a medical practice…
allowing for the practice to maintain a healthy revenue flow.
A/R Deposit Balancing
Accounts receivable or A/R is money owed to the practice for services rendered and billed. Payments due from patients, payers, or other guarantors are considered accounts receivables.
Daily Deposits
When patients are seen in the office, any copayments, deductibles, coinsurance, or patient balances may be collected by the office staff.
The amount posted in the practice management system must match the deposit amount for that batch. I
Direct Deposits
Many insurance payers pay claims using direct deposit. When the adjudication process has been finalized, the payer sends the remittance advice (RA) to the provider and an explanation of benefits (EOB) to the patient.
This process must be performed with great accuracy to avoid posting errors.
Section Review 9.2
What is the function of a claim scrubber?
Answer: A. To identify errors that will prevent a claim from being paid
What are payments due from patients, payers, or other guarantors considered to be?
Answer: B. Accounts receivable
Who is required to obtain a prior authorization for a service or procedure?
Answer: D. The physician performing the procedure or service
Who generates the remittance advice?
Answer: D. To the insurance payer
When a claim has been paid, where is an EOB sent?
Answer: B. To the patient
Rationale: Once the adjudication process has been finalized, the payer will send the remittance advice (RA) to the provider and an explanation of benefits (EOB) to the patient.
Technology and Claims Submission
Healthcare claims can be submitted manually, by paper, or electronically by computer. Electronic claims submission has many benefits such as:
*Minimize claim rejections and re-submissions
*Deliver the claims to health insurers in real time
*Expedite payer responses and boost the cash flow
*Reduce cost of claim submission
The savings inherent in electronic claims submission is substantial.
Cost to submit manual claims: $6.63 x 6,200 = $41,106
Cost to submit electronic claims: $2.90 x 6,200 = $17,980
Average annual savings per physician from automating claims submission: ≈$23,126*
Based on an annual average of 6,200 claims submitted for a single physician.
Electronic Claims
Electronic claims can be submitted to a carrier from a provider’s office using a computer with software that meets electronic filing requirements as established by the HIPAA claim standards.
Clearinghouse Report
Due to the vast amount of insurance payers, each with their own specific criteria for submitting claims, it would be an overwhelming task for individual practices and billing companies to maintain the required billing software needed to submit claims to each individual payer. This dilemma is resolved through the services of a clearinghouse.
A clearinghouse is an entity that processes or facilitates the processing of claims for providers and healthcare plans.
Clearinghouses have the capability to convert nonstandard data received from payers to standard transaction data to meet HIPAA requirements.
