Payments RAs

1. 1

2. Chapter 14 2 Learning Outcomes After studying this chapter, you should be able to: 14.1 Describe the steps payers follow to adjudicate claims. 14.2 List ten checks that automated medical edits perform. 14.3 Describe the procedures for following up on claims after they are sent to payers. 14.4 Identify the types of codes and other information contained on an RA/EOB.

3. Chapter 14 3 Learning Outcomes (Continued) 14.5 List the points that are reviewed on an RA/EOB. 14.6 Explain the process for posting payments and managing denials. 14.7 Describe the purpose and general steps of the appeal process. 14.8 Discuss how appeals, postpayment audits, and overpayments may affect claim payments.

4. Chapter 14 4 Learning Outcomes (Continued) 14.9 Describe the procedures for filing secondary claims. 14.10 Discuss procedures for complying with the Medicare Secondary Payer (MSP) program.

5. Chapter 14 5 Key Terms Aging Appeal Appellant Autoposting Claim adjustment group codes (GRP) Claim adjustment reason codes (RC) Claimant

6. Chapter 14 6 Key Terms (Continued) Explanation of benefits (EOB) Grievance HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835)

7. Chapter 14 7 Key Terms (Continued) Medicare Outpatient Adjudication remark codes (MOA) Medicare Redetermination Notice (MRN) Medicare Secondary Payer (MSP) Overpayments Pending

8. Chapter 14 8 Claim Adjudication Initial processing Automated review Manual review Determination Payment

9. Chapter 14 9 Claim Adjudication Initial processing Automated review Manual review Determination Payment

10. Chapter 14 10 Claim Adjudication Initial processing Automated review Manual review Determination Payment

11. Chapter 14 11 Claim Adjudication Initial processing Automated review Manual review Determination Payment

12. Chapter 14 12 Claim Adjudication Initial processing Automated review Manual review Determination Payment

13. Chapter 14 13 Claim Adjudication Initial processing Automated review Manual review Determination Payment

14. Chapter 14 14 Automated Review Screening edits reflect the payer’s payment policies. Failure to pass an edit may cause the claim or portion of a claim to be denied. Ten types of edits will be discussed.

15. Chapter 14 15 Automated Review Checks patient enrollment in the plan for the date of service Premium payment must be current Waiting periods apply to certain policies Preexisting conditions may not be covered

16. Chapter 14 16 Automated Review Checks dates for the claim-filing time limits Time limits vary from plan to plan Claims not filed in a timely manner may result in denied or reduced payment

17. Chapter 14 17 Automated Review Checks for preauthorization or referral number as the plan requires

18. Chapter 14 18 Automated Review Checks for repeat billing of the same service Dates of service should not be rebilled

19. Chapter 14 19 Automated Review

20. Chapter 14 20 Automated Review Valid code linkage

21. Chapter 14 21 Automated Review Bundled codes

22. Chapter 14 22 Automated Review Procedure codes match diagnosis codes Procedures are not elective Procedures are not experimental Procedures are essential for treatment Procedures are furnished at an appropriate level

23. Chapter 14 23 Automated Review Checks for appropriateness of hospital-based services

24. Chapter 14 24 Automated Review Checks validity of claims when two practitioners provide service on the same date of service

25. Chapter 14 25 Manual Review Problems lead to suspended claims Payer has a development process Provider is likely to need to respond to questions and provide additional information

26. Chapter 14 26 Determination Determination is the decision whether the payer will -- Pay -- Deny -- Reduce payments for a claim.

27. Chapter 14 27 Payment Final step—payer sends payment Payment is accompanied by a remittance advice (RA) RAs are also called explanations of benefits (EOB)

28. Chapter 14 28 Monitoring Claim Status

29. Chapter 14 29 Monitoring Claim Status

30. Chapter 14 30 Monitoring Claim Status

31. Chapter 14 31 Monitoring Claim Status

32. Chapter 14 32 The Remittance Advice/Explanation of Benefits (RA/EOB) Covers a group of claims Major sections: - Header information - Totals - Claim information - Glossary Adjustments Claim adjustment group codes Claim adjustment reason codes REM – Remittance advice remark codes

33. Chapter 14 33 The Remittance Advice/Explanation of Benefits (RA/EOB)

34. Chapter 14 34 Reviewing and Processing RAs/EOBs Check patient’s name, account number, insurance number, and date of service against the claim. Verify all billed CPT codes are listed. Check payment for each CPT against the expected amount. Analyze the payer’s adjustment codes to locate all unpaid, downcoded or denied claims for closer review. Pay special attention to RA/EOBs for claims submitted with modifiers. Some payers’ claim processing systems automatically ignore modifiers, so that E/M visits billed on the same date of service as a procedure are always unpaid and should be appealed. 6. Decide whether any items on the RA/EOB need clarifying with the payer, and follow up as necessary.

35. Chapter 14 35 Reviewing and Processing RAs/EOBs Date of deposit Payer name and type Check number - Total payment amount Apply amounts - Reconciliation

36. Chapter 14 36 Reviewing and Processing RAs/EOBs Manage Denials

37. Chapter 14 37 Appeals, Postpayment Audits, Overpayments, and Grievances Appeals may be filed if a claim is denied or underpaid Payer’s audits after payments are released may alter amounts received Claims may be overpaid, requiring refunds to a payer or a patient The practice may elect to file a grievance with state insurance commissioners

38. Chapter 14 38 Appeals Participating providers can file an appeal for a denied or reduced claim Claims must be appealed within the allotted time frame There are generally several levels to a payer’s appeal process

39. Chapter 14 39 Medicare Appeals The Medicare appeals process involves five steps: Redetermination Reconsideration Administrative law judge Department appeals board Federal court (judicial) review

40. Chapter 14 40 Postpayment Audits Payers perform postpayment audits to study treatments and outcomes to confirm or alter best practice guidelines verify the medical necessity of reported services uncover fraudulent practices

41. Chapter 14 41 Refunds of Overpayments Medicare and other payers’ postpayment audits may cause reversal or reduction of a paid claim Payers may also overpay claims occasionally Overpayments must be refunded to the payer

42. Chapter 14 42 Compliance Tips Because overpayments are a major Medicare fraud and abuse initiative, it is important to actively find and refund overpayments. A policy should clearly state the procedures to follow when an overpayment is discovered, regardless of the source

43. Chapter 14 43 Grievances Grievances are complaints against a payer filed by a practice with the state insurance commissioner Used to resolve repeated problems with payers

44. Chapter 14 44 Billing Secondary Payers Secondary and tertiary plans are billed after the primary claim has been paid Often handled automatically under electronic claim processing Paper claims usually require a secondary paper claim

45. Chapter 14 45 Medicare as Secondary Payer Over age 65 and employed with insurance coverage through employer’s group plan Over age 65 and covered through a spouse’s group health plan Disabled beneficiary under age 65 with insurance coverage through an employer group health plan

46. Chapter 14 46 Medicare as Secondary Payer End-Stage Renal Disease (ESRD) Workers’ Compensation Automobile, No-Fault, and Liability Insurance Veterans’ Benefits

47. Chapter 14 47 TRICARE TRICARE and CHAMPVA do not duplicate benefits of other insurance Medicaid or supplemental policy TRICARE/CHAMPVA is primary Other health plan TRICARE/CHAMPVA is secondary Workers’ compensation TRICARE/CHAMPVA pays only when all other benefits are exhausted

48. Chapter 14 48 Secondary Claims Medigap policices Primary payer is Medicare Medi-Medi Primary payer is Medicare Crossover claims

49. Chapter 14 49 Secondary Claims Secondary payer Covered under an employer’s group plan Workers’ compensation No-fault or liability insurance Employer’s group plan for a patient with ESRD, first 18 months