Comprehensive Health Insurance Billing Coding Reimbursement

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Comprehensive Health Insurance

Billing | Coding | Reimbursement

CHAPTER

SECOND EDITION

Refunds, Follow-up, and Appeals

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Key Terms and Abbreviations

• administrative law judge (ALJ) hearing

• documentation

• Employee Retirement Income Security

Act (ERISA) of 1974

• follow-up

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Comprehensive Health Insurance: Billing, Coding & Reimbursement, Second Edition

Deborah Vines Allen • Ann Braceland • Elizabeth Rollins • Susan Miller

Key Terms and Abbreviations

• qualified independent contractor (QIC)

• redetermination

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Chapter Objectives

• After completing this lecture, you

should be able to complete the

following learning objectives:

– 17.1: Understand reimbursement follow-up.

– 17.2: Know the common problems and solutions for denied or delayed

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Chapter Objectives

• After completing this lecture, you

should be able to complete the

following learning objectives:

– 17.3: Use problem-solving and

communication skills to answer patients' questions about claims.

– 17.4: Format medical records with proper documentation.

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Chapter Objectives

• After completing this lecture, you

should be able to complete the

following learning objectives:

– 17.6: Understand ERISA rules and regulations.

– 17.7: Write letters of appeal on denied claims.

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Chapter Objectives

• After completing this lecture, you

should be able to complete the

following learning objectives:

– 17.9: Rebill insurance claims.

– 17.10: Discuss the three levels of Medicare appeals.

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Reimbursement Follow-Up

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17.1: Reimbursement Follow-Up

• Follow-up with Insurance Carriers

– The majority of a provider's income is generated through the payment of

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17.1: Reimbursement Follow-Up

• Follow-up with Insurance Carriers

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17.1: Reimbursement Follow-Up

• Follow-up with Insurance Carriers

– Follow-up is needed when payments are denied, late, or incorrect.

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17.1: Reimbursement Follow-Up

• Follow-up with Insurance Carriers

– Depending on the situation and

insurance carrier requirements, the

follow-up may take place by phone, by e-mail, online through the carrier's

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17.1: Reimbursement Follow-Up

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Denied or Delayed

Payments

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: The claim is not for a covered

benefit.

– Solution: Bill the patient, noting that the

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: The patient's preexisting

condition is not covered.

– Solution: Bill the patient. If the provider

believes the condition was not

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: The patient's coverage has

been cancelled.

– Solution: Bill the patient, noting the

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: Workers' compensation (WC)

is involved, and the case is still under consideration.

– Solution: Call the employer and ask for

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: The carrier considers the

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Solution: Any new procedure with an

unlisted procedure code must include an explanation of the procedure and proof of medical necessity along with the

claim. Call the carrier to discuss, if

necessary. If still denied, an appeal may be filed or a request made for peer

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: The carrier believes there is a

need for coordination of benefits with another carrier.

– Solution: Call the patient for information

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: Required preauthorization was

not obtained.

– Solution: If authorization was obtained,

call the carrier and provide the

authorization number. If there is a

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: Services were provided before

the patient's health coverage was in effect.

– Solution: Bill the patient, noting that no

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17.2: Denied or Delayed Payments

• Common Problems and Solutions

– Problem: The carrier asks for additional

information.

– Solution: Send the requested

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Patients' Questions About

Claims

17.3: Use problem-solving and

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17.3: Patients' Questions About

Claims

• Answering Patients' Questions

– Good problem-solving and

communication skills are essential in communicating with patients about outstanding claims and insurance issues.

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17.3: Patients' Questions About

Claims

• Answering Patients' Questions

– Patients may receive bills or EOBs that they are upset about or don't

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17.3: Patients' Questions About

Claims

• Answering Patients' Questions

– The first step is to find out the exact nature of the patient's problem.

– The medical office specialist can help

patients review their insurance benefits to understand which

services/procedures are covered and which are not or any limitations of

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17.3: Patients' Questions About

Claims

• Answering Patients' Questions

– It may be necessary to call the

insurance carrier to obtain additional

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17.3: Patients' Questions About

Claims

• Techniques to Use in Communicating

with Patients About Insurance

Questions

– Volunteer to explain. Speak slowly and calmly.

– Use simple language, avoiding the use of insurance jargon.

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17.3: Patients' Questions About

Claims

• Techniques to Use in Communicating

with Patients About Insurance

Questions

– Ask “Do you understand?” or say “Perhaps I can explain that better.”

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17.3: Patients' Questions About

Claims

• Techniques to Use in Communicating

with Patients About Insurance

Questions

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Proper Documentation

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17.4: Proper Documentation

• Documentation Guidelines

– Documentation is the chronological

recording of pertinent facts and

observations regarding a patient's health status and treatment (the medical record).

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17.4: Proper Documentation

• Documentation Guidelines

– Information must be recorded in a format that allows the physician to

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17.4: Proper Documentation

• Documentation Guidelines

– Documentation must include

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17.4: Proper Documentation

• Documentation Guidelines

– Insurance carriers may request

documentation to verify the place of service, the medical necessity of

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17.4: Proper Documentation

• SOAP Format

– The most widely used medical record format is the SOAP format, which

includes Subjective, Objective,

Assessment, and Plan information.

– Subjective (E/M history): the patient's

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17.4: Proper Documentation

• SOAP Format

– Objective (E/M examination): objective

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17.4: Proper Documentation

• SOAP Format

– Assessment (E/M decision making):

physician's diagnosis or impression at the time of the encounter

– Plan (E/M recommended treatment):

recommended treatment, tests,

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Appeals

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17.5: Appeals

• The Appeals Process

– The first step is to understand the

appeals policy and deadlines of each carrier/payer.

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17.5: Appeals

• The Appeals Process

– The medical office specialist must differentiate between a denial of

charges and a disallowance (partial

payment of a claim because the amount was above the maximum allowed

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17.5: Appeals

• The Appeals Process

– Standard form letters are used for

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17.5: Appeals

• The Appeals Process

– Written appeals may be required when a claim is denied as not medically

necessary or the carrier has misquoted benefits.

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17.5: Appeals

• The Appeals Process

– Explanations and clinical information are attached to standard appeal letters to

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17.5: Appeals

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17.5: Appeals

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ERISA

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17.6: ERISA

• ERISA Rules and Regulations

– The Employee Retirement Income

Security Act (ERISA) of 1974 is federal legislation enacted to protect the

interests of individuals enrolled in pension and health benefit plans sponsored by private employers.

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17.6: ERISA

• ERISA Rules and Regulations

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17.6: ERISA

• ERISA Rules and Regulations

– Per ERISA, insured individuals have certain rights if a claim is denied, including the right to appeal.

– The provider has at least 60 days (longer with some plans) to file an appeal.

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Letters of Appeal

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17.7: Letters of Appeal

• Writing Effective Appeal Letters

– Standard appeal letters can be used, with the specific details of each case inserted at the appropriate locations.

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17.7: Letters of Appeal

• Writing Effective Appeal Letters

– It is important to understand the federal and state laws that affect the

submission of health insurance claims.

– To strengthen an appeal, appropriate references to court rulings can be

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17.7: Letters of Appeal

• Writing Effective Appeal Letters

– Effective appeal letters are written in professional language and include:

 The patient's name, policy number, and a

description of the charges being appealed

 Names of people contacted at the

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17.7: Letters of Appeal

• Writing Effective Appeal Letters

– Effective appeal letters are written in professional language and include:

 Concise explanation of what is being

requested, along with supporting information

 Clear description of the desired

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17.7: Letters of Appeal

• Involving the Patient in the Appeal

Process

– When a provider is willing to file an appeal to attempt to overturn a claim denial, patients appreciate the effort

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17.7: Letters of Appeal

• Involving the Patient in the Appeal

Process

– The patient should be copied on letters of appeal sent to carriers/payers and asked to also appeal on his or her own behalf.

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Refund Guidelines

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17.8: Refund Guidelines

• Refunds to Patients and Carriers

– Credit balances and refunds result from overpayments by the patient or

insurance carrier. Overpayments are common and can result from:

 The patient paying in excess of his/her

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17.8: Refund Guidelines

• Refunds to Patients and Carriers

 The patient having primary and

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17.8: Refund Guidelines

• Refunds to Patients and Carriers

 The insurance company making a

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17.8: Refund Guidelines

• Refunds to Patients and Carriers

– Carriers must request refunds in

writing, clearly stating why a refund is warranted.

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17.8: Refund Guidelines

• Refunds to Patients and Carriers

– To avoid overpayments, patient copayments, coinsurance, and

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Rebill Insurance Claims

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17.9: Rebill Insurance Claims

• Resubmitting Claims

– Before rebilling, the claim status should be checked online if the carrier's

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17.9: Rebill Insurance Claims

• Resubmitting Claims

– Some providers automatically rebill if

payment hasn't been received within 30 days, but this may be perceived as

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17.9: Rebill Insurance Claims

• Resubmitting Claims

– Rebilled claims should be clearly

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17.9: Rebill Insurance Claims

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Medicare Appeals

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17.10: Medicare Appeals

• Levels of Medicare Appeals

– First Level: Redetermination

 A provider has 120 days to file a request

for a Medicare review, also known as a

redetermination, with a Medicare carrier.

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17.10: Medicare Appeals

• Levels of Medicare Appeals

– Second Level

 The second level of the appeal is handled

by a qualified independent contractor

(QIC) who processes reconsiderations of

carriers' initial determinations and redeterminations. Providers have 6

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17.10: Medicare Appeals

• Levels of Medicare Appeals

– Third Level

 The third level of appeal is an

administrative law judge (ALJ). Providers

have 60 days to file a third-level appeal, and the value of the claim must be

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Issue Refunds

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17.11: Issue Refunds

• Calculate and Issue Refunds

– Before issuing a refund to a patient, check to see if the patient has an

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17.11: Issue Refunds

• Calculate and Issue Refunds

– If there is an outstanding balance, first apply the refund to the balance and

then refund any difference.

– Usually an accounting department or

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17.11: Issue Refunds

• Calculate and Issue Refunds

– A patient with both primary and

secondary insurance coverage may have a secondary policy that will pay

copayments due on the primary policy.

– If the patient paid a copay at the time of service and both insurance

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17.11: Issue Refunds

• Calculate and Issue Refunds

– Before processing this refund, check if the patient owes any outstanding

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17.11: Issue Refunds

• Calculate and Issue Refunds

– To issue a refund, the medical office specialist makes an adjustment to the balance of a patient's account.

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17.11: Issue Refunds

• Calculate and Issue Refunds

– When issuing a refund, enter a positive adjustment and make a note in the