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8 Cards in this Set
- Front
- Back
Kong 38, IHI 7, and GI 25 combined
Claims and Benefits Administration and Claims Operations Management |
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Objective and Purposes of CBA
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To pay legitimate claims promptly and accurately.
to meet contractual obligations to avoid overpaying conform to Plan Policy and Procedure enforce UM service & relationship with patients and providers to prevent lawsuits to attract customers. |
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CLAIMS BUSINESS FUNCTIONS
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1. Gather Info (may be tested as “Describe sources of information available to the Claims Examiner”)
ph’s claim form Date of Loss, Proof of Loss, Beneficiary info Itemized bills APS Ins Cpy’s doctor’s report original Underwriting file anything the agent knows ph’s past claims history 2. Code the claim 3. Determine Liability verify eligibility contract in force during claim? authorized provider / procedure? exclusions (experimental, pre-existing condition; not med’ly necessary) Check for Fraud; determine Contestability and Rescission fraudulent application is error material? Definition of Disability Interpret ambiguous contractual benefits HIPAA portability/continuity regulations run rebundling, un-upcoding software apply COB and Subrogation Which plan is primary? secondary? “Earlier birthday rule” for children Ways of Determining the Secondary Plan’s payment: Maintenance of Benefit method (= “Supplemental method”) Non-Duplication method (= “Carveout method”) Avoid “loopholes” and “deceptive practices”. compute cost-sharing 4. Customer Service explain company decisions 5. Make Claims Adjustments clerical financial 6. Pay the Claim for Disability, keep verifying that ph is still disabled 7. Pended Claims Mgmt Reasons for a claim to be Pended: Eligibility problem exclusion contract ambiguous Disability still being investigated UM problem (no authzn or referral) data problem missing or invalid data provider missing DRG code missing questionable data coded wrong 8. Report to Management Turnaround Time (TAT) Accuracy # of pended claims $ processed Additional Steps are needed for Disability claims. (See below) |
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DIFFERENCE IN CLAIMS MGMT (CBA) for MEDICAL VS. DISABILITY INSURANCE
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Medical
Claim review is retrospective. Claims examiner can’t affect benefits. Disability Claim review is prospective. Difficulties in CBA for Disability Insurance Must consider future outlook of claim Greater scrutiny of claims is required Disabilities are subjective Hard to judge how much income was lost Must not pay ph too much (else “malingering”) Claims Reserves harder to estimate LTD claims are submitted after a long incurral period Fraud common |
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In addition to Steps 1-8 above, the Disability CBA Process Includes:
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Review contractual definition of disability (own occ, any occ)
Establish claimant’s true condition doctor’s statement; ins. cpy doctor’s statement surveillance Establish a plan for managing the disability timeline for recovery workplace accommodations Choose the periodic income payment judge how much income the ph really lost should only replace a portion Coordination of Benefits Consider all of ph’s other sources of income (Medicare, Workers Comp) Ongoing review to make sure still disabled COLA Pay for rehabilitation programs Allow "trial" return to work Ease the transition back to work vocational activities (training) “partial disability” benefits Communicate end of coverage Negotiate deals (lump-sums) |
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SPECIAL ISSUES / DIFFERENCES IN CBA FOR MANAGED CARE VS. TRADITIONALS
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payments are made to the providers, not to the patient
variety of reimbursement types medical necessity must be proven treatment setting protocols followed provider levels (in-network, out-of-network) carve-outs common e.g. pharmacy benefits handled by a PBM more entities involved better claim databases and info systems are needed. |
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FRAUDULENT CLAIMS
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by insureds
faking a disability falsifying an application (medical info, age) not disclosing income sources by providers upcoding; unbundling; lying by employees of the insurer a claim examiner paying money to himself. |
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CLAIMS OPERATIONS MGMT (FROM KONG 38 ONLY)
These are the internal, behind-the-scenes actions involved in CBA. |
1. Sort and Count the claims
2. Workflow Control Inventory control log claim receipts display type and processing stage paper or electronic? Pended? Active? Rejected? properly authorized? document archiving Tracking and Monitoring of Pended Claims the volume of pended claims represents quality of: UM provider contract data software logic Reasons for a Claim to be Pended: Same list as in “Pended Claims Mgmt”, above. Workflow Mgmt (“Task Allocation” “Work Distribution”) On-line adjudication Batch adjudication (requires less-skilled ees) 3. Monitor Productivity Establish goals for TAT TAT, and TAT goals, depend on: volume type (hosp. worst) plan complexity staffing degree of Automation Monitor TAT, using: pended claims report paid claims report check register 4. Develop a CBA Quality Assurance (Quality Measurement) Process Compute claims Accuracy overall accuracy payment accuracy Financial Accuracy = |$ error| / total $ paid out # of customer complaints Audit each claim examiner’s work 5. Follow Plan Policy And Procedure Administrative work flow and work distribution TAT goals inventory reporting Coordinative Medical-operational, e.g. authorization adjudication UCR billing 6. Coordinate CBA With Other Departments billing dept UM dept customer service dept provider relations dept finance dept 7. Develop Systems Support / MIS capability to handle CBA The MIS capability needed depends on: number of data elements complexity of claims/provider contracts/products customer service desired General Considerations in CBA MIS must support operational tasks claims logic validity edits Develop Guidelines for handling pended claims s/b Easy to use Claims should be searchable include a Claims History Database avoid duplicate claims keep track of accumulating deductibles and maximums. use Electronic Claims Submission. 8. Outsource the Claims Processing, if necessary They might say “Describe Common CBA Problems” on the exam Reasons Why an MCO should Outsource Claims Processing lack of expertise * outdated computer system * inexperienced staff * poor claims performance poor accuracy backlog * poor pended claims too many complaints outdated structure/task allocation * poorly-written contracts Poor coordination * occurs when MCO starts a new block of business For a good flowchart of the Claims Operations Management process, see Kong (4th edition), page 744. Done. |