Cbcs Study Guide 2.1 Chapter 4 - Payment Adjudication Q&a

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WHAT DOES THE ACCOUNTS RECEIVABLES DEPARTMENT MANAGE?

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THE CHARGE DESCRIPTION MASTER (CDM)

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WHAT IS THE CHARGE DESCRIPTION MASTER (CDM)

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INFORMATION ABOUT HEALTH CARE SERVICES THAT PATIENTS HAVE RECEIVED AND FINANCIAL TRANSACTIONS THAT HAVE TAKEN PLACE

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WHAT IS THE PRIMARY PURPOSE OF THE CHARGE DESCRIPTION MASTER?

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TO MAKE SURE THAT THE PROVIDER ACCURATELY CHARGES THE PATIENT FOR ROUTINE SERVICES AND SUPPLIES

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WHAT INFORMATION IS IN THE CHARGE DESCRIPTION MASTER?

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THE DESCRIPTION OF SERVICE (EVALUATION AND MANAGEMENT VISIT, OBSERVATION, OR EMERGENCY ROOM VISIT), CPT/HCPCS CODE (MUST CORRESPOND TO THE DESCRIPTION OF SERVICE), REVENUE CODE (ALSO CALLED THE UB-04 CODE), THE CHARGE AMOUNT, CHARGE OR SERVICE CODE, GENERAL LEDGER KEY, AND ACTIVITY OR STATUS DATE

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WHAT IS THE POSSIBLE OUTCOME AND RISK OF UNDER CHARGING FOR SERVICE?

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THE POSSIBLE OUTCOME IS UNDERPAYMENT, AND THE POSSIBLE RISK IS LOST REVENUE.

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WHAT IS THE POSSIBLE OUTCOME AND RISK FOR OVERCHARGING FOR SERVICES?

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THE POSSIBLE OUTCOME IS OVERPAYMENT AND THE POSSIBLE RISK IS COMPLIANCE.

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WHAT IS THE POSSIBLE OUTCOME AND RISK OF INCORRECT HCPCS OR DIAGNOSIS CODE?

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THE POSSIBLE OUTCOME IS CLAIMS REJECTION OR DENIAL AND THE POSSIBLE RISK IS LOST REVENUE

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WHAT IS THE POSSIBLE OUTCOME AND RISK OF INCORRECT REVENUE CODE?

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THE POSSIBLE OUTCOME IS CLAIMS REJECTION OR DENIAL AND THE RISK IS LOST REVENUE

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WHAT ELSE IS THE AGING REPORT KNOWN AS?

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AGE TRIAL BALANCE

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WHY ARE AGING REPORTS USEFUL?

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THEY HELP THE OFFICE STAFF SEE WHICH ACCOUNTS HAVE NOT BEEN PAID

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BY CHECKING WHAT REPORTS SHOULD YOU BE ABLE TO FIND OUT A REASON WHY AN ACCOUNT HAS AN OUTSTANDING BALANCE?

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THE EXPLANATION OF BENEFITS (EOB) OR THE REMITTANCE ADVICE (RA)

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WHAT ARE SOME REASONS FOR LACK OF PAYMENT?

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THE THIRD PARTY PAYER HAS NOT PROCESSED THE CLAIM. A PATIENT HAS NOT PAID HIS OR HER BALANCE AND HAS NOT NOTIFIED THE OFFICE. A CLAIM IS HELD UP IN THE OFFICE BECAUSE THE PROVIDER HAS NEGLECTED TO GIVE THE BILLING STAFF NECESSARY INFORMATION

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WHAT ARE SOME REASONS FOR WHY A CLAIM WAS NOT PROCESSED BY THE THIRD PART PAYER?

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THE DELAY MIGHT BE BACKED UP ON THE INSURANCE SIDE, OR THE CLAIM WAS NOT FILLED OUT CORRECTLY AND COULD NOT BE PROCESSED. IF A CLAIM HAS TO BE REVIEWED MANUALLY, THAT WILL ALSO DELAY ACTION ON THE CLAIM

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HOW MAY THE OFFICE STAFF SET PRIORITIES ABOUT WHICH ACCOUNTS TO ADDRESS FIRST?

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ACCOUNTS WITH HIGH DOLLAR AMOUNT OR THOSE OLDER WHEN IT IS TIME TO COLLECT PAYMENT, WHICH GROUP TO CONTACT FIRST (THIRD PARTY PAYER, PATIENT, OR A PROVIDER IN THE OFFICE)

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WHY WOULD THE OFFICE STAFF SET THESE PRIORITIES FOR COLLECTING PAYMENT?

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BECAUSE THE OLDER THE ACCOUNT OR THE LONGER IT REMAINS UNPAID, THE LESS LIKELY THE FACILITY WILL RECEIVE REIMBURSEMENT FROM THE THIRD PARTY PAYER

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WHAT DO APPROPRIATE FOLLOW UPS FOR COLLECTION INCLUDE?

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CONTACT THE THIRD PARTY PAYER(S) INVOLVED TO FIND OUT WHY THE CLAIM HAS BEEN DELAYED. IF THE THIRD PARTY PAYER ALERTS THE STAFF TO A PROBLEM, THEN THE OFFICE WILL NEED TO FIX IT. CALL PATIENT TO FIND OUT WHY PAYMENT HAS BEEN DELAYED. IF THE PATIENT IS EXPERIENCING FINANCIAL DIFFICULTIES, IT MIGHT BE POSSIBLE TO WORK OUT A PAYMENT PLAN. IF THE PATIENT IS ABLE BUT UNWILLING TO PAY, THEN MEDICAL OFFICES HIRE A COLLECTION AGENCY TO TRY AND COLLECT THE OUTSTANDING BALANCE. WORK WITH THE HEALTH CARE PROFESSIONAL IN YOUR OFFICE TO GET ALL THE INFORMATION NEEDED FOR A CLAIM

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HOW LONG DO MOST WAIT BEFORE CONTACTING A COLLECTION AGENCY?

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90 TO 120 DAYS

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WHAT TYPE OF FORM IS USED TO HELP BILLING STAFF TO COMMUNICATE WITH PHYSICIANS?

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A QUERY FORM

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WHAT INFORMATION SHOULD BE INCLUDED O A QUERY FOR?

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THE PATIENT’S NAME, SERVICE DATE, HEALTH RECORD NUMBER, ACCOUNT NUMBER, DATE QUERY INITIATED, NAME AND CONTACT INFORMATION OF THE INDIVIDUAL INITIATING THE QUERY, AND STATEMENT OF THE ISSUE IN THE FORM OF A QUESTION WITH SPECIFIC FROM THE CHART REFERENCED

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WHAT IS AN AGING REPORT?

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AN AGING REPORT IDENTIFIES THE OUTSTANDING BALANCES IN EACH ACCOUNT. AGING REPORTS ARE USUALLY ORGANIZED IN 30 DAY INCREMENTS

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WHAT IS THE BASIC INFORMATION IS ON A TYPICAL REMITTANCE ADVICE?

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NAME OF HEALTHCARE INSURANCE COMPANY, DATE OF REPORT, NAME OF THE SUBSCRIBER AND IDENTIFICATION NUMBER(CERTIFICATE OR MEMBER NUMBER), SUBSCRIBER’S GROUP NUMBER, NAME AND ADDRESS OF PROVIDER(MEDICAL OFFICE OR A DURABLE MEDICAL EQUIPMENT VENDOR), HEALTH CARE SERVICES RECEIVED AND THE DATE OR DATES

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WHAT INFORMATION ON A REMITTANCE ADVICE PERTAINS TO PAYMENT ISSUES?

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ACTUAL CHARGE, ALLOWABLE CHARGE, WRITE-OFFS, COST SHARING, AND REJECTIONS OR DENIAL

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WHAT OTHER INFORMATION IS ON A REMITTANCE ADVICE (RA)?

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1) IF CLAIMS ARE SUBMITTED IN GROUPS, OFTEN REFERRED TO AS BATCHES, THE RA MAY INCLUDE NAMES OF MULTIPLE PATIENTS AND THEIR ACCOUNT NUMBERS. SOMETIMES THE BIRTHDAYS OF PATIENTS ARE INCLUDED AS WELL. 2) PRIOR APPROVAL NUMBER, EITHER AUTHORIZATION OR A PRE-CERTIFICATION NUMBER. 3) PROVIDER/PRACTITIONER NUMBER, IN ADDITION TO THE NAME AND ADDRESS. 4) TAX IDENTIFICATION NUMBER. 5) CHECK NUMBER AND AMOUNT 6) PAYMENT DUE 7) SERVICES CODE AND MODIFIERS 8) CLAIM STATUS: PAID, DENIED OR REJECTED, REVERSED (CORRECTED), OR SUSPENDED 9) REJECTIONS, REVERSALS, DENIALS, DISALLOWED CHARGES, ALLOWANCES, REASON CODS, AND OTHER DETAILS FOR MULTIPLE PATIENTS

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WHAT IS THE DIFFERENCE BETWEEN A REMITTANCE ADVICE (RA) AND A EXPLANATION OF BENEFITS (EOB)?

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AN RA IS SENT TO THE PROVIDERS OFFICE FROM THE THIRD PARTY PAYER, WHILE THE EOB IS SENT TO THE POLICY HOLDER. THE RA INCLUDES MORE INFORMATION THAN THE EOB, INCLUDING THE BREAKDOWN OF THE ALLOWABLE CHARGE VS THE ACTUAL CHARGE, WRITE-OFFS, AND INFORMATION FROM MULTIPLE PATIENTS. THE EOB IS AN EXPLANATION OF THE BENEFITS APPLIED FOR ONE POLICY HOLDER

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WHAT DOES THE TERM RECONCILIATION MEAN?

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RECONCILIATION REFERS TO THE PROCESS THE BILLING OFFICE GOES THROUGH TO DETERMINE WHAT PAYMENTS HAVE COME IN FROM THE THIRD PARTY PAYER AND WHAT PATIENT OWE THE PROVIDER. THE BILLING OFFICE USES THE RA, EOB, AND MSN TO MAKE THESE DETERMINATIONS

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WHAT IS THE REVENUE CYCLE?

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PATIENT PRESENTS TO HEALTH CARE FACILITY > SUBSCRIBERS INFORMATION COLLECTED > HEALTH CARE SERVICE PROVIDED > CODING > CLAIM SUBMITTED > EOB TO PATIENT MSN TO MEDICARE PATIENTS OR PATIENT PRESENTS TO HEALTH CARE FACILITY > SUBSCRIBERS INFORMATION COLLECTED > HEALTH CARE SERVICE PROVIDED > CODING > CLAIM SUBMITTED > RA TO PROVIDER >RECONCILIATIONS AND COLLECTIONS

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WHAT ARE THE POSSIBLE REASONS FOR A CLAIM TO BE DENIED?

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DIFFERENCE IN THE PATIENT’S NAME OR IT’S SPELLING (SUCH AS A NICKNAME OR A HYPHENATED LAST NAME),MISSING OR INVALID PATIENT IDENTIFICATION NUMBER, MISSING OR INVALID PATIENT INFORMATION (SUCH AS SEX, DATE OF BIRTH OR SOCIAL SECURITY NUMBER), MISSING OR INVALID SUBSCRIBER (MEMBER) NAME, MISSING OR INVALID CERTIFICATE OR GROUP NUMBER, LACK OF AUTHORIZATION OR REFERRAL NUMBER, FAILURE TO CHECK TO BOX FOR ASSIGNMENT OF BENEFITS, INVALID DATES OF SERVICE, MISSING OR INVALID MODIFIERS, MISSING OR INVALID PROVIDER INFORMATION (SUCH AS TAX IDENTIFICATION NUMBER), OR INCORRECT PLACE OF SERVICE.

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WHAT ARE SOME OF THE LESS COMMON REASONS FOR A CLAIM TO BE DENIED?

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MISSING SOME TESTS AND PROCEDURES, DIAGNOSIS AND PROCEDURE CODING ERRORS OR OMISSIONS, PAST FILING LIMITS FOR SUBMISSION OF CLAIM, AND DENIAL BECAUSE THE MEDICAL NECESSITY PROVISION HAS NOT BEEN MET

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HOW SHOULD DENIALS BE TRACKED?

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BY PAYER, TYPE OF DENIAL, AND PROVIDER.

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WHAT SHOULD YOU DO IF DENIALS START TO LOOK LIKE A TREND?

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PROVIDERS OR STAFF SHOULD BE INFORMED.

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HOW CAN YOU PREVENT DENIALS?

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MONITOR CORRESPONDENCE, INSTRUCTIONS, AND OTHER UPDATES FROM HIGH VOLUME PAYERS, AND SHARING INFORMATION WITH APPROPRIATE PROVIDERS AND STAFF MEMBERS.

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WHAT TYPE OF DENIAL CODES DOES MEDICARE USE?

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NONMEDICAL CODES

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WHY DOES MEDICARE USE NONMEDICAL CODES FOR DENIALS?

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TO PROVIDE MORE INFORMATION ABOUT A CLAIM, INCLUDING WHY IT WAS REJECTED

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WHAT CATEGORIES DO DENIAL CODES FALL UNDER?

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GROUP CODES, CLAIMS ADJUSTMENT REASON CODES, REMITTANCE ADVICE REMARK CODES, AND PROVIDER-LEVEL ADJUSTMENT REASON CODES

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WHAT INFORMATION IS REQUESTED FROM THE INSURANCE COMPANY FOR AN APPEAL?

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THE REASON THE CLAIM WAS DENIED, AN ACKNOWLEDGMENT OF THE RIGHT OF THE PATIENT TO FILE AN INTERNAL APPEAL, ACKNOWLEDGMENT OF THE RIGHT OF THE PATIENT TO REQUEST AN EXTERNAL REVIEW, IF THE INTERNAL APPEAL WAS UNSUCCESSFUL, AND IDENTIFICATION OF WHETHER A CONSUMER ASSISTANCE PROGRAM IS AVAILABLE WHICH VARIES FROM STATE TO STATE.

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AFTER REQUESTING AN INTERNAL APPEAL HOW LONG DOES THE PLAN HAVE TO RESPOND?

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72 HOURS AFTER RECEIVING THE REQUEST THE APPEAL IS FOR THE DENIAL OF A CLAIM FOR URGENT CARE. IF THE APPEAL CONCERNS URGENT CARE, IT MIGHT BE POSSIBLE TO HAVE THE INTERNAL AND EXTERNAL REVIEW TAKE PLACE AT THE SAME TIME. WITHIN 30 DAYS FOR DENIALS OF NON-URGENT CARE NOT YET RECEIVED. WITHIN 60 DAYS FOR DENIALS OF SERVICES ALREADY RECEIVED

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WHO PROVIDES THE INFORMATION ON REQUESTING AN EXTERNAL INDEPENDENT REVIEW AFTER AND INTERNAL APPEAL IS DENIED?

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THE PLAN MUST PROVIDE THE INFORMATION ON THE EXTERNAL INDEPENDENT REVIEW.

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WHAT ARE TWO REASONS WHY A CLAIM MAY BE DENIED?

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AN INVALID SUBSCRIBERS NAME WAS GIVEN OR A CODING ERROR WAS MADE

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WHAT IS THE ROLE OF THE ACCOUNTS RECEIVABLE DEPARTMENT?

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THE ACCOUNTS RECEIVABLE DEPARTMENT MANAGES FOLLOW UP TO THE BILLING PROCESS FOR A PROVIDER’S OFFICE

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WHAT ARE 2 KINDS OF INFORMATION THE CDM STORES?

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AMONG THE CORRECT RESPONSES ARE DESCRIPTION OF SERVICE, CPT/HCPCS CODE, REVENUE CODE, CHARGE OR SERVICE CODE, GENERAL LEDGER KEY, AND ACTIVITY/STATUS DATE

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WHAT DOES THE AGING REPORT REFER TO?

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THE CLAIMS THAT ARE OUTSTANDING

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WHAT IS THE ALLOWABLE CHARGE?

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THE AMOUNT THE INSURANCE COMPANY WILL PAY PROVIDERS

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A CHARGE THE PATIENT IS NOT EXPECTED TO PAY?

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DIFFERENCE BETWEEN A PROVIDER’S CHARGES AND WHAT THE INSURANCE COMPANY WILL PAY

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WHAT DOES RECONCILIATION MEAN?

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DETERMINING HOW MUCH THE PROVIDER HAD BEEN REIMBURSED AND HOW MUCH PATIENTS OWE

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WHAT ARE THE FOUR TYPES OF NON-MEDICAL CODES USED BY MEDICARE TO EXPLAIN CLAIMS?

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GROUP CODES, CLAIMS ADJUSTMENT REASON CODES, REMITTANCE ADVICE REMARK CODES, AND PROVIDER-LEVEL ADJUSTMENT REASON CODES.

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WHO BENEFITS FROM THE NEW APPEALS PROCESS AND WHY?

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THE PATIENTS BENEFITS BECAUSE THE NEW PROCESS LAYS OUT STEPS THE INSURANCE COMPANY MUST FOLLOW AND MAKES SURE THAT TASKS GET DONE IN A TIMELY FASHION

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WHEN CAN A PATIENT REQUEST AN EXTERNAL INDEPENDENT REVIEW?

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THE PATIENT CAN REQUEST AN EXTERNAL INDEPENDENT REVIEW AFTER AN INTERNAL APPEAL HAS BEEN DENIED