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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
Objective and Purposes of CBA
 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.
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
 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)
 Claim review is retrospective. Claims examiner can’t affect benefits.

 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
In addition to Steps 1-8 above, the Disability CBA Process Includes:
 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
 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)
 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.
 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.
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.