Billing & Reimbursement Flashcards
What is Charge Capture?
The provider indicates services and supplies provided to the patient during a given encounter, along with relevant diagnoses.
What is the National Uniform Claim Committee(NUCC)?
This committee provides guidelines for each block of the CMS-1500 form.
What is the Electronic Format of the CMS-1500 Claim Form?
837P
What are the Six basic questions payers want to be answered?
Who, What, When, Why, & Where
What should you refer to for billing success?
The NUCC’s 1500 Health Insurance Claim Form Reference Instruction Manual
What information do blocks 1-13 include?
Patient demographics & insurance information
What information do blocks 14-33 include?
Provider & Procedure information
What is the Date of Service used for?
To determine insurance coverage & Global periods
What is Medically Unlikely Edits(MUE)?
This is a feature of the NCCI system and is used to prevent overpayments of codes with an unlikely value.
What does a Claim Edit program do in your billing software?
It identifies conflicting code entries or other edits and inconsistencies before claims are submitted to payers.
What is Claim Editing?
A step in the claims process in which appropriate codes and rules are verified before the claim is submitted.
What is Local Coverage Determination(LCD)?
This describes coverage determined by a MAC(Medicare Administrative Contractor) about a particular service on a local scale.
What is National Coverage Determination(NCD)?
This describes Medicare coverage for a specific services procedure or device on a national level.
What are exceptions to Medicare’s electronic filing rule?
- Claims submitted by beneficiaries
- Home oxygen therapy claims
- Organizations that submit roster claims, such as immunizations
- Organizations with less than 10 full-time employees
What is Optical Character Recognition(OCR)?
This is the red ink on the CMS-1500 claim form used to allow for optical scanning.
What is a Batch Claim Report?
This summarizes claim details including patient, payer, and date of transmission.
What is a Scrubber Report?
This is a clearinghouse summary of the number and total amount of claims.
What is a Transaction Transmission Summary?
This displays the status of claims as accepted or rejected.
What is a Rejection Analysis Report?
This identifies the most common errors by batch.
How can denied claims be resolved?
By appealing the decision and providing additional details and patient history of the condition or treatments to date.
What do Delinquent claims refer to?
Claims that are 30-45 days old
What does managing problem claims involve?
A focused approach by researching and resolving the type of problem.
When is resubmitting/rebilling a claim an effective method?
When the payer indicates no claim on file, referred to Lost Claims.
What if a claim was rebilled with no corrections?
It will be denied as a Duplicate Claim.
Where on the CMS-1500 form do you indicate that it is a “Corrected” claim?
Box 19
What is the Clerical Error Reopening(CER)?
This is a correction process used by Medicare that enables the correction of minor errors and omissions without resubmitting or appealing the claim.
What is an Appeal?
This is a request submitted to a third-party payer to reconsider a claim that has been paid incorrectly or denied.
What is the Appeals Process used for?
Claims that cannot be corrected, but the organization believes it was paid incorrectly or denied in error.
How can Appeals be performed?
By phone, provider portal, or written submission
What are two requirements of appeals that the biller must be familiar with?
- Have knowledge of the claim details
2. Be prepared to provide relevant details that support the claim
What do all Appeal Processes have that cannot be skipped?
Levels
What is a Payer Mix?
The showing of a percentage of usage under a specific payer. It shows how many patients of each payer the organization provides care to.
Why is the Payer Mix useful?
It helps when contract negotiations are being considered.
What are corrections you can make in the CER?
Add/Change/Delete Modifiers, Place of Service Codes, Adding/Changing Diagnosis Codes, Correcting the Date of Service, and Most Procedure Codes
How many Levels does the Medicare Appeal Process have?
Five
What are the Levels of the Medicare Appeal Process?
- Redetermination
- Reconsideration
- Disposition by Office of Medicare Hearings and Appeals(OMHA)
- Review by the Medicare Appeals Council(Council)
- Judicial Review in the U.S. District Court
What happens during Claim Adjudication?
The payer validates patient eligibility and determines the medical necessity of the claim. They also check the claim for accuracy and process it based on the organization or provider status and plan details.
What is the next step after Adjudication?
Receipt of Payment & the ERA/EOB
What is the ERA/EOB provide?
It provides the organization with the adjudication details made by the payer.
What is the Electronic Format of a Remittance Advice(ERA)?
835
When do you generate a patient statement?
After the insurance payment is posted and the patient’s financial responsibility has been applied.
What must you include when billing a Secondary or Tertiary(3rd) insurance?
You need the Primary insurance’s EOB and the Secondary insurance’s EOB for the Tertiary plan. You need to let the billed insurance know what balance is remaining for them to pay.
What is a Crossover Claim?
Medicare automatically forwards a claim/EOB to the secondary payer, relieving the biller of this task.
What is important to do before you bill the patient after a denial for a non-covered service?
Review all options with the payer
What does it mean when your Provider is In-Network?
Your provider or organization is contracted with that Payer/Insurance
What is a Fee-Schedule?
This is a list of the maximum allowed amount the provider will be paid for each service, regardless of the billed amount.
What is a Contractual Adjustment?
When the provider charges more than the allowed amount for a given payer and the overage is written off.
What is Electric Funds Transfer(EFT)?
The computer-based transfer of money. In the context of medical billing, it usually refers to an organization receiving reimbursement from a third-party payer.
How soon can you expect an EFT?
As little as 7 days
How soon can you expect payment on a paper claim?
Typically 30 days, but can take up to 1-3 months
What do you match the EFT with when posting payments?
The ERA
What is the final step in the Revenue Cycle?
Patient Collections
What is Collections?
The process of collecting data used to recover funds from denied, delayed, or rejected claims to obtain patient balance amounts.
What are some Best Practices for Collections?
- Call once a day between 8 am & 9 pm
- Be professional & courteous; explain why the balance is due
- Offer options
What is the Truth In Lending Act(TILA)?
This regulation applies to organizations that allow patients to make payment arrangements for a bill that is more than four installments. Must be a Written Agreement.
What is the Fair and Accurate Credit Transactions Act(FACT)?
It provides increased consumer protections against identity theft.
What is the Equal Credit Opportunity Act(ECOA)?
This is used in health care organizations that extend credit to patients for services rendered.
What do Collection Techniques begin with?
Clear Communication
Who regulates collection agencies?
Fair Debt Collection Practices Act(FDCPA)
What is an Estate Claims?
This is used when the patient is deceased but has an outstanding balance.
What happens if the patient responsibility amount remains unpaid after all collection attempts?
The organization may decide the amount is to be charged off or written off as a Bad Debt.
