Chapter 10: A/R and collection Concepts Flashcards
What is the first step to a denied claim?
Determine and understand why the claim was denied
Which denial is when the patient is covered under another insurance?
Coordination of benefits
Which are the two main types of bankruptcy seen by medical practices?
Chapter 7 & 13
Chapter 7 - liquidation
Chapter 13 - adjustment of debts of an individual with regular income
What is a statement sent to the patient from the insurance carrier explaining services paid for on their behalf?
EOB - explanation of benefits
What is the best way to handle a denial for incorrect information?
Contact the insurance company and the patient to see where the error is and get it corrected
Can a patient be refused treatment due to the ability to pay for the service?
Yes, if it is not an emergency situation
What is a lower level of care denial?
-Care provided on an inpatient basis is typically provided on an outpatient basis.
-Outpatient procedure could have been done in the providers office.
-Skilled nursing care old have been performed by a HH agency.
- An appeal should be written to insurance explaining why the higher level of care was required.
Which federal act states that third party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of the debt?
Fair debt collection practices act (FDCPA)
Which is the highest level of appeal process of medicare?
Judicial Review - final level of appeal for medicare
What is an ERA (Electronic Remittance Advice)?
An electronic statement sent by an insurance carrier to the medical provider
What information does the RA and ERA include?
Identifying information of the patient.
Claim amounts - total billed, adjustment, amount paid, claim total.
Claim status - paid, denied, pending
Explanation of decision
What represents money owed to the healthcare practice by patients and/or insurance carriers?
A/R - Account Recceivable
What are the functions of accounts receivable management?
Insurance verification
insurance eligibility
prior authorization
billing and claims submission
posting payments
collections
Which act prohibits third party debt collectors from calling debtors at odd hours?
Fair Debt Collection Practices Act (FDCPA) - third party collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred
What is the Prompt Payment Act?
A federal law that ensures that federal agencies pay their bills within 30 days of receipt and acceptance of material and/or services
Bankruptcy:
Chapter 7 vs. Chapter 13
Chapter 7: liquidation - assets are sold and payment is made to debtors. Most medical debt is discharged. (Written off)
Chapter 13: Adj. of debts of an individual with regular income - debts owed by the debtor are combined and the monthly payment is potentially reduced for the debtor. Provider or facility has the potential to receive a portion of the debt owed. Instructions for filing a claim will be on the back of the notice.
What steps must be taken when a provider or facility receives notice a patient has filed for bankruptcy?
- get case number (from patient or notice)
- verify case filing with bankruptcy court
- verify medical provider or facility is listed as a creditor
- stop all collection efforts on balances owed if listed as creditor (for balances inquired prior to filing for bankruptcy.)
What should be included in a Financial policy?
- total cost of the visit
- copays, coinsurance, and/or deductible that are required to be paid at time of service
- list insurance plans that are accepted
- practice policy for patients with out of network insurance plans
What is the prompt pay discount?
A discount given to self-pay patients when they pay at the time of service. Must be used consistently. Usually a percentage of the standard fee schedule
(Don’t confuse this with the prompt payment act!!!)
Prompt Payment Act vs. Prompt Payment Discount
Prompt payment act - federal law that ensures federal agencies pay their bills within 30 days of receipt and acceptance of materials and/or services
Prompt payment discount - a discount given to self pay patients when they pay at the time of service
Which act protects information collected by the consumer reporting agencies?
Fair Credit Reporting Act - protects information collected by the consumer reporting agencies such as the credit bureaus, medical information companies, and tenant screening services.
What is considered acceptable for when a provider wants to give a discount on services to a patient?
A provider who practices routine write-offs of copays and deductibles is at risk of violating insurance carrier contracts or federal and state laws. When a patient covered by insurance is offered a discount at the time of service, the insurance carrier must also be offered the same discount.
When should patient invoices/statements be sent to the patient?
As soon as the RA is posted and a balance is transferred to the patients account (pt responsibility)
*The sooner the invoice is received the sooner it is likely to be paid.
What are some potential errors that can occur during patient registration?
- Invalid address
- Invalid insurance information
- Invalid phone number
- Incorrect subscriber and DOB
- Patient Name and DOB doesn’t match insurance
