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Medical Office Billing - A Self-Study Training Manual

Medical Office Billing - A Self-Study Training Manual

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Published by Liz Boten
Sarah J. Holt, PhD, FACMPE
Sarah J. Holt, PhD, FACMPE

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Published by: Liz Boten on Feb 07, 2013
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05/14/2014

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LESSON 8
Understanding the RevenueCycle — Post-visit: BulkClaims Management
153
OBjECTIVES
5
 
Identiy the elements o the post-visit phase o the revenue cycle dealing withbulk claims management.
5
 
Describe the claims submission process.
5
 
Clariy the role o the clearinghouse.
5
 
Examine between electronic and paper claims fling.
5
 
Understand the major elements o inormation included on the CMS 1500.
5
 
Describe the importance o timely and accurate payment processing.
POST-VISIT
Ater the patient visit, the insurance sta’s main work starts. The post-visit phase occurs aterdocumentation, coding, charge capture, and charge entry have taken place. The post-visitphase is considered in terms o bulk claims management and individual claims management.It is important to note that each medical practice must assess processes based on the volumeo generated claims and specialty type. It is critical that the claims management process betimely; the claim should be led as quickly ater the service is provided as possible. Filing orgenerating and submitting claims daily, is key to quick turn-around rom insurance carriers.Exhibit 8.1 provides a general overview o the claims management process.
CLAIM SUBMISSIO
Ater the patient has been seen, documentation o the visit has been completed, andcharges have been entered, the claim should be generated and submitted to the insurancecarrier as soon as possible, preerably the next day. Most medical practices submit claimselectronically. The submission o electronic claims should be utilized whenever possiblebecause it is more ecient and cost eective. It is important to have a computer vendorthat can ensure correct ormatting or the various claim types. Once the ormatting is set,the issue o human error is less problematic. Claims led electronically can be processed byinternal computer unctions.
 
154 MEDICAL OFFICE BILLING: A SELF-STUDY TRAINING MANUAL
A 2005 Medicare rule requires that claims or beneciaries be sent to comply with theelectronic claims ormat outlined by HIPAA. Thereore, more than 90 percent o claims aresent electronically. However, based on the individual carrier’s requirement, some claims areto be sent manually. Paper claims are likely to go through a more lengthy review or editprocess at the carrier that delays payment. Insurance sta must know the elements o thepaper claim, because those elements are mapped to the electronic claim. The fowchart inExhibit 8.2 provides a general overview o how to process bulk claims.The computer system should have some capability to scrub the claim beore it is led toidentiy whether it is a clean claim. I the claim needs to be corrected, it must be done beorethe claim is led. I the claim-scrubbing process is not electronic, then the process mustoccur manually in order to guarantee that claims that leave the practice are clean claims.Only clean claims will have a good chance o being paid.
ExHIBIT 8.1
 
n
 
Overview of Claims Management Process
Daily Processes: Bulk ClaimsManagement
5
 
Claims generated
5
 
Claims scrubbed
5
 
Claims corrected beore submission
5
 
Claims submitted
5
 
Confrm electronic claims submission
5
 
Generate/mail paper claims
5
 
Electronic payment posting
5
 
Manual payment posting — insurance
5
 
Manual payment posting — personal
5
 
Veriy payment amounts or accuracy
Manage Secondary Claims
5
 
Batch
5
 
Send
5
 
Follow up on Medicare crossover claims
5
 
Send letterI two carriers paid as primaryAsk or carrier resolution
Payment: Daily Bulk Management
5
 
Balance individual batches
5
 
Balance collective batches
5
 
Create daily deposit
5
 
Deposit daily income
 
 
LESSON 8 |
Understanding the Revenue Cycle — Post-visit: Bulk Claims Management
 
155
CLEARIGOUSES
Claims sent rom a medical practice typically do not go directly to the insurance carrier.Rather, when a claim leaves the medical practice, it goes through a clearinghouse beore itreaches the carrier. The clearinghouse, selected by the practice, acilitates claims processingand delivery. The role o the clearinghouse is to provide an interace or claims management.Clearinghouses receive claims rom a practice management system (PMS) through aninterace and move that inormation to the appropriate payers, both government andcommercial. In the role o acilitating claims processing, clearinghouses may receiveinormation containing nonstandard elements in a non-standard ormat and move thatinormation into a ormat acceptable to the payer intended to pay the claim. The reversemay also be true; standard transactions received by the clearinghouse may be put into a non-standard ormat or the receiving organization. Clearinghouses, like healthcare providers andhealth plans, are governed under the Privacy Rule. Clearinghouses operate with providersand health plans on a business-to-business level and do not deal directly with individualpatients. You can nd the ocial denition o a healthcare clearinghouse in the Departmento Health and Human Services nal HIPAA Privacy Rule in Section 160.103 (www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pd).Clearinghouses typically use decision-support tools to validate that claims are clean in regardto completeness and accuracy to ensure they are correct when submitted to the payer. Notall clearinghouses are alike, varying in their commitment to the provider and in their abilityto deliver high-quality services to providers.Some clearinghouses have high claims acceptance rates and good editing processes withshort time rames or reviewing claims or billing conficts. Clearinghouses are good businessassociates i they are able to provide the medical practice with ease in viewing, editing,
ExHIBIT 8.2
 
n
 
Post-visit Claims: Daily Bulk Management Flowchart
SubmitClaimsConfirmElectronicClaimsSubmissionMail PaperClaims
© 2012 Sarah J. Holt, PhD, FACMPE

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