Insurance calling tips - 2014

Here is the list of Alphabet and how can we express during the insurance eligibility verificaton or any other calling process.

A for Alfa
B for Bravo
C for Charlie
D for Delta
E for Echo
F for Fox
G for Golf

Types of Reimbursement - 2014

Fee-For-Service

Fee-for-service is a method of payment where the provider is paid a fee for
each procedure performed and billed.

Global Reimbursement

Global reimbursement is a method of payment where the provider is paid one
fee for a service that consists of multiple procedure codes that are rendered
on the same date of service or over a span of time rather than paid
individually for each procedure code.

If a provider bills for several individual procedure codes that are covered
under a global procedure code, which is referred to as “unbundling,” Medicaid
Program Integrity will audit the provider’s billing.

Who is Pay to provider and what is offset - 2014

Pay-to-provider is a term used in the Medicaid program to refer to the enrolled Medicaid provider who receives payment from Medicaid for covered services provided to eligible recipients. The pay-to-provider can be the provider who has provided treatment to a Medicaid recipient or the provider group to which the treating provider belongs.

What is Offset

When an Insurance company had paid excess amount in the previous EOB to the provider or the billing office it will adjust that excess amount in the next EOB they sent (by reducing the exceeded amount). Thus the process of adjusting the excess amount paid by the insurance to the provider in their next EOB is called “OFFSET”.

What Is Difference Between Claim Rejection And Claim Denial?

Claim may have been rejected for lack of information that you didn’t provide ,denial usually means what ever you have applied for you didn’t get and that could lead back to the rejection due to lack of information.

There is no relationships between above three question so dont cofuse.

Overpayment Recovery (WO)

• Used when a previous overpayment is recouped from the provider of service.

• Used when a reversal and corrected claim are not reported in the same transaction. WO prevents the prior claim payment from being deducted from the transaction.

• Used to offset the PLB 72.

• Used when a reversal and corrected claim are reported and the overpayment is not immediately recouped. WO prevents the prior claim payment from being deducted from the transaction. 

Reference ID

• The Reference ID for the PLB WO contains the beginning date of service from the claim and the patient account number.

• When reporting a voided check, the Reference ID in the PLB WO is the voided check number (Medicare Solutions platform).

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund. We report a reversal to the original claim and

a corrected claim in the 835. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by

reporting the amount as a negative value in the PLB WO.

• If the reversal and corrected claim are not reported in the same 835 transaction, the 835 transaction that contains the reversal claim reports a negative value in the PLB WO. The 835 transaction that contains the corrected claim reports a positive value in the PLB WO

Overpayment Reduction (specific to Medicare Advantage products and plans carrying the Medicare Solutions or Evercare®name)

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund and report a reversal to the original claim and a corrected claim. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the overpayment amount as a negative value in the PLB WO. 

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

For Solicited Refunds:

• The reversal and corrected claim were reported in a prior 835 and included a PLB WO so that overpayment funds weren’t recouped.

• Once the refund is received by UnitedHealthcare, the refund amount is noted as a negative value in the PLB segment with the 72 Adjustment Reason Code.

• A PLB WO with the amount of the refund is then created to offset the PLB 72 and balance the 835 transaction. The PLB WO will contain a positive value

For Unsolicited Refunds:

• When we post a refund, we usually enter both a reversal of payment and a corrected claim so that the reversal and PLB 72 will be in the same 835 file.

• If the refund does not cover the entire overpayment amount, the 835 will also contain a PLB WO for the amount remaining to be refunded. The PLB WO will contain a negative value.

Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• When we receive a refund, we note the refund amount as a negative value in the PLB segment with the 72 Adjustment Reason Code.

• When a physician returns a UnitedHealthcare check, the voided check amount is noted as a negative value in the PLB 72.

The Reference ID in the PLB 72 will contain the voided check number.

• A PLB WO with the amount of the refund or voided check is reported as a positive value to offset the PLB 72 and balances the 835 transaction. We do not report a reversal and corrected claim in the 835 transaction

Billing and Reimbursement—Account Reconciliation

Negative Balance

Definitions

NEGATIVE BALANCE—A dollar amount owed to Harvard Pilgrim that is reflected on the summary page of the Explanation of Payment (EOP). Negative balances are created when Harvard Pilgrim retracts a previously paid claim. 

When a paid service is retracted on an EOP, the amount retracted becomes a negative or “owed” dollar amount. Harvard Pilgrim will recover this negative dollar amount by using other claims payments as credits to satisfy the negative balance.

When the negative balance amount exceeds the amount of credits available on the EOP, the negative value will be carried to a future EOP.

BEGINNING NEGATIVE SERVICE BALANCE—Retractions (Adjustments Not Applied) that were listed on a previous EOP that were not applied on the previous check run. This amount may or may not be applied during the current check run.

ADJUSTMENTS NOT APPLIED—Retractions that have not been subtracted from the current check amount. Amounts have not been subtracted because there was not enough money in the claims submitted during the current run.

EOP NEGATIVE BALANCE NOT APPLIED—Refers to a provider’s previous negative balance that has not been applied during the current check run. There is still a negative balance. The Negative Balance Not Applied is not cumulative. This amount will continue to appear on each EOP until it can be applied.

Retraction Causes

Some situations that cause a retraction and produce a negative balance include, but are not limited to:

• Duplicate payment • Payment to the wrong provider

• Payment for the wrong member 

• Contractual payments

• Internal and external audits • Retroactive termination of a member

Negative Balance Report

If a negative balance is created and/or if an existing negative balance is offset by claims activity during the check run, a negative balance report is produced. The Negative Balance Report provides a history of the debit and credit dates made to offset the negative balance.

Invoicing Negative Balances

When a provider’s federal tax identification number (TIN) is terminated or changed, recovery of any negative balance will occur through the standard claims run out period of 90 days. This also occurs when a provider (contracted or non-contracted) has a negative balance or no activity on their account within our system for 90 days. 

If a balance still exists after 90 days, Harvard Pilgrim invoices the provider for the amount owed. (Invoices are net 30 days.) If payment is not received through the invoicing process, Harvard Pilgrim reserves the right to place any uncollected funds in a collection status.

In Connecticut, Maine and New Hampshire, retractions including negative balances will be made in accordance with state retroactive denial claim guidelines.

To effectively collect the debt that agencies refer, the Treasury issues demand letters, conducts telephone follow-up, initiates skip tracing, refers debt for administrative offset, and refers debt to a private collection agency (PCA). 

Other collection tools may include Federal salary offset and administrative wage garnishment. The PCA could collect the debt with tools such as skip tracing, credit report search, demand letters, and telephone calls.

Hyperlink Table

Treasury Offset Program (TOP)

Overpayment Collection Process

If you do not pay the overpayment in full, you will receive an IRL 60–90 days after the initial demand letter. The IRL advises you that unless you refund the overpayment or take steps to establish an ERS, the MAC will refer the overpayment to the Federal level for collection. 

To collect the overpayment, CMS refers eligible delinquent debt to the Treasury or a Treasury-designated Debt Collection Center (DCC). Either the Treasury or the DCC works through the Treasury Offset Program (TOP) to collect the overpayment.

How To Tell If You Need One

You can easily tell if you would directly benefit from subscribing to an medical billing clearinghouse service by answering a few questions:

o Does your practice bill (or plan to soon bill) electronically?

o Does your practice bill a number of insurances, or just one?

o Is your staff experienced at billing electronically? (The less experience, the greater the need, and greater the benefit).

o What is your claim volume? The cost of a clearinghouse is often offset by no longer having to send in paper claims.

o Would it help to quickly and greatly reduce medical claim errors?

o Would it help to drastically shorten reimbursement times?

o Do you have better things to do than be on hold with carriers trying to figure out claim errors?

Emergency and Humanitarian Medical Care.

1. VA is authorized in accordance with 38 C.F.R. 17.43(b) (1), (3) to provide medical care or services to the general public and employees and their families in an emergency or on a humanitarian basis. 

Billing for such care is authorized in 38 C.F.R. 17.102(b). If a person provides their health insurance information, VA may bill the health insurance and balance bill the individual for the amount not paid by the individual’s health insurance. If a person does not have health insurance  information, a form letter will be sent to the person treated requesting payment for medical care or services provided to that person.

2. VA is authorized in accordance with 38 C.F.R. 17.43(b)(2) to provide medical care or services to a person – thought to have been discharged or retired from the Armed Forces – in an emergency. The person will be billed for medical care or services if it is subsequently determined that he or she was not eligible for treatment by VA. 

Billing for such care or services is authorized in 38 C.F.R. 17.102(a). If a person provides their health insurance information, VA may bill the health insurance and balance bill the individual for the amount not paid by the individual’s health insurance. If a person does not have health insurance information, a form letter will be sent to the person treated requesting payment for medical care or services provided to that person.

3. Interest and other late-payment charges are to be assessed on these debts as prescribed in Volume XII Chapter 1A, Interest, Administrative Costs and Penalty  Charges.

4. Compromise offers received on emergency or humanitarian medical debts will be processed in accordance with Volume XII Chapter 1C, Compromise of Debts. Referrals to the Treasury Offset Program (TOP) are governed by the procedures in Chapter 1E, Treasury Offset Program and Treasury Cross-Servicing. 

The procedures for suspension or write-off of collection action are contained in Chapters 1H, Suspension of Collection Action and 1I, Termination of Collection Action and Debt Close Out, respectively. Referrals for enforced collection are governed by the procedures in Chapter 1G, Referrals for Enforced Collection (Litigation).

C. Debt Collection Activities. VA will adhere to VA’s debt collection standards when collecting medical care debts from Veterans who received health care and services from VA medical facilities. It is important that VA advises the debtors of their due process rights.

Refer to Volume XII Chapter 1, VA Debt Collection Standards for more information on the standards to be followed by VA in its debt collection process. Refer also to the subchapters under Chapter 1 for delegation of authority responsibilities assigned to various VA officials for other various actions relating to debt collection; including waiver, suspension, compromise, termination of collection action, voluntary and involuntary offsets, and referrals of debts to Treasury or the Department of Justice (DOJ).

2. Referrals to the DMC and TOP. The VistA system does not allow automatic copayment referral to the DMC or TOP for Veterans with a service-connected rating of 50 percent or greater or for those in receipt of a VA pension. A manual review must be completed and if determined to be appropriate, charges will be verified and then referred to the DMC.

VA will monitor the co-payment debt collection activity using the following methods.

a. DMC. Accounts referred to the DMC are those that have a balance of $25 or more (accounts can consist of single or multiple charges), 30 days or more have passed since the third patient statement was mailed and bills are in an active status (not in a repayment plan), suspended pending an administrative decision, or referred to Regional Counsel.

These debts are then matched against the DMC pension system to identify those Veterans in receipt of VA benefits. Only accounts of those Veterans with an active award and a net check amount of greater than $25 are loaded into the DMC’s computer system and set up for offset.

All other accounts are returned to the medical center for other collection actions and eventual referral to TOP.

Any accounts not eligible for DMC offset are considered “DMC rejects” and are automatically stored in a file at the AITC. The “DMC Reject” file is used to create potential offset notification letters that the AITC sends to the Veteran informing them of impending referral to TOP.

The AITC holds the file of returned accounts for 60 days before passing them to TOP.

This “hold” ensures these debtors have the required amount of time to resolve their debt before referral to TOP.

b. AITC compiles referral information from all medical centers into an offset file and forwards to DMC. The DMC merges the VHA debt data with the VBA debt data and the Veterans Canteen Service (VCS) debt data and sends a master VA file to Treasury.

TOP Referrals include:

• First Party Medical Debts, including both ChampVA and TRICARE copayments;

• Ex-employee Debts;

• Current Employee Debts (unless in a repayment plan); and

• Vendor debts.

These bills have an account balance of $25 or more, including principal, interest, administrative cost, the debt is at least 120 days delinquent (150 days old) and the status of the bill is active.

Debts not referred to TOP include:

• Debts where the Veteran has included VA debts in their bankruptcy petition;

• Debt is in litigation – referred to DOJ;

• Debts where the debtor’s date of death is recorded in VistA;

• Debt is on repayment plan in VistA;

• Debt is in a suspended status; and

• Third-party (Insurance) debts are not eligible for referral to TOP

As debts become eligible, they are referred during the next monthly TOP transmission.

If a debt resides at Treasury for payment offset, the Account Receivable (AR) software will transmit increases and decreases to the debt balance. 

Increases may include new delinquent debts as well as additional interest and administrative charges.

Offset payments are recorded in the Financial Management System (FMS) by the DMC staff using Transfer Disbursing Authority (TDA). An electronic copy of the offset list is placed on a secure SharePoint server. VA and CPAC staff who have authorization can retrieve the TOP listing as it is posted.

3. Referrals to the RC/DOJ. First-party co-payment receivables will be referred for enforced collection (litigation) as prescribed in Volume XII Chapter 1G, Referrals for Enforced Collection (Litigation).

4. Write-Off. The fiscal officer, including the CPAC Fiscal Officer or their designees, may either write-off or refer for write-off, any delinquent first-party co-payment debt that meets the criteria set forth in Volume XII Chapter 1I, Termination of Collection Action and Debt Close Out. 

Write-off of any co-payment debt may be accomplished by delegation to the revenue program, even if they do not directly report to the finance activity; however, the responsibility and accountability remains with the finance activity, including CPAC finance activity.

5. Waiver. The fiscal officer, including the CPAC Fiscal Officer or their designees, may waive delinquent first-party co-payment debt that meets the criteria set forth in Volume XII Chapter 1B, Waiver of Debts. 

0506 DEFINITIONS

050615 Treasury Offset Program (TOP). Program required by the Debt Collection Improvement Act of 1996 to recover all referred agency debts delinquent more than 120 days, by offset of tax refunds and other Federal payments, including salary offsets,Federal retirement offsets or vendor offsets. Third-party receivables (health insurance, Tortfeasor, non-Federal Workers Compensation and No-Fault Auto claims) will not be referred to TOP.

0509 REVISIONS

Section Revision Office / Reason for Update / Effective Date

050617 Treasury Offset Program (TOP)

Updated to reflect mandatory change of 180 days to 120 days

OFP (047G)

To comply with new Law

APPENDIX B: FUNDS FOR DEPOSITS AND REFUNDS AND ASSOCIATED ADMINISTRATIVE FUNDS

The following table depicts the funds used for deposits and refunds for Medical Care Collections and the associated administrative funds.

RECEIVABLE TYPE          FUND COLLECTIONS DEPOSITED FUND REFUNDS RECORDED

Treasury Offset Program (TOP) Fee 

None 

36X0160X4

Examples of inappropriate increase adjustments for third-party AR are provided below:

A claim is issued to an insurance carrier for $120 for Mr. Smith. VA receives payment in the amount of $300. Upon receiving the payment, the AR staff contacts the insurance carrier for an explanation of their payment of the claim. 

The insurance carrier representative states “Yes, we overpaid VA on that claim by $180; however, we don’t need a refund, because we have offset your claim for treating another patient.” 

The AR staff increases the principal balance of Mr. Smith’s claim by $180, thereby retaining the overpayment, and decreases the balance of the other patient’s claim by $180, bringing the balance to zero. VA facilities may not adjust third-party claims in order to accommodate insurance carrier offset preferences.

The correct action is to refund the overpayment of $180 for the first claim.

The U.S. Government has paid the attached Medical Bills for you or your authorized dependent. The payment was authorized by the Department of State, office of Medical Services (State/MED). 

The U.S. Government acts a secondary payer of medical expenses authorized by State/MED for covered employees (16 FAM 520). You are hereby advised that you MUST file these USG paid medical expenses with your insurance companies. 

All reimbursements by your insurance companies MUST be returned to USAID. You are requested to file a claim with your insurance companies within 10 days of receipt of this notice. You must provide evidence or a written certification to this billing office that you have filed your claim within the 10 day window.

Insurance reimbursements MUST be provided to this billing office not later than 90 days from the date of this Billing Memorandum. If the insurance reimbursement has not been received by the employee within the 90 day window, a written explanation for the cause of the delay must be provided to this billing office. 

USPSC employees are expected to file claims with both their Medical Evacuation and Health Insurance Providers. Claims should be made first under the Medical Evacuation Policies and second under Health Insurance Policies. If an employee fails to maintain health insurance coverage (USPSC staff must maintain both health and medical evacuation insurance coverage), then the USG will NOT act as a secondary payer for these medical costs and the total amount becomes immediately due and payable by the employee (16 FAM 520).

If the employee has not provided full insurance claim reimbursement to this billing office 90 days from the billing date indicated above, or has failed to maintain health insurance (and medical evacuation coverage for USPSC staff), then the total medical bill debt is considered delinquent and the imposition of interest, penalty charges and administrative costs will be assessed against the debt in accordance with 22 CFR 213. 

USAID may collect this debt by administrative offset, salary offset as outlined within (5 U.S.C. 5514, 31 U.S.C. 3716, 5 CFR 550 K, and 31 CFR 900 through 904), or refer to the Department of Treasury, Financial Management Services (FMS). 

FMS will use all means available to the Federal Government for collection of this debt including offset against other payments that may be due you, administrative wage garnishment, collection agencies, and reporting the indebt ness to a credit bureau. Further, FMS will collect their administrative costs in addition to the amount you owe USAID. 

If FMS is unsuccessful in collecting the delinquent debt, there is a possibility that the debt may be referred to the Department of Justice for litigation.

You have a right to inspect and copy USAID records related to this debt. You may discuss and propose a repayment agreement for the indebt ness. You may dispute the validity of the debt and the dispute will be handled as outlined in 22 CFR 213. 

Interest, penalty charges, and administrative costs will continue to accrue on the debt during administrative appeal and during wavier consideration by the Agency unless precluded by statue. You should contact the billing office to discuss any questions concerning this debt. 

Scenario 2: The insurer adjusts and pays one or more line items. The provider submits a reconsideration bill with supporting documentation for payment of the original charged amount(s) for the original line item(s), and the original bill has been previously filed with the division.

In this scenario, the original bill has been electronically filed with the division within 45 calendar days of payment, adjustment and payment, disallowance or denial. When the reconsideration bill is received from the provider and paid by the insurer, submit a replacement bill, with a Report Reason Code of “03” (Replacement Report), to the division with the same control number used in the original submission. 

Include all of the original line items, reporting the new paid amounts (or any other data that have been changed) for those line items affected by the reconsideration, within 45 calendar days of receiving the reconsideration bill from the provider. 

The new paid amount must reflect the full amount paid to the provider for each line item – namely, the original amount plus the additional amount combined. Please report the received date of the original bill in the “Date Insurer Received Bill From Provider” field and the original paid date in the “Date Insurer Paid, Adjusted and Paid, Disallowed or Denied Bill” field. 

This replacement bill submission will allow a “final” version of the paid bill to be placed in the division’s medical database, without resulting in duplicate line item amounts that would erroneously offset the actual payment data.

When we can billing Medicaid patients? - 2014

We cant send the statement to Medicaid patient unless untill there are some valid reason behind it.

Other than copayments and coinsurance, the provider cannot seek payment from a recipient for a compensable service for which a claim has been submitted, regardless of whether the claim has been approved, partially approved or denied except under the following circumstances:

• The recipient is not eligible to receive Medicaid services on the date of service.

• The service the recipient receives is not covered by Medicaid.

• The provider has verified that the recipient has exceeded the Medicaid coverage limitations or frequency cap. The provider must inform the recipient that he or she has exceeded the frequency cap for the specific service to be rendered.

Medicaid copayment and coinsurance - List of service and its copays - 2014

For certain Medicaid services, the recipient is responsible for a set copayment or coinsurance that is to be paid directly to the provider

Copayment

A copayment is a predetermined amount of money, specified by Medicaid, that the recipient pays to a provider.

Coinsurance 

A coinsurance is a percent of the Medicaid payment that the recipient pays to provider.

Medicare Crossovers

Insurance calling process 2013

How to call insurance

The Night caller or AR caller (India) will call the insurance companies based on the patient accounts given by the Analyst (If it is in India, In US both persons are same). Caller will documents the telecom conversion in those respective patient accounts; also caller will send a report to the A/R Analyst on daily basis.

A/R caller will calls insurance companies over the telephone in order to get the reimbursement in a timely fashion. Let us see how the A/R caller calls the

What is ABN(Advance Beneficiary Notice) (Waiver of Liability) 2013

What is ABN(Advance Beneficiary Notice) (Waiver of Liability)

A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice

Assignment of insurance benefits

Glossary Durable Medical Equipment 2013

What is Durable Medical Equipment

Equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a contracting physician for use in the home. Examples are oxygen equipment, wheelchairs, hospital beds, and other items that the insurance company determines are medically necessary, in accordance with Medicare laws, regulations and guidelines.


E Codes:

Glossary Non-Participating 2013

What is Non-Participating.

In this scenario then the AR needs to identify if out-of-network benefits would be given to a particular patient under this Insurance in some cases the Insurance does not pay for out of network benefits, whereas in other instances there is a penalty of low reimbursement rate, and a slower processing time. Therefore these considerations need to be looked at critically in order to effectively coordinate the collection level.

What is NPI?

The National Provider Identifier (NPI) is another key initiative, which will help in the prevention of fraud and abuse.

NPI is an industry wide unique identifier for providers and suppliers created under the authority of the Health Insurance Portability and Accountability Act of 1996.
CMS developed the NPI effective from 1st Jan 1997.