MULTIPLE SERVICE PAYMENT POLICIES FOR THERAPY SERVICES PART 01

Rejected or denied claims

Reviewing all rejected/denied claims as soon as received.  In the case of electronic transactions, claims that contain bad data are pre-screened at the claims clearinghouse and are often seen back in your practice management software within 24 hours for quick correction and resubmittal.  Electronic claims that pass on to the payer can be processed within just a few days by receiving an ERA right into your medical billing system.

Iridium Suite Practice Management Software

Iridium Suite Practice Management software optimizes the advantages of electronic claims responses and remittances with unique warning system.  The user will see visual alerts when claims have been rejected or an ERA contains a denial.  These tools assist office staff to be continually aware of situations that negatively affect your Accounts Receivables.

Rejected or denied claims

Regular monitoring of all claims dated over 61 days for activity by office staff or payer.  Whether you have just had no payer response or you are waiting on a reply to some type of re-submittal, you must evaluate your aging Accounts Receivables for proper activity.  For instance, a claim sent with records for appeal should prompt a call to the payer at least every 4 to 6 weeks for a status update.

Iridium Suite Practice Management Software

Iridium Suite Practice Management software is designed for paperless AR follow up with an entire module in the software dedicated to sorting and prioritizing your ARs the way you like to see them.  Specific payers or issues can be divided up and assigned to individual office staff allowing for tracking of progress and positive resolutions.

The best plan for an efficient and productive medical office is to have a workflow process in place.  Hopefully you can implement the recommendations from this 6 part series to help you and your staff to create an office environment where each person can fulfill their duties with ease and confidence.

Medical Office Workflow Step 5: Payment Posting

Once your charges have made it out the door, you should expect to see payer responses in as little as 5 days for electronic claims transactions and 3 weeks for paper claims.  You may receive these responses electronically, which is commonly referred to as an Electronic Remittance Advice (ERA) or on paper.  The appropriate payments can also be received electronically via Electronic Funds Transfer (EFT) or by paper check.

Iridium Suite Practice Management Software

Iridium Suite Practice Management software imports the ERA and often can adjudicate the payments automatically in the indicated patient's account.

Prevent claim denials

Information regarding denials is attached to the designated services with complete details allowing medical office staff to research and choose the best action in order to resolve the denial with the payer.

Medical billing hint “Understanding Explanation of Benefits Statements.”

Whether or not your medical billing software has the ability to automatically post your ERA’s, you will need to have a full understanding of the terminology used on any format of payer remittance.  The “Amount Paid” column is of course the most self-explanatory; it is the details that accompany the non-payment amounts that are much trickier to navigate.

Explanation of benefits

The explanations for non-payment amounts are indicated by using a combination of the Claim Adjustment Group Code (two alpha characters)and a Claim Adjustment Reason Code that can be numeric or alpha-numeric.  There are 5 Claim Adjustment Group Codes:

CO - Contractual Obligation – most commonly refers to un-allowed amounts based   on the payer’s contractual fee schedule amount.

CR  - Corrections and Reversal – used to indicated a reprocessing of a claim that was overturned on appeal or denying a previously approved service

OA - Other Adjustment – default code used when others may not be applicable

PI - Payer Initiated Reductions – may reflect a penalty imposed by the payer

PR  - Patient Responsibility - typically applies to amounts for deductible, copayments and coinsurance per patient policy

Claim Adjustment Reason Codesrange from 1 to W2 and help to define the adjustment, by communicating why a claim or service line was paid differently than it was billed.