Understanding Billings, EOBs and Claim Denials (Pg. 80-84)

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Questions and Answers

What is the main advantage of electronic claim submission compared to paper claim submission?

It does not need external audits.

It allows for quicker payment processing. (correct)

It eliminates the need for clean claims.

It requires less accuracy.

What defines a clean claim?

A claim that is rejected by the insurance company.

A claim that is processed with no errors. (correct)

A claim that requires special inquiries.

A claim submitted only through paper methods.

Which type of audit is conducted after a claim has been submitted and remittance advice received?

Prospective audit

Internal audit

Retrospective audit (correct)

External audit

Which type of referral does not require prior authorization for medical necessity?

Self-referral Signup and view all the answers

What happens when a claim is rejected by an insurance company?

It cannot be processed and must be recompleted. Signup and view all the answers

Which form is the standard paper claim form used to bill insurance for rendered services?

CMS-1500 Signup and view all the answers

In the coordination of benefits, what determines the order of payment between multiple insurance payers?

Which payer is primary and secondary Signup and view all the answers

Which of the following should NOT be included when filling out a paper claim submission?

Punctuation as required Signup and view all the answers

What is the primary purpose of an Explanation of Benefits (EOB)?

To provide an overview of charges and payment responsibilities Signup and view all the answers

What distinguishes a rejected claim from a denied claim?

Rejected claims are never received by the insurer Signup and view all the answers

Which of the following is NOT a common reason for denied insurance claims?

Unauthorized medical services Signup and view all the answers

In the context of managing claims, what does the term 'appeal' refer to?

A request for reconsideration of payment after billing Signup and view all the answers

How is electronic remittance advice (ERA) related toExplanation of Benefits (EOB)?

ERAs are electronically sent versions of EOBs Signup and view all the answers

What does the reconciliation process involve regarding EOBs?

Comparing original bills with the EOBs from insurance companies Signup and view all the answers

What does it mean if a claim status is 'pending'?

The claim is awaiting additional information Signup and view all the answers

What action should medical assistants take when handling EOBs?

They must check EOBs and cross-reference them with billed services Signup and view all the answers

What should denied claims be submitted as to avoid duplicate service issues?

Corrected claims Signup and view all the answers

Which action should a healthcare provider take if they have questions regarding third-party reimbursement amounts?

Submit an appeal letter Signup and view all the answers

What is the primary purpose of a clearinghouse in the claims process?

To facilitate payment exchanges Signup and view all the answers

What does balance billing refer to?

Billing the patient for the difference in service reimbursement Signup and view all the answers

What do aging reports help medical offices determine?

Overdue invoices needing collection Signup and view all the answers

What should medical assistants do if a patient arrives while they are on the phone?

Smile and indicate to the patient that they will be assisted shortly Signup and view all the answers

Which aspect of the revenue cycle management process does collection involve?

Finalizing unpaid bills Signup and view all the answers

How often should fee slips be reviewed for accuracy?

Every year Signup and view all the answers

What is the role of encounter forms in medical practices?

To detail provided services for insurance processing Signup and view all the answers

What is the main function of cross walking in medical coding?

To map equivalent codes between different code sets Signup and view all the answers

Under what circumstances can providers write off unpaid bills?

As bad debt for accounting purposes Signup and view all the answers

What is crucial for medical assistants to understand regarding encounter forms?

The software used for completion Signup and view all the answers

Which of the following is the responsibility of a successful medical administrative assistant?

Balancing phone calls and patient interactions Signup and view all the answers

Why is record retention important in a medical setting?

To meet legal and regulatory requirements Signup and view all the answers

Study Notes

Explanation of Benefits (EOBs)

An Explanation of Benefits (EOB) is a summary of charges from a patient's visit, not a bill
Outlines services provided, insurer payment amounts, and patient/policyholder responsibility
Insurers send EOBs to providers, who must reconcile with the original bill
Many EOBs are now electronic, called electronic remittance advice (ERA)
ERAs and EOBs may not always include payments
Claims can be rejected, denied, or pending
Rejected claims: never reach the payer due to invalid information or coding
Denied claims: received by the insurer, but not paid
Pending claims: waiting on additional information
Medical assistants must review EOBs and match them against billed services

Appeals

Reconsideration of payment denial after a medical provider bills the patient
Can be granted or denied by the insurance, a third party, or the provider

Claim Denials

Common reasons for denied or rejected claims:
- Incorrect patient or policy information
- Missing documentation
- Coding errors
- Benefits not matching services
- Duplicate claims
Rejected vs. Denied claims:
- Rejected claims: can be corrected and resubmitted promptly
- Denied claims: require contact with the insurance company for resolution
- Denied claims must be resubmitted as corrected claims, not new ones
Providers can appeal claim denials to dispute payment amounts and request additional documentation

Claims Tracking & Follow-Up

Claims tracking ensures awareness of payment status
Follow-ups are necessary if patients, insurance companies, or third-party payers fail to make payments

Clearing Houses

Financial institutions facilitating payment exchanges for transactions involving securities, derivatives, or payment
Act as intermediaries between clearing firms

Cross Walking

Mapping equivalent or near-equivalent codes between different code sets
Most commonly performed between ICD-10 and ICD-9 codes

Superbill/Encounter Forms

Used by medical practices to summarize patient services for insurance processing
Include diagnostic and procedural codes, and fees charged by the provider
Preprinted fee slips are often used to track individual patient fees
Automated systems are being adopted for electronic encounter forms
Medical assistants must understand the use of these forms in the revenue cycle
Forms should be reviewed annually for accuracy in case of code updates

Record Retention

Storage duration of documents, determined by governing regulations
Ensures medical records are accessible when needed

Balance Billing

Charging patients for the difference between insurance reimbursement and provider fees

Aging Reports

List unpaid patient invoices categorized by date ranges
Helps medical offices identify overdue invoices requiring collection efforts

Telephone Courtesy

Professionalism is crucial in medical office settings
Medical assistants should practice professionalism in phone conversations, paperwork completion, and patient interactions
Proper response when dealing with patients arriving during phone calls:
- Acknowledge the patient with a smile
- Use an index finger to signal they will be assisted shortly
- Ask the person on the phone to hold
Professionalism must be maintained during conflicts with patients and coworkers

Electronic Claim Submission

Submitting claims electronically instead of on paper
Often done through billing agencies, especially for Medicare and Medicaid claims

Clean Claims

Claims with no unusual circumstances preventing timely payment
Easy submission processes for quicker payment

Types of Audits

Audits assess claims for accuracy and completeness before submission
External Audits: conducted by private payers or government agencies
Internal Audits: conducted by medical office staff or hired consultants
Retrospective Audits: conducted after claim submission and remittance advice received

Referrals

Formal Referrals: authorization request is required to determine medical necessity; usually obtained in writing or by fax
Direct Referrals: simplified form completed and signed by the doctor and handed to the patient
Verbal Referrals: primary care physician contacts the specialist and gives approval
Self-Referral: patient initiates the referral themselves

Claim Rejections

Claims failing to meet specific criteria and data requirements
Cannot be processed by the insurance company and require correction

Paper Claim Submission

Paper claims use Form CMS-1500 to bill insurance for services and supplies
Instructions for paper claim submission:
- Use original forms, preferably printed in red
- Use blue or black ink for any handwritten additions
- Ensure clear printing with dark toner
- Use font size 12 or larger in uppercase letters
- Print information within the designated blocks
- Avoid punctuation
- Avoid sending attachments unless required by the payer

Secondary Payer Coordination

In cases of multiple payers, coordination determines the:
- Primary payer: pays first
- Secondary payer: pays the difference after the primary payer's payment

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Description

This quiz explores the concepts of Explanation of Benefits (EOBs), appeals, and claim denials in the medical billing process. You will learn about the distinctions between rejected, denied, and pending claims, as well as the role of medical assistants in reviewing EOBs. Test your knowledge on how these elements affect patient billing and insurance interactions.