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

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

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.