Exam (elaborations)
CHAM ARRIVAL - REVENUE CYCLE QUESTIONS AND ANSWERS 2024
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CHAM ARRIVAL - REVENUE CYCLE QUESTIONS AND ANSWERS 2024
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CHAM ARRIVAL - REVENUE CYCLEIf the hospital employs physicians or bills for professional services, they may bill
on the 1500 claim form also known as the - ANSWERS-837p in electronic format.
Many functions happen in billing and dependent upon the accuracy of the front
Patient Access and middle Case Management/HIM, this determines how much
effort it will take to - ANSWERS-collect on a claim. The higher the clean claim rate
the lower the cost to collect.
Clean Claim Rate- - ANSWERS-This is the percentage of claims that pass internal
claim scrubber edits and EDI (claims clearinghouse edits) and go directly to payer.
Ensuring a high clean claim rates accelerates cash collection.
Cost to Collect- - ANSWERS-Clean Claim Rate This is the percentage of claims that
pass internal claim scrubber edits and EDI (claims clearinghouse edits) and go
directly to payer. Ensuring a high clean claim rates accelerates cash collection.
Functions performed by back office: - ANSWERS-1.Scrubbing of claim before
submission, working edits as they arise 2.Submission of claim- UB04, 1500, 837i or
837p3.Payer acknowledgment and adjudication a.Denial of payment b.Receipt of
Payment c.Request for more information 4.Posting of Payments and patient
payments 5.A/R Management and follow up: Denials, Patient Balances and Payors
,Insurance Follow Up - ANSWERS-Keeping track of each claim that is billed and
systemically documenting each event in the process of receiving payment is the
key to excellent customer service and financial success.
Follow up is truly critical but keep in mind the follow up has to be frequent and
systematic to be of any value. - ANSWERS-One phone call every month is not an
effective method to use in obtaining a payment. Thorough documentation is
critical. Not only for your own records, but is that others may understand what
actions have been taken or are expected. Do not rely on memory or cryptic notes.
One rule of thumb to remember with documentation is that if it is not
documented, it did not happen. Be sure to include first and last name of the
person you are speaking to. Remember in a large company there may be 5
women named Susan.
In general, the time periods for the insurance carrier to make their payment can
vary by plan type. - ANSWERS-
This varies based on - ANSWERS-facility contracts with payers including various
group plans. For example: An indemnity or PPO plan is to be paid within 30 days
An HMO is to be paid within 45 days Workers' compensation claim is to be paid
within 60 days Medicare pays generally pays within 30 days.
The claim is to be paid or denied within the above mentioned time periods,
provided the insurance carrier receives a clean claim. A clean clam is very
important. If the insurance carrier requires information that was incomplete or
missing, they receive additional - ANSWERS-time to process claim. *An extra 30
days if the requesting plan is an indemnity PPO. *An extra 45 days if the
requesting plan is an HMO.
, If a claim is being contested or denied, we are to be notified in - ANSWERS-writing
with the reason for the action spelled out specifically and clearly.
If the claim is not paid or denied within the legal period, - ANSWERS-the insurance
company is non-compliant. Note that there may be more specific laws at state
level
The number one delay tactic used by an insurance company is that they -
ANSWERS-have not received the claim. Ask the person to whom you are speaking
to verify the claim billing address. Even when the claim is sent electronically,
carriers will deny receipt of claim. Although electronic billing firms send us
confirmation of receipt, the carriers claim they do not have a system to track
incoming claims. However, the confirmation we receive through National
Association of Insurance Commissioners is sufficient for us to argue for prompt
payment. If the insurance carrier continues to delay the payment without
reasonable cause, notify your manager. If necessary, the account will be turned
over to a collection agency or legal department to pursue.
To improve claims management, denials must be quantified and processes put in
place for improvements. Best practices include: - ANSWERS-*Form a denials team
or include this in the revenue cycle team, to include finance, managed care
contracting, patient access for data accuracy and insurance verification, care
integration, HIM, and clinical departments. *Maintain a denial database,
preferably automated with a consistent coding structure to more easily trend
issues. With a historical database, appeals may be filed with positive outcomes.
The team will understand why claims are denied and be able to educate staff and
work with physicians and standards of care. *Contracts review - This team will
work with payers and will see how contract terms relate specifically to denials and
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