Ch. 8 Tracing Delinquent Claims and Problem Solving

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					Ch. 8 Tracing Delinquent Claims
and Problem Solving
Claim Management Techniques:
 Insurance Claims Register - See
  2.23, Ch. 2
 Tickler file or follow-up file: a way
  to track claims which have been
  submitted to payers
See figure 2-21, ch.2; Tickler files
 should be reconciled when
 remittance advice is received.
Any claims remaining in the file
 after a certain time frame should be
 investigated (see Table 8-1)
Problem claims

Delinquent, pending or suspense
 - payment to the provider of care
 is overdue
Lost claims - claim that cannot be
 located after sending it to an
 insurer (review procedure in text)
Rejected claims: claims submitted
 to insurance carrier that is
 discarded by the system due to a
 technical error or because it does
 not follow Medicare instructions.
 Claims are rejected for numerous
  reasons (see p. 269).
Denied claims: claims submitted
 to an insurance carrier in which
 payment has been rejected due to
 a technical error because of
 medical coverage policy issues
 See p. 270 reasons for denial
Downcoding:
 medical necessity is not evident in
  diagnosis codes
 unspecified codes are used
 invalid codes
 sex/code mismatch
Partial payment: if provider is
 entitled to more, go through
 appeal process
Payment paid to patient in error:
 p. 272
Two-party check
Overpayment: Refund the money
 immediately. See scenarios in
 text.
Rebilling

Rebilling: sending another
 request for payment for an
 overdue bill to either the
 insurance company or patients.
Claim Inquiries

Claim Inquiries or Tracers -
 inquiry made to an insurance
 company to locate the status of
 an insurance claim
Review and Appeal Process

Appeal: request for more
 payment made by asking for a
 review of an insurance claim that
 has been paid or denied by an
 insurance company.
Review p. 274 for reasons
Medicare Review and Appeal
Process
Inquiry
Request for review to look over a
 claim to assess how much
 payment should be made
 must be written and filed within 6
  months from date of initial
  determination (Fig. 8-2)
Fair Hearing: requested within 6
 months from date of review
 determination letter and amount
 in question is at least $100
Administrative Law Judge
 Hearing: must be requested
 within 60 days of the fair hearing
 decision and amount in question
 is at least $500
Appeals Council Review: must be
 made within 60 days of ALJ
 decision
Federal District Court Hearing:
 amount in question must be at
 least $1000 and must hire an
 attorney
Commissioner of Insurance

Monitors the activities of
 insurance companies to make
 sure the interests of policy
 holders are protected
Verifies contracts are carried out
 in good faith
Makes sure that insurance
 companies and brokers follow
 insurance laws of that state