Billing 101B Series Part IIBilling 101B Series Part II

Introduction

Router / Billing Cycle

Follow-Up Terminology Acronyms

MGBS Follow-Up Process

Appeals Process

Questions

TRANSACTION WITHIN THE UCSF BILLING SYSTEMS

Nancy Baird Router

TES (Edit Checking)

Pre-Bill (Edits)

IDX BAR

(Edits)

SMS (Edits)

Payor

Payor

(Electronic/Paper) Claims

(Electronic/Paper) Claims

(Electronic) Payments Rejections

(Electronic) Payments Rejections

(Manual) Payments Rejections

(Manual) Payments Rejections

Encounter Entry

THE BILLING CYCLE

Client Relations/ Services

A/R Analysis and Reporting

Billing Inquires (Customer Services)

QA and Training

1. Appointment Scheduling and Registration – The process of scheduling an appointment and obtaining and/or updating all current demographic, financial and insurance information.

2. Arrival/Check-In – The process of arriving patients, verify information and updating as necessary.

4. Coding and Batching the Encounter forms – The process of coding a visit completing an encounter form and batching encounter forms.

5. Charge Entry – The process of entering charges, CPT codes, and ICD-9 codes into a billing system.

3. Patient Care

6. Edit Resolution – The process of data verification encompasses TES, Z-Claim and Pre-Bill editing systems (in this order).

7. Claims Submission and Patient Billing – The process of submitting claims to third-party payors and mailing patient statements (bills).

8. Payment Posting – The process of posting payments and adjustments to open accounts.

9. A/R Follow-Up – The process of resolving outstanding accounts (non zero balance).

The billing cycle includes nine major steps and is supported by ongoing quality assurance and training, customer service, analysis and reporting and client relations

TerminologyTerminology

What is FSC?What is IMF?Edits (TES, Z-Claim, Pre-Bill)What is an EOB, EOMB & ERA?

Explanation of BenefitsExplanation of Medicare BenefitsElectronic Remittance Advice

What is POS?What is DRQ?What is A/R?

MGBS Follow Up ProcessMGBS Follow Up Process

Myth:Having insurance = paid services/automated

payment

Fact:

MGBS Follow-Up ProtocolMGBS Follow-Up Protocol

Follow-Up Phones, FAX, & Internet

PCS Workfile

Modified Account Balance

Example of PCS Workfile

Modified Account Balance Modified Account Balance CriteriaCriteria

1. FSC Category

2. Initial Claim Date

3. Tickle Code Assignment

4. Dunning Level (Self-Pay Only)

5. Sum of Invoice(s) Balance

PCS Workfile - examplePCS Workfile - example

Myth:Myth:Everything that we bill for gets paidEverything that we bill for gets paid

Fact:Fact:

Possible Actions on an Possible Actions on an Adjudicated ClaimAdjudicated Claim

AdjustmentsContractual Adjustments

Coding Adjustments

Risk Management Adjustments

Bad Debt

AdjustmentsAdjustments

Date of Service Contractual

Adjustment Amount

Billed Amount Allowed Amount

Possible Actions on an Possible Actions on an Adjudicated ClaimAdjudicated Claim

Rejections/Denials

Rejection/DenialRejection/Denial

Appeals ProcessAppeals Process

ManualWhen does MGBS file an appeal?

What process does MGBS use for appeal?

How do I know if a claim is being appealed?

Are appeals always paid?

What happens when an appeal is denied?

Appeals ProcessAppeals Process

Automated (EOB Resolve)Criteria:

Electronic payors for claims and payments

What payors are included?

Results since implementation (October 2007)?

Aetna (Appealing underpayments and clinical edits of $125k)

Blue Shield (Appealing underpayments and clinical edits of $68k)

Questions?