Posting Insurance Payments and Creating Patient Statements

1. 8 Posting Insurance Payments and Creating Patient Statements

2. 8-2 Learning Outcomes When you finish this chapter, you will be able to: 8.1 Describe how an adjustment is calculated if the payer pays less than the provider’s usual fee. 8.2 List the five steps for processing a remittance advice. 8.3 Demonstrate how to enter insurance payments. 8.4 Demonstrate how to apply insurance payments to charges. 8.5 Demonstrate how to enter capitation payments. 8.6 Demonstrate how to create patient statements.

3. 8-3 Learning Outcomes (Continued) When you finish this chapter, you will be able to: 8.7 Explain how statements are edited. 8.8 Demonstrate how to print patient statements.

4. 8-4 Key Terms • capitation payments • cycle billing • electronic remittance advice (ERA) • fee schedule • once-a-month billing • patient statement • payment schedule • remainder statements • standard statements

5. 8-5 8.1 Third-Party Reimbursement Overview • A fee schedule is a document that specifies the amount the provider bills for provided services • List of the provider’s standard fees • Not necessarily the amount a provider is paid • Difference between amount in fee schedule and amount paid is an adjustment • A payment schedule is a document that specifies the amount the payer agrees to pay the provider for a service, based on a contracted rate of reimbursement

6. 8-6 8.2 Remittance Advice (RA) Processing • An electronic remittance advice (ERA) is an electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier • ERA – uses the ASC X12 835 Remittance Advice Transaction (or 835) • RA – Paper format

7. 8-7 8.2 Remittance Advice (RA) Processing(Continued) • Steps for processing • Verify all procedures listed on the claim are represented on the RA • Review payment amount against expected amount • Identify reasons for denials or payment reductions; resubmit claim or appeal if necessary • Post payment information in the PMP • Bill patient’s secondary health care plan (if appropriate)

8. 8-8 8.3 Entering Insurance Payments • Payment information is entered in Medisoft through the Enter Deposits/Payments option on the Activities menu • Deposits are created within the Deposit List dialog box

9. 8-9 8.3 Entering Insurance Payments(Continued) • The Deposit List dialog box lists deposits for a specific date, or all deposits can be viewed • There are several other sorting features as well

10. 8-10 8.3 Entering Insurance Payments(Continued) • The Deposit List dialog box includes a column where the Payor Type can be identified • Capitation payments are made to physicians on a regular basis (such as monthly) for providing services to patients in a managed care insurance plan • Flat fee is paid to the physician no matter how many times a patient receives treatment

11. 8-11 8.3 Entering Insurance Payments(Continued) • To enter a deposit, click the New button in the Deposit List dialog box and the Deposit dialog box appears Deposit dialog box

12. 8-12 8.3 Entering Insurance Payments(Continued) • The type of payor—patient, insurance, or capitation—is selected from the Payor Type drop-down list Payor Type

13. 8-13 8.3 Entering Insurance Payments(Continued) • Other information entered about the deposit includes: • Deposit date • Payment method • Check number • Description/Bank No. • Payment amount • Deposit code • Insurance • Codes for payments, adjustments, withholds, deductibles, and take backs

14. 8-14 8.3 Entering Insurance Payments(Continued) • Once a payment is entered, it appears in the Deposit List window • Exercise 8-1 page 258

15. 8-15 8.4 Applying Insurance Paymentsto Charges • Once a deposit is entered, the next step is to apply the payment to patient accounts • Highlight the payment in the Deposit List and click the Apply button, opening the Apply Payment/Adjustments to Charges dialog box Apply Payments/ Adjustments to Charges dialog box

16. 8-16 8.4 Applying Insurance Paymentsto Charges (Continued) • Next, the patient who has a transaction listed on the RA is selected from the drop-down list in the For box • The upper-right area of the dialog box lists the amount of the deposit that has not yet been applied

17. 8-17 8.4 Applying Insurance Paymentsto Charges (Continued) • The middle section of the Apply Payments to Charges window is where payments are entered and applied

18. 8-18 8.4 Applying Insurance Paymentsto Charges (Continued) • The lower third of the Apply Payment/Adjustments to Charges window contains several options that affect claims and statements • Exercise 8-2 page 26 • Exercise 8-3 page 267 • Exercise 8-4 page 268

19. 8-19 8.5 Entering Capitation Payments • Capitation payments are entered in the Deposit List dialog box • Capitation is selected from the Payor Type drop-down list in the Deposit window Deposit dialog box for a capitation payment

20. 8-20 8.5 Entering Capitation Payments(Continued) • Capitation payments are entered but not applied • The charges in each patient’s account must be adjusted to a zero balance to indicate that the obligation has been met by the insurance company and patient

21. 8-21 8.5 Entering Capitation Payments(Continued) • A second deposit is entered with a zero amount to adjust the account Deposit dialog box with a zero payment amount

22. 8-22 8.5 Entering Capitation Payments(Continued) • When zero amount is saved, the deposit appears in the Deposit List window • Payment column lists “EOB Only,” since no payment is associated with zero amount deposit • Exercise 8-5 page 274 • Exercise 8-6 page 275 • Exercise 8-7 page 275