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Billing 101B Series Part II

Billing 101B Series Part II. Introduction Router / Billing Cycle Follow-Up Terminology Acronyms MGBS Follow-Up Process Appeals Process Questions. Terminology. What is FSC? What is IMF? Edits (TES, Z-Claim, Pre-Bill) What is an EOB, EOMB & ERA? Explanation of Benefits

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Billing 101B Series Part II

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  1. Billing 101B Series Part II Introduction Router / Billing Cycle Follow-Up Terminology Acronyms MGBS Follow-Up Process Appeals Process Questions

  2. Terminology What is FSC? What is IMF? Edits (TES, Z-Claim, Pre-Bill) What is an EOB, EOMB & ERA? Explanation of Benefits Explanation of Medicare Benefits Electronic Remittance Advice What is POS? What is DRQ? What is A/R?

  3. MGBS Follow Up Process Myth:Having insurance = paid services/automated payment Fact:

  4. MGBS Follow-Up Protocol Follow-Up Phones, FAX, & Internet PCS Workfile Modified Account Balance Example of PCS Workfile

  5. Modified Account Balance Criteria • FSC Category • Initial Claim Date • Tickle Code Assignment • Dunning Level (Self-Pay Only) • Sum of Invoice(s) Balance

  6. PCS Workfile - example

  7. Myth:Everything that we bill for gets paid Fact:

  8. Possible Actions on an Adjudicated Claim Adjustments Contractual Adjustments Coding Adjustments Risk Management Adjustments Bad Debt

  9. Adjustments Date of Service Contractual Adjustment Amount Billed Amount AllowedAmount

  10. Possible Actions on an Adjudicated Claim • Rejections/Denials

  11. Rejection/Denial

  12. Appeals Process Manual When 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?

  13. Appeals 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)

  14. Questions?

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