Medical Billing process - AR analysis

Role of Account receivable person AR - part 1


Bringing down receivables

Let us discuss each category in detail.CLAIMS NOT IN SYSTEM
There may be various reasons why insurance carriers say claims are not in system.
(a) The claims mailing address may be incorrect.
(b) The claims have been sent inadvertently to another insurance company.
(c) The individual NPI, provider #, group provider # or the tax id # being used is incorrect or does not tally with the one available in the insurance company’s records.
(d) There has been a bombed transmission left unidentified.
(e) There has been a transmission rejection not acted upon.
(f) The claims have not been sent out at all in the first place either by transmission or by paper.
(g) The claims would be in transit.
(h) The insurance company would have a backlog in processing of claims.

CLAIMS DENIED

If the rules and regulations of the insurance company are not followed when reporting a claim, the claim will be denied. The insurance company sends an Explanation of Benefits (EOB) describing in detail why the claim was denied.


AR analysis role - denail managment is the key


The following may be the reasons why denied claims may still be sitting in the books.


(a) The denial would have been received and entered in the system but action not taken.


(b) The denial would have been received but not entered in the system and also no action taken.


(c) The denial would not have been received and the information that the claim was denied was received only through follow up call and no action has been taken.


(d) Action has been taken on the denials received or through follow up call but the corrected claim has not been resubmitted.


(e) Certain denials may require information from the provider or from the hospital such as an authorization #. If no action is taken to obtain this the claims will be just sitting in the books.


CLAIMS PENDED

Sometimes the claims may be PENDED by the insurance company for various reasons:

The following may be the reasons why claims would be PENDED.
(a) The insurance company may require some additional information to further proceed in processing of the claim. This information may be required either from the provider or from the patient and still not been submitted.

CLAIMS IN PROCESS

This information is either received through follow up call or by way of a regular mail (EOB). Until actual payment is posted against the claim, claims in process will still remain in the books. But once you have identified claims in process, it should ultimately either be paid or denied. If this turnaround doesn’t take place within a reasonable amount of time, investigation is required.


CLAIMS PAID

After claims have been paid by the insurance company, the AR analyst heaves a sigh of relief because one more claim has been reduced from his burden. But there are certain cases where even after checks have been issued by the insurance company, the claims are still outstanding:

The following may be the reasons why PAID claims would still remain in the books.
(a) The checks issued by the insurance company, but not sent.
(b) The checks issued by the insurance company to the correct address not received by the billing office.
(c) The checks issued by the insurance company to an incorrect address not received by the billing office.
(d) Cash received has not yet been posted.
(e) Cash received has been kept in unposted.
(f) Cash received has been posted to an incorrect claim.
(g) Claim would be sitting in the books as Low Paid but in reality it may not be so.

The analyst should find out whether the claims outstanding fall into any of the above category. If so, he should not only take corrective action but also ensure that the system check exists such that in future such errors do not occur. If every analyst performs his duty to the core, we will never face any problems in AR days and collections.

Let us discuss the AR strategy of major types of carriers.

Medicare

Average AR days:
For electronic claims 30 days
For paper claims 45 days

Filing Limit:
Next year Dec 31st


Appeal Limit:
Six months from the EOB date.

Medicare makes payment in 14 days for claims transmitted electronically and 27 days for claims transmitted on paper. Giving some time for posting of checks by the carrier, depositing in bank account, clearing of checks and receipt of EOBs at the billing office there should be no claims outstanding greater than 30 days for claims transmitted electronically and 45 days for claims sent by paper.

Medicaid

Average AR days:
For electronic claims 45 days
For paper claims 90 days

Filing Limit (for certain states):
New York Medicaid 90 days from DOS
Texas Medicaid 95 days from DOS
Pennsylvania Medicaid 180 days from DOS
Florida Medicaid 1 year from DOS

Since Medicaid is a state insurance plan, the processing time varies from state to state. Overall, you should not have any outstanding for more than 45 days for electronic and 90 days for paper claims. Since the filing limit for Medicaid claims is only 90 days for certain states (Some states have 180 days while some 1 year), we need to ensure that all claims reach the carrier within the first filing limit. This is very important because claims which do not reach the carrier within the filing limit would be blindly denied for crossing the filing limit and has to go through appeal process wherein you have to prove with supporting documents that you have submitted the claim within the filing limit.

BCBS

Average AR days:
For electronic claims 45 days
For paper claims 60 days

Filing Limit (in general): 6 Month from DOS

BCBS has various plans covering all states. Each one of them has different rules and regulations. There are local plans and out-of-state plans. You need to be clearly focused on where you should submit the claims. Also the id formats for each plan differ.

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