8 posting insurance payments and creating patient statements
TRANSCRIPT
8Posting Insurance Payments
and Creating Patient Statements
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.
8-2
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.
8-3
Key Terms• capitation payments • cycle billing • electronic remittance
advice (ERA)• fee schedule • once-a-month billing • patient statement • payment schedule • remainder statements • standard statements
8-4
8.1 Third-Party Reimbursement Overview
8-5
• 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
8.2 Remittance Advice (RA) Processing
8-6
• 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
8.2 Remittance Advice (RA) Processing
(Continued)
8-7
• Steps for processing1. Verify all procedures listed on the claim are
represented on the RA2. Review payment amount against expected
amount3. Identify reasons for denials or payment
reductions; resubmit claim or appeal if necessary4. Post payment information in the PMP5. Bill patient’s secondary health care plan (if
appropriate)
8.3 Entering Insurance Payments8-8
• 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
8.3 Entering Insurance Payments(Continued)
8-9
• 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
8.3 Entering Insurance Payments(Continued)
8-10
• 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
8.3 Entering Insurance Payments(Continued)
8-11
• To enter a deposit, click the New button in the Deposit List dialog box and the Deposit dialog box appears
Deposit dialog box
8.3 Entering Insurance Payments(Continued)
8-12
• The type of payor—patient, insurance, or capitation—is selected from the Payor Type drop-down list
Payor Type
8.3 Entering Insurance Payments(Continued)
8-13
• 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
8.3 Entering Insurance Payments(Continued)
8-14
• Once a payment is entered, it appears in the Deposit List window
• Exercise 8-1 page 258
8.4 Applying Insurance Paymentsto Charges
8-15
• 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
8.4 Applying Insurance Paymentsto Charges (Continued)
8-16
• 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
8.4 Applying Insurance Paymentsto Charges (Continued)
8-17
• The middle section of the Apply Payments to Charges window is where payments are entered and applied
8.4 Applying Insurance Paymentsto Charges (Continued)
8-18
• 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
8.5 Entering Capitation Payments8-19
• 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
8.5 Entering Capitation Payments(Continued)
8-20
• 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
8.5 Entering Capitation Payments(Continued)
8-21
• A second deposit is entered with a zero amount to adjust the account
Deposit dialog box with a zero payment amount
8.5 Entering Capitation Payments(Continued)
8-22
• 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