Your One-Stop Free Source for Medical Billing, Coding, Claims
Reimbursement and Medical Office Management Information
Providing free resources and useful informations for Physicians,
Office Managers, Medical Billers and Medical Coders
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Tracking Your Claims Reimbursement
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before posting payments to the patient’s account. Responsibly ask
yourself, were
you reimbursed correctly? Are you sure the claims were processed
properly?
Look at the following scenario:
100% or Full Reimbursement is definitely NOT a good sign! The
insurance could
have reimbursed you below the maximum based on your fee schedule.
The worst
scenario would be, you are perhaps charging the insurance lesser or
lower than
what they are willing to pay on maximum. Do you have your fee schedule?
If no,
you must request this from the insurance companies that you are
contracted with.
Always review your contracts.
The EOB shows NO PAYMENT is most likely due to Coding Issues or
Non-
Coverage of the patient. Make sure you use the proper codes. Be careful
with
outdated codes. Always discuss coding solution rather than more on what
you
want to get reimbursed. Consider lack of documentations. Many insurance
companies require attached documentations to support medical
necessity on each
claim submitted. Consider Workman’s Comp or Auto Accident Cases.
Managed
Care Patients.
The EOB shows “reduced rate” payment. You must suspect that this might
be due
to improper coding. There might be one or more procedure code lines.
Many
procedures also require codes for drugs, radiology to be coded
separately.
Proper use of modifier is also an issue. Use of place of service POS
code 11 or
such as 22. Most insurance company pays lesser if the procedure is done
in an
outpatient hospital than in the office. Limitations on number of frequency
per day
might also be the reason for reduced rates. Non-Authorization is also a
possible
cause. Be careful with unbundling codes and mutually exclusive
procedure codes.
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