| Highlights |
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| Providing free resources and useful informations for Physicians, Office Managers, Medical Billers and Medical Coders |
| Tracking Your Claims Reimbursement |
were you reimbursed correctly? Are you sure the claims were processed
properly?
Look at the following scenario:
(1) 100% or Full Reimbursement is definitely NOT a good sign! The insurance
company could have reimbursed you below the maximum amount based on
your fee schedule or contracted rate.
The worse scenario would be, you are perhaps charging the insurance
company lesser or lower than what allowable amount!
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.
(2) 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outdated codes.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 may also be the
reason for no payment. Many insurance
companies require attached documentations to support medical necessity on
each claim submitted. Consider Workman’s Comp or Auto Accident Cases.
Surgical claims with modifier 59 or modifier 22 may need additional
documentations such as the operative report or pathology report. Another issue
maybe not meeting the reimbursement guidelines.
Your procedure code might not crossing over with the ICD9 or Diagnosis
codes based on Medical Necessity and Policy Guidelines. You can browse
your Insurance Policies and Guidelines Here.
properly?
Look at the following scenario:
(1) 100% or Full Reimbursement is definitely NOT a good sign! The insurance
company could have reimbursed you below the maximum amount based on
your fee schedule or contracted rate.
The worse scenario would be, you are perhaps charging the insurance
company lesser or lower than what allowable amount!
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.
(2) 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outdated codes.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 may also be the
reason for no payment. Many insurance
companies require attached documentations to support medical necessity on
each claim submitted. Consider Workman’s Comp or Auto Accident Cases.
Surgical claims with modifier 59 or modifier 22 may need additional
documentations such as the operative report or pathology report. Another issue
maybe not meeting the reimbursement guidelines.
Your procedure code might not crossing over with the ICD9 or Diagnosis
codes based on Medical Necessity and Policy Guidelines. You can browse
your Insurance Policies and Guidelines Here.
(3) 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 maybe 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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