Document

Report
8
Posting Insurance
Payments and Creating
Patient Statements
Learning Outcomes
8-2
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.
Learning Outcomes (Continued)
8-3
When you finish this chapter, you will be able to:
8.7
8.8
Explain how statements are edited.
Demonstrate how to print patient statements.
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
8-5
8.1 Third-Party Reimbursement Overview
• 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
• 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
8-6
8.2 Remittance Advice (RA) Processing8-7
(Continued)
• Steps for processing
1. Verify all procedures listed on the claim are
represented on the RA
2. Review payment amount against expected
amount
3. Identify reasons for denials or payment
reductions; resubmit claim or appeal if necessary
4. Post payment information in the PMP
5. Bill patient’s secondary health care plan (if
appropriate)
8.3 Entering Insurance Payments
• 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
8-8
8.3 Entering Insurance Payments
(Continued)
• 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
8-9
8.3 Entering Insurance Payments
(Continued)
• 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
8-10
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)
• The type of payor—patient, insurance, or
capitation—is selected from the Payor Type
drop-down list
Payor Type
8-12
8.3 Entering Insurance Payments
(Continued)
• 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,
8-13
8.3 Entering Insurance Payments
(Continued)
• Once a payment is entered, it appears in the
Deposit List window
• Exercise 8-1 page 258
8-14
8.4 Applying Insurance Payments
to 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 Payments
to Charges (Continued)
• 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
8-16
8.4 Applying Insurance Payments
to Charges (Continued)
• The middle section of the Apply Payments to
Charges window is where payments are
entered and applied
8-17
8.4 Applying Insurance Payments
to 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 Payments
• Capitation payments are entered in the
Deposit List dialog box
– Capitation is selected from the Payor Type dropdown list in the Deposit window
Deposit dialog box for a
capitation payment
8-19
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)
• A second deposit is entered with a zero
amount to adjust the account
Deposit dialog box with a
zero payment amount
8-21
8.5 Entering Capitation Payments
(Continued)
• 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
8-22
8.6 Creating Statements
• Patient statements are a list of the amount of
money a patient owes, organized by the
amount of time the money has been owed,
the procedures performed, and the dates the
procedures were performed
– Created after an insurance claim has been filed
and RA has been received
8-23
8-24
8.6 Creating Statements (Continued)
• Statements are created in the Statement
Management area of Medisoft
Statement Management
dialog box
8-25
8.6 Creating Statements (Continued)
• When the Create Statements button is clicked,
the Create Statements dialog box opens
8-26
8.6 Creating Statements (Continued)
• The Create Statements dialog box contains
several filters, including:
–
–
–
–
–
–
–
–
Transaction Dates
Chart Numbers
Billing Codes
Case Indicator
Location
Provider
Amount
Statement Type
8-27
8.6 Creating Statements (Continued)
• Standard statements show all charges
regardless of whether the insurance has paid
on the transactions
• Remainder statements list only those charges
that are not paid in full after all insurance
carrier payments have been received
8-28
8.6 Creating Statements (Continued)
• Once statements have been created, they are
listed in the Statement Dialog box with a
status of Ready To Send
• Exercise 8-8 page 281
Ready To
Send status
8.7 Editing Statements
• If changes are necessary, highlight the
statement in the Statement Management
dialog box and click the Edit button
Edit button
8-29
8-30
8.7 Editing Statements (Continued)
• The Statement dialog box has three tabs that
contain important information that can be
edited:
– General Tab
– Transactions Tab
– Comment Tab
•Three
Exercise
8-9
tabs of the
Statement diaolg box
page 285
8.8 Printing Statements
• The Print/Send button in the Statement
Management dialog box is used to print
statements that are then sent out to patients
and guarantors
Print/Send button
8-31
8-32
8.8 Printing Statements (Continued)
• When the Print/Send button is clicked, a
statement method (paper or electronic) is
chosen from the Print/Send Statements dialog
box
8-33
8.8 Printing Statements (Continued)
• Next, the type of statement is chosen from the
list provided in the Open Report dialog box
8-34
8.8 Printing Statements (Continued)
• When the
Print/Send button
is clicked, paper
statements are
printed and
mailed by the
office
8-35
8.8 Printing Statements (Continued)
• Practices uses different methods to send
statements to patients
– In once-a-month billing, statements are mailed to
all patients at the same time each month
– In cycle billing, patients are divided into groups
and statement printing/mailing is staggered
throughout the month
• Exercise 8-10 page 289

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