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Section 4 CRCR
Post Service Financial Care
| Question | Answer |
|---|---|
| Fraud | Occurs where cash changes hands a human failing that can be minimized by hiring the right staff, effective supervision and internal and external controls, employee awareness of cross checks, audits, and prosecution |
| Cash Posting Mail Receipt of Checks | Opened and endorsed the checks are deposited. Then a second person does the actual posting and the balance of payments is done by another person |
| Cash Receipts | Sent to the supervisor for special handeling |
| Lock Box | improves security and expedites the deposit of funds. Deposit details are sent via ERA which can be posted to hospital account |
| ERA | Electronic Remittance Advice |
| EFT | Electronic Funds Transfer |
| What is EFT | transfer of funds from payer to payee. the fastest way to move money |
| EFT Balance & Control | cash deposited directly omt a healthcare providers account. Bank informs provider of the amount received and issues a deposit. Providers balance the deposit to ERA received |
| ERA 835 Data Set | Standardized healthcare claim payment remittance advices used to electronically send 3rd party payment details to healthcare providers. There are 4 different levels of automation that can be used |
| Level 1 | electronic receipt of data only. ERA received and printed. Printout is processed as a paper remittance advices. Standard format for data entry |
| Level 2 | Electronic receipt and electronic data entry. ERA is received & entered into a computer electronically & viewed on a terminal. Automated entrty of information but a manual matching of remittance into a individual account & reconciliation submitted |
| Level 3 | Electronic receipt data entry posting and closing ERA received is a.nd enter into a computer electronically. The remittances is electronically posted by the patient accounting software simultaneously updating the patient account. |
| Level 4 | total automation of receipt, data entry payment posting and adjustment processing. Level 3 and is linked with banking information to allow reconciliation of payments received electronically through a non bank network with funds received electronically |
| Credit Balances Netted | Payment and contractual adjustments posted and exceed the overall chares. Identify and resolve in accounts receivable. If there is a credit balance and it is not identified the accounts receivable is understated |
| Reasons for Credit balances | Posting error, billing and payment error, overpayment, duplicate payments, Late charge credits, primary and secondary payers, inaccurate estimate or collections |
| Credit balance liability | reported on the financial statement as a liability. Must be reported to CMS quarterly on CMS 838 |
| Incorrectly posted allowances or payment estimates | occurs when a payer with multiple health plans. Patients are registered with the wrong plan type |
| Duplicate Payment | happens when providers re-bill claims based on nonpayment from the initial bill submission |
| Late charge credits processed after the claim is billed | originates from service department that did not process charge withing the organization suspension days |
| The primary and secondary payers both paying as primary | coordination of benefits is not captured correctly during registration. The secondary is not aware of the primary |
| Inaccurate up front collections bast on incorrect estimates of patient liability | results when there are other healthcare claims in process and the anticipated deductible and coinsurance amounts still show open but have been met |
| Claims rejection | health plan cannot process the claim due to bad claim data and is returned to the provider |
| Types of Denials | clinical, technical, and underpayment |
| Clinical Denial | deals with dcare of service |
| Technical Denial | doesn't meet health plans rules. missing incomplete claim information |
| Underpayment Denial | health plan does not pay the contractual amount |
| Pre-service denials | no pre-authorization, clinical information not called in for certification, insurance not verified, incorrect data entry, invalid registration information |
| Time of service denials | new technology used but coverage not determined, charges bundled incorrectly, Patient acuity level changes but service does not, admission notification incomplete, patient admitted as inpatient and should be observation, Test performed not on order |
| Post service denials | Late charges added after suspense days, multiple claims sent with dates of service overlap and untimely filing |
| RAC | Recovery Audit Contractors |
| What is RAC | Protects medicare from fraud and abusive billing. Identifies improper payment |
| Medicare Appeals Beneficiary | individuals can dispute the decision of the claim by reconsideration, a hearing, and judicial review of the final decision after the hearing |
| Medicare Appeals Provider | Section 1878 allows for the provider and other entities to request a hearing to dispute the cost to its Medicare Administrative contractor the amount must be more than $1000 and less than $10000 |
| MAC | Medicare administrative contractor |
| Waiver of Liabilty | established by Medicare used to protect patients and providers from liability if services are denied due to inappropriate or medical unnecessary services |
| Types of Liens | Agreement, Judicial, and Statute |
| ACA Requirements | Community health needs assessments, Policies related to financial assistance, Emergency medical care, and Billing and collection activities |
| FAP | Financial Assistance Policy |
| Title I | Truth in Lending Act : Regulation Z |
| Title III | Restrictions on garnishment = 25% of a workers disposable income per week pr the amount in which the weekly wage exceeds 30 times the federal minimum wage whichever is less |
| Title VI | Fair credit reporting act: |
| Title VIII | FDCPA |
| Section 804 | Regulates skip tracing |
| Section 805 | Communication with consumer |
| Section 806 | Harassment |
| Section 807 | False, deceptive or misleading representation |
| CFPB | Consumer Financial Protection Bureau |
| What is CFPB | an independent government agency responsible for consumer protection in the financial sector. Reviews activities under FDCPA |
| Dodd-Frank Wall Street Reform and Consumer Protection Act | created CFPB |
| Policies and procedure | segmenting responsibility so that not one person has the responsibility to post changes , payments, or write offs without balancing control |
| Cash Posting : Payment made during registration , reception or other places | Immediately noted on the registration form . Patient can get a receipt. The receipt number must be controlled during the reconciliation process. |
| Processing General Ledger cash | requires separation of duties. Payments are logged to the correct department Receipts are group and cash batched by groups. Totals are balanced. Payments are totaled and documented. Money is taken to the cashier to total again, cash slip is created. |
| Incorrectly posted allowance or incorrect payment estimate | occurs when there is a payer with multiple health plans and the patient was registered with the incorrect plan. |
| How do you resolve incorrect posted allowance or incorrect prepayment estimate | Compare contractual rates with the reimbursement rates and compare . If the remittance advice is correct adjust the cotrontractual posted at the time of billing . If contractual is correct contact the payer for the payment correction |
| Inpatient Reasons for Denial | a patient bill for observation but they should have been billed for admissions. PT was admitted but not medically necessary and the registration is incomplete. |
| Follow Up Work flow. | Open third party balance. A policy specifying when unresolved 3rd party clean claim becomes the patient responsibility |
Created by:
greenaka1908