Billing 101B Series Part II

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Billing 101B Series Part II

• Introduction
• Router / Billing Cycle
• Follow-Up Terminology Acronyms
• MGBS Follow-Up Process
• Appeals Process
• Questions

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Terminology

• What is FSC?
• What is IMF?
• Edits (TES, Z-Claim, Pre-Bill)
• What is an EOB, EOMB ERA?
• Explanation of Benefits
• Explanation of Medicare Benefits
• Electronic Remittance Advice
• What is POS?
• What is DRQ?
• What is A/R?

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MGBS Follow Up Process

• MythHaving insurance paid services/automated
  payment

Fact
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MGBS Follow-Up Protocol

• Follow-Up
• Phones, FAX, Internet
• PCS Workfile
• Modified Account Balance
• Example of PCS Workfile

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Modified Account Balance Criteria

• FSC Category
• Initial Claim Date
• Tickle Code Assignment
• Dunning Level (Self-Pay Only)
• Sum of Invoice(s) Balance

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PCS Workfile - example
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MythEverything that we bill for gets paid
Fact
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Possible Actions on an Adjudicated Claim

• Adjustments
• Contractual Adjustments
• Coding Adjustments
• Risk Management Adjustments
• Bad Debt

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Adjustments
Date of Service
Contractual Adjustment Amount
Billed Amount
Allowed Amount
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Possible Actions on an Adjudicated Claim

• Rejections/Denials

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Rejection/Denial
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Appeals Process

• Manual
• When does MGBS file an appeal?
• What process does MGBS use for appeal?
• How do I know if a claim is being appealed?
• Are appeals always paid?
• What happens when an appeal is denied?

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Appeals Process

• Automated (EOB Resolve)
• Criteria
• Electronic payors for claims and payments
• What payors are included?
• Results since implementation (October 2007)?
• Aetna (Appealing underpayments and clinical edits
  of 125k)
• Blue Shield (Appealing underpayments and clinical
  edits of 68k)

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Questions?