Insurance AR Followup

Aida Anderson and Karen Lands

2010 HealthSystems
Webinar Series
May 25, 2010
Agenda for Today
• AR Reports

What is represented on the report?
• AR and Billing Components/Criteria

Use this valuable tool to review problem Financial Classes
• Billing spreadsheet/Columns/Sort

Manipulate columns and sort columns
Ӱɑ for quick review
• Drill down into visit

Transaction Tab

Notes tab/Centricity Scrub

Claims tab/Clearinghouse and Payer response

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A/R Defined
Accounts receivable (A/R) is one of a series
of accounting transactions dealing with the
billing of a customers for goods and services
received by the customers. In most business
entities this is typically done by generating an
invoice and mailing or electronically
Ӱɑ

delivering it to the customer, who in turn

must pay it within an established timeframe
called credit or payment terms

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Financial Class Defined
Financial classes identify and track groupings
of patients for reporting purposes. They
also determine which fee schedules are
used. A financial class can be Private Pay,
Medicare, Medicaid, PPO, Self Pay, etc.

The Financial class associated with the

primary insurance will be the financial class
defaulted for a patient

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Entered in Registration/Insurance

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F/C will be defaulted on visits created

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Modifying Financial Class
FC can be changed within the visit-without
modifying Patient Registration
• Work Comp
• Auto Accident
• Self Pay

Financial class is locked in when batch is closed

Money owed on a visit will remain in the financial
class for reporting purposes, regardless of
responsibility
What report shows AR by F/C?
• Aging by Financial Class
– This report lists accounts receivable for patient and insurance balance totals by
financial class. The totals are separated by aging category. The difference between
this report and the Procedure Date Aging by Financial Class report is that this
report takes all account activity (for example, balance forwards and transferred
balances) into consideration when aging the balances. The Procedure Date
Aging by Financial Class report ages based on the Date of Service/Date of Entry
of the procedures only and does not restart based on other account activity.

– This report is useful in analyzing what financial classes generate the highest
percentage of accounts receivable and where those figures fall in the aging
categories, which could assist in collections efforts or financial planning for your office.
Specifically, this report could be used to analyze negotiated contracts with various
insurance carriers according to their assigned financial class. The Aging by Financial
Class report could also be used to market your practice to desired financial classes
that may not be represented at the desired level within the accounts receivable.

– Note: For the ending A/R total to match the Financial Summaries, this report must be
generated through the current date or by date of service.
Aging by Financial Class Report

Leave options blank to

view “All”
Report example
Accounts Receivable Criteria
Accounts Receivable Module

Ӱɑ
Billing criteria
Billing Screen displays in Visit Status order
Accounts Receivable or Billing??
The choice is yours!
Accounts Receivable Billing

New Visits not displayed
All visit statuses available

Transactions viewed from
Must drill into visit to see
spreadsheet transactions

Must drill into Patient
Statements can be printed
demographics to produce a for visits selected on
statement spreadsheet

Must drill into visit to
Mass approvals and
approve or batch a visit batching can be done

Total Panel represents
Total Panel represents
selected Patient Total Spreadsheet Total
Visit Status is the key to follow up!
All of the following are included in the Ins A/R report
• In Progress
• Approved
• Approved Failed
• Batched
• Filed
• Sent
• File Succeeded
• File Rejected
• Collections
• User Assigned statuses
Visit Status: IN PROGRESS

The Visit status

flips to IN
PROGRESS after
charge entry,
copay posting, or
changing the data
when it’s NEW.
Caution Ahead: Things to Remember
IN PROGRESS-

A Visit can transition to a status of IN PROGRESS
by an accidental opening of the Visit in the Billing
component and clicking OK.

When a Visit transitions to IN PROGRESS, it
ɘҖ

separates itself from automatically updating if any

changes are made to Patient Information.
Visit Status: APPROVED

The Visit has “passed”
the 1st CPOPM edits
and the claim will be
“cleanly” printed to
paper or is ready for
the 2nd CPOPM edits,
“Batching” for electronic
submission.
Visit Status: APPROVE FAILED

The Visit can fail the 1st CPOPM internal

edits. These edits are system based and
check to see that a paper claim can be
“cleanly” generated. The edits do not check
clinical appropriateness (i.e., Dx, CPT
accuracy). A Visit can fail due to one or all
of the following general reasons:

Patient Information Errors

Charge Entry Errors

Administrative Setup Errors
The “Notes” tab of the Visit will contain the
reasons for the failure.
Visit Status: APPROVE FAILED

Details of the
Ӱɑ
APPROVE FAILED
visit will appear
here.
Visit Status: FILED

The Visit has been printed to
paper to the primary,
secondary, tertiary, or
beyond carriers the status
will change from Approved to
Filed-Primary, Secondary,
Tertiary, or Alternate.
The “Claims” tab of the Visit 㡐‫ى‬

will contain the details of the

filing history.

Filed-Secondary/Tertiary/Alt:
The Visit has “crossed-over”
to that carrier.

The Visit is now waiting for
payments and/or
adjustments.
Visit Status: BATCHED
This status is seen if:

filing to a supported clearinghouse.

A Visit has been successfully prepared (passed 1st
and 2nd Centricity edits) and “batched” in a file for
submission to the clearinghouse
‫ܖ‬
Visit Status: FILED REJECTED (Internal)
This status can have 2 different definitions:
Internal & External

File Rejected – Internal:

This status indicates that the Visit has failed the
2nd CPOPM edits as it attempts to “cleanly”
prepare the Visit for electronic submission.
These edits are system based and organizes
the data for electronic filing to the
clearinghouse. The edit does not checkጠ◌ܺ
clinical appropriateness (i.e., Dx, CPT
accuracy). A Visit can reject due to 1 or all of
the following general reasons:

Patient Information Errors

Charge Entry Errors

Administrative Setup Errors
The “Notes” tab of the Visit will contain the
reasons for the failure.
Visit Status: SENT
Indicates that a claim has been transmitted but reports have
not been received.

It is possible these claims NEVER reached the clearinghouse

ጠ◌ܺ
Visit Status: FILED SUCCEEDED

Claim has passed
Clearinghouse edits

Claim passed
Intermediary or Payer ጠ◌ܺ

edits
Visit Status: FILED REJECTED (External)
File Rejected – External:
If using a Supported
Clearinghouse AND if the Payer’s
Reports are capable of being
processed by CPOPM, the Visit
will be rejected whenK

it does not meet the
clearinghouse’s electronic “clean
claim” edits ጠ◌ܺ
AND / OR

it does not meet the payer’s
electronic “clean claim” edits

The rejection details are located

on the “Claims” tab of the Visit or
within an EDI Report
 Visit Status: WAITING PATIENT PAYMENT

The Visit status will transition to Waiting Patient Payment
when the entire balance (responsibility) is for the patient. In
other words, insurance has paid or adjusted off their
balance.

ጠ◌ܺ
Visit Status: COLLECTION

Indicates that this visit has an outstanding balance and

been placed in collections.
 Visit Status: OVERPAID

The Visit status will transition to OVERPAID when all payments to the
Visit have exceeded TOTAL Visit balance.

‫ܞ‬
Visit Status: BALANCE FORWARD

A Visit status of BALANCE FORWARD is achieved when the Balance
Forward component is utilized to “bring over” a credit or debit balance
into CPOPM from an outside product or process.
Visit Status: REFILE, REFUND, HOLD

These are manually
transitioned, user-
defined Visit statuses
that are typically used
according to office
policy and procedure. ጠ◌ܺ

Sometimes they are

used in conjunction with
the Visit Owner feature.
 Work visit statuses regularly

ܑ
縐◌
Customize Billing Screen view-User Based
You can control how the columns display on the
Accounts Receivable window.
Specifically, you can hide columns so that they do
not display.
You also can adjust the width of each column
ጠ◌ܺ

independently.
Billing Screen-adjust columns
Step 1-Right Click in Title

狐‫ل‬
Step 2-Select Columns to view

‫ܰ◌ܣ‬
Step 3-Arrange order of Visible Columns

綐‫ك‬
Adjust Column Width

To manually resize a column, place the pointer between the

columns you want to resize. The pointer changes to a
double-arrow which allows you to manually resize either the
column to the left or right of the pointer .
ጠ◌ܺ
Right Click on Header to save/sort

ꄐ‫ܞ‬
Drill into Visit-Transaction Tab

㡐‫ى‬
Drill into visit-Notes Tab
System generated rejections are
displayed in the notes tab

Examples
• Insured ID Missing
• COB information not balanced
• Assignment
‫ر‬
of Benefits not complete
• Referring Physician required

Correction needs to be made

• Patient Demographics
• Within the visit
• Administration
Correspondence Tab
• Click Add to Enter
note
• Note is date
stamped with
User name ጠ◌ܺ

• Cannot be
deleted or
modified
• Can be printed
Claims Tab

Ҟ
Claims Tab-Upper List Panel
• File Name: The name of the file (only applies to electronically filed claims).
• Filing Method: The name of the filing method.
• Filing Type: The filing type; either Electronic or Paper.
• Clearinghouse: The clearinghouse to which the file was sent (only applies to
electronically filed claims).
• Filed By: The user who filed the claim.
• Filed To: The insurance carrier to which the claim was filed.
ጠ◌ܺ
• Submission #: A number that uniquely identifies a claim (only applies to
electronically filed claims).
• Created By: The user who created the file.
• Date Created: The date the claim was created (only applies to electronically
filed claims).
• Procedures Filed: A comma separated list of procedure codes (not CPT
Codes) that were filed.
• Amount Filed: The total amount filed.
Claims tab overview-Paper claims

懠‫ܔ‬
Claims Tab overview-electronic claims

ጠ◌ܺ
Claims Tab Lower List Box
Displays a list of all report files that have been
generated related to the visit
• Date Received: The date the report file was
received from the clearinghouse.
• File Name: the name of the report file.
Җ

• DescriptionLists: the visit's claim results.

Double Clicking a report file launches a notes

editor, showing the contents of the Description
Field
Claims Tab overview-electronic claims

恰‫ܠ‬
Double clicking on the report will open the response

ҟ
Clearinghouse Edits update status
• File Succeeded-File Rejected
– If the ticket passes the clearinghouse edits an electronic message is
returned that updates the visit status to “File Succeeded”
– Clearinghouse may have payer specific edits by payer
– If the ticket does not pass the clearinghouse edits an electronic
message is returned that updates visit status to “File Rejected”
ጠ◌ܺ

Payer Responses update status

• File Rejected
EDI Reports from CEDI

• The reports from Centricity EDI Clearinghouse will

automatically Process and automatically Archive and will
display the information contained in the reports on the
Claims tab of each visit. The report filename structure is:
IDXRPTIDXRPT########.rpt. ‫ٰ◌ر‬

• The reports will update visit statuses to Filed Succeeded or

Filed Rejected accordingly.
EDI Reports from McKesson-aka RelayHealth
• 08_082004
– Transmission Report
– Auto Archives
– Transmission to the Clearinghouse was successful or not
• XA_082004 and XS_082004
– Technical Edit
– Auto Processes and Auto Archives
– McKesson applies technical edits to the FORMAT of your file, i.e. checking for punctuation,
etcKThe results of this report are stored on the Claims tab of each visit.
– If visit was accepted, visit status is changed to File Succeeded. If rejected, visit status is changed
to File Rejected 愐‫ܠ‬
• CA_082004
– Claims Acknowledgement
– Auto Processes and Auto Archives
– McKesson reporting whether or not they will accept each claim, after applying payer edits. The
results of this report are stored on the Claims Tab of each visit.
– If visit was accepted, visit status is changed to File Succeeded. If rejected, visit status is changed
to File Rejected
• EC_082004
– Excluded Claims Report
– Auto Processes and Auto Archives
– For the claims that excluded in the CA report. This report will list the REASON for the Rejection.
The results of this report are stored on the Claims tab of each visit.
– The visit status is changed to File Rejected
EDI reports from McKesson cont.
• SF Report
– Payer Report
– Auto Processes and Auto Archives
– Payer Response
– Will update visit status to “File Rejected” if Payer rejects

җ
Unable to interpret the denial?
• CEDI gives clear explanation plus gives added
advantage of the CEDI dashboard

• McKesson may be more difficult

ጠ◌ܺ

www.wpc-edi.com is an excellent resource-add

the link to your favorites!
Washington Publishing Co. website

www.wpc-edi.com

ጠ◌ܺ

Click here for Code Lists

53
Claim status codes

魨‫ذ‬

Select Claim Status Codes

54
 Claim status codes

Select
List for
review 螠‫ܞ‬

55
Payer Responses-What to expect!
Electronic Claims

• Initial response from clearinghouse within hours

• Acceptance/Rejection from Payer 24-48 hours
• Payment 7 days
• Visit updated automatically 魨‫ذ‬

Paper Claims

• Rejections received within 14 days-via mail

• Payment 14 days
• Manually review and document within Centricity
Questions and Answers

Thank you for attending!

ܑ
阐◌

Aida and Karen

We value your feedback

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