Question

Lisa Warren is a newly hired health insurance specialist at a small medical practice, and she is responsible for completing and submitting CMS-1500 claims. Toward the end of her second day on the job, she is asked to take a phone call from a patient who has questions about his submitted claim.

The patient tells Lisa that he just received an explanation of benefits (EOB) from his third-party payer, and it makes no sense because the bottom part of the form that is supposed to include a tear-off check is blank. He tells Lisa that EOB says that he agreed to the assignment of benefits. The patient is upset because he needs that money to buy groceries.

Lisa uses the medical practice’s electronic health record system to quickly access the patient’s record, submitted CMS-1500 claim, and remittance advice the practice received from the payer. Lisa explains to the patient that the physician accepts assignment from this payer. She further explains that according to her file, the account is considered paid in full because the patient paid her $20 copayment at the time of the encounter.

The patient argues that the medical practice owes him money because he was supposed to receive a check from the payer.

What area of confusion is occurring between Lisa and the patient? How should this be resolved for the patient?