Question

Reconciliation is the process of resolving or settling the payment of claims. This month ABC Pediatrics had 10 Explanation of Benefits (EOB)/Remittance Advices (RA) returned back to the organization, with details of the status of claims including suspended claims, denials, and rejections for various patients and physicians. Discuss some steps the reimbursement manager and insurance specialist can take to record the completed transactions and address the suspended claims, denials, and rejections. Also discuss the significance of the 10 returned claims, out of 200 claims submitted for the month.

Answer 1

Financial responsibility for the reimbursement manager and insurance specialist they have to provide personal and insurance information to the provide to make sure their eligible to receive services from the provider..once the information given to the patient biller have to decide which services are covered under the patients insurance plan..To be eligible for payment,a claim goes through a number of processes..There are number of processes..There are number of steps that comprise the lifestyle if a medical claim..

There are many reasons for Patients insurance rejected.. Because the bill was submitted to EDS before it was submitted to the patient's private insurance company.. Reimbursement manager must obtain all insurance information from the Patient even if that insurance will not pay for services provided.. submit the claim to the primary carrier then send in a bill with the attached Explanation of Benefits (EOB) to EDS..check out the coding,check the expiry claim..some times services provided with out proper Authorization can cause claim rejected..sometimes providers services before insurance company confirmed them the claim will be denied..wrong managing company the claim will be denied..

There are vital steps the lifestyle of a medical claim:

Data entry phase:

During first step data entered, verified and classified as per bill processing agency (BPA) rules..

Editing phase:

Once the data entered and validated it will more to editing or suspended claims phase..during this phase, claims can be denied if MITS detects third-party responsibility..

Pricing phase:

During this phase, MITS use the rate and price and calculate the final payment prior to Authorization rates..

Audit phase:

Service data cross-checked against claims..In this stage, denials can be on account of duplicate services..service conflicts or limitation on services..

Disposition phase:

It is stage of status of paid, suspended or denied..suspended claims denied on account of compliance, timeliness or errors..

Reimbursement phase:

This phase constitutes the distribution of payment to providers After the processing a claim achieve paid status, payment is released to the providers..the final step of a medical claim posting the payment to the account of the provider..

The above phases goes through several complicated and time-bound consuming phases before it is finally reimbursed by the insurance company..