| Subject | Post-submission claims reviews… read your EOBs! |
| Source | Coding Corner-March/April 2010 |
| Publication | Coding Corner-March/April 2010 |
| Effective Date | Mar 1, 2010 |
| Publish Date | Mar 1, 2010 |
Post-submission claims reviews... read your EOBs!
Post-submission claims reviews, ie, reading your EOBs (Explanations of Benefits), is a critical component to an OMS' revenue stream. Failure to do so can leave legitimate monies due you on the table. There are several reasons that this process is so important.
For one, a provider can double check that an insurance carrier is processing claims correctly; for example, following coding guidelines, adhering to contractual agreements and utilizing proper adjudication methods. Upon review a provider may find, for instance, that a carrier is downcoding certain services or perhaps applying a multiple procedure reduction to a surgical service, which may or may not be appropriate. In addition, review of an EOB will inform the provider what amounts, if any, must be written off as opposed to forwarded on to a secondary carrier and/or the patient. Most importantly, however, it can alert a provider to a situation where a coding change needs to be made, such as the addition of a modifier, or a case where an appeal of a denied claim is warranted. The exercise of postsubmission claims review can also be used as an educational opportunity for coding and billing staff to aid in future claims submissions.
Being familiar with and understanding standardized claim adjustment reason codes (http://www.wpc-edi.com/content/view/180/223/) can assist providers with post-payment claims review. These codes communicate an adjustment, meaning an explanation as to why a claim or service line was paid differently than it was billed. An example of this is the following statement: "these are non-covered services because this is not deemed a ‘medical necessity' by the payer." If there is no adjustment to a claim/ line, then there is no adjustment reason code. Remittance advice remark codes (http://www.wpc-edi. com/content/view/739/1) should also be of interest to the provider, as they are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a claim adjustment reason code. Each remittance advice remark code identifies a specific message as shown in the remittance advice remark code list. For instance, an EOB may reflect the statement "missing/incomplete/ invalid diagnosis or condition" to alert the provider to issues with the claim. Health care claim status codes (http://www.wpc-edi.com/content/ view/715/1) conveying the status of an entire claim or a specific service line, claim status category codes (http://www.wpc-edi.com/content/ view/727/1) indicating the general category of the status (accepted, rejected, additional information requested, etc.) further detailed in the claim status codes, and health care services decision reason codes (http://www.wpc-edi.com/content/ view/769/1) used to indicate the primary reason for the certification action code assigned as part of a health care services review, are worthy of note.
If the above are not reasons enough to prompt you to conduct postsubmission claims reviews, remember also that carriers may perform their own retrospective reviews and may attempt to recoup monies on claims reimbursements deemed overpayments. It is best if such cases are identified up front by the provider and immediately researched to prevent carrier refund requests or withholding of future payments from occurring.
OMSs, coders and billing staff interested in learning more about this and other general OMS billing issues are encouraged to participate in the AAOMS OMS Billing Conference, held immediately following AAOMS Beyond the Basics Coding Workshops. For more information on 2010 offerings, visit .aaoms.org/coding_workshops.php .