Tracking Your Medical Claims Reimbursement

EOB’s (Explanation of Benefits) with it’s attached claims must always be monitored before posting payments to the patient’s account. Responsibly ask yourself, were you reimbursed correctly? Are you sure the claims were processed properly?

Look at the following scenario:

(1) 100% or Full Reimbursement is definitely NOT a good sign! The insurance could have reimbursed you below the maximum based on your fee schedule. The worst scenario would be, you are perhaps charging the insurance lesser or lower than what they are willing to pay on maximum. Do you have your fee schedule? If no, you must request this from the insurance companies that you are contracted with. Always review your contracts.

(2) The EOB shows NO PAYMENT is most likely due to Coding Issues or Non-Coverage of the patient. Make sure you use the proper codes. Be careful with outdated codes. Always discuss coding solution rather than more on what you want to get reimbursed. Consider lack of documentations. Many insurance companies require attached documentations to support  medical  necessity on each claim submitted. Consider Workman’s Comp or Auto Accident Cases. Managed Care Patients.

(3) The EOB shows “reduced rate” payment. You must suspect that this might be due to improper coding. There might be one or more procedure code lines. Many procedures also require codes for drugs, radiology to be coded separately. Proper use of modifier is also an issue. Use of place of service POS code 11 or such as 22. Most insurance company pays lesser if the procedure is done in an outpatient hospital than in the office. Limitations on number of frequency per day might also be the reason for reduced rates. Non-Authorization is also a possible cause. Be careful with unbundling codes and mutually exclusive procedure codes.