Explain The Adjudication Process

It is important to follow payer guidelines when completing a claim form; otherwise, reimbursement will be delayed until the form is corrected.

According to Chtourou (2013), a CDI program focuses on enhancing the accuracy of clinical documentation quality which requires a huge input from CDI specialists, heath information management professionals, coders and clinicians to collaborate together to review the quality of documentation reported/captured in order to ensure accuracy and complete of patient’s clinical encounter. As a healthcare provider, medical records that are incomplete or inaccurate often times, compromise the quality of care reporting and inevitably affect the clinical decision support system of the organization including the accuracy of reimbursement. This is reasonable since the CDI program has emerged as a new paradigm to meet the changing needs of maintaining a sound health record documentation across the healthcare industry (Hauger, 2014). Most of the CDI programs have to a great extent concentrated on boosting the Diagnosis-Related Groups (DRGs) installments by securing clinical documentation to support medical complications and co-morbidities (Hauger, 2014).

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

Responsible coder collects post and manages account payments, submitting claims and keeping in touch with insurance companies. If patient information is coded incorrectly or incomplete it could leave an impact that can be brought to a claim. Inaccuracy in patient information can leads to denials, none payment and investigation. It is important to get all the details right by verifying insurance coverage properly. Make sure that the patient’s name is spelled correctly, date of birth and sex of patient are correct; and most important be sure that the policy number is valid.0verall before claims are sent, documentation should be in order and the claim should be checked for completeness and accuracy.

You are letting the provider know what the patient chief complaint or reasoning is to be seen at the office that day. All information the patient has prior will be beneficial for the process of the claim.

Prepare Claims/Check Compliance - The person that bills makes sure the claim meets the standard of compliance.

Claim submission processes are claims that are submitted online, and payments are processed electronically after a visit to the doctor office the physician send out a bill to the insurance claims processing center all information that is relevant the intake forms and the patient appointment sheet as well as the proper services documentation. Which is evaluated to see if it covers the services if the services are covered by the insurance company a payment is then submitted for the balance that is remained if not insured the person is reliable for the balance that is left over as well as the co-payment.

Allied HealthMedicare Appeals ProcessReimbursement and CollectionsPage 1 of 2Lab Assignment Medicare Appeals ProcessPart 1It's important to note differences in the Medicare Appeals Process. First, take some time to review the following PDF document and explore the process and its distinct characteristics.Medicare Parts A and B Appeal ProcessPart 2Once you have read through the file, write one-to-two paragraphs below, describing the following:Differences in the processReasons why appeals are escalated from one level to the nextQuestions you have about the processThere are a few differences between the 5 different levels in the appeal processes. You must go through each level to proceed to the next. In the

The officer have to go a website to register the facility’s physicians and tax identification number. After, registration the facility will start to receive audits electronically. The audit will declare that RAC have been reviewing a certain doctor usage of a CPT code and they want to receive a specific month or period of time of those records. The compliance officer looks for documentation the RAC auditor requested and prints it out. The process at SCHC is to send the request and log it in the RAC notebook. Recovery Auditor Contractor gives the facility a certain amount of time to respond to the audit. Medicaid and Medicare also conducts audits by randomly pulling paid claims usually retrospectively to make sure they are paying for the right procedure every quarter. If there was a charging error and the facility was overpaid by Medicare for a claim, the facility must resubmit the claim with the corrected CPT code and pay back the overpayment amount. Medicaid and Medicare also performs prospective audits this method is when the facility sent a claim to the insurance and they are not going to pay it without documentation. Typically, this means they are looking at something very specific that they think is incorrect. The billing department does their own internal prospective audit. The compliance officer audits the doctor’s CPT codes and staff to make sure codes were interpret correctly. The Joint Commission’s on-site survey process is the tracer methodology. The tracer methodology uses information from the organization to follow the experience of care, treatment or services for a number of patients through the organization’s entire health care delivery process (Facts about the Tracer Methodology, 2016). The system South Carolina Heart Center uses conduct tracer methodology is printing out arrive appointments and the router ticket

OCE designed to processes claims for all outpatient institutional providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as hospitals that are NOT (Non-OPPS). Each OCE results in one of six different dispositions. The dispositions help to ensure that all fiscal intermediaries are following similar procedures. There are four claim-level dispositions: Rejection, Claim must be corrected and resubmitted; denial, claim cannot be resubmitted but can be appealed; return to provider, problems must be corrected and claim resubmitted; and suspension, claim requires further information before it can be processed. There are two line item–level dispositions: rejection, claim is processed but line item is rejected and can be resubmitted later; and denial, claim is processed but line item is rejected and cannot be resubmitted. (Essentials of Health Care Finance, 7th Edition. Jones & Bartlett Publishers p. 26).

Responsible coder collects post and manages account payments, submitting claims and keeping in touch with insurance companies. If patient information is coded incorrectly, or incomplete it could leave an impact that can be brought to a claim. Inaccuracy in patient information can lead to denials, none payment and investigation. It is important to get all the details right by verifying insurance coverage properly. Make sure that the patient’s name is spelled correctly, date of birth and sex of the patient are correct; and most important be sure that the policy number is valid.0verall before claims are sent, documentation should be in order and the claim should be checked for completeness and accuracy.

3. The Claimant’s amount of the sequence of events relating to the treatment in question. Care should be taken to avoid importing text and phraseology from medical records or reports that the Claimant would not use in the normal course of discussing the case.

Filing claims and appeals is all about accuracy. Before a claim can be filed medical office personnel must make sure that they have all the patients information correct. No misspellings on names or address, insurance information is up-to-date, and that they are aware of any co-pays, deductibles, or procedures that may be excluded. Release and assignment of benefits need to be signed as well. Care that the patient received must be coded correctly, and be consistent with the care that was given to the patient.

This included report writer reports, eligibility processor, ezkey, pricing software, claim viewer and any home-grown processes that access the JTMG data. All processes that send data to external sources were updated which included weekly eligibility files to clearinghouses as well as the encounter data process that submits claims to the health plans on a weekly and monthly basis. The report writer portion of this objective took a while longer than expected however it did not affect the overall

specialist determine the ICD, CPT or HPCS coding. The coder or biller may have to communicate with the healthcare provider if there are any questions on any of the diagnoses, treatments or duration of the office visit (Dietsch, 2011). Because insurance companies are very strict on correct medical billing and coding, a small mistake can cause the insurance company to deny the claim and will then require the doctor to fix the error and the claim will need to be resubmitted (Cocchi & White, n.d.).