Tracking your Claims Reimbursement (EOB)
by: Ms. Pinky Mcbanon
Senior Medical Billing Specialist (Dansalan Group, Inc.)
by: Ms. Pinky Mcbanon
Senior Medical Billing Specialist (Dansalan Group, Inc.)
EOBs (Explanation of Benefits) with its 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 3 scenarios:
(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careful with outdated codes.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.
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 3 scenarios:
(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.
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