Chapter 28 — Exercises

How to use these. Section C is the one to drill until it is automatic. The group code decides who owes, and everything expensive in this chapter follows from getting it right or wrong.

Section G is the promise six earlier chapters made. Work it slowly, and notice that step 1 — building the expected allowed amount — is the whole difficulty and the only part that requires anything you do not already have.

And Section I should be attempted before you read §28.11, if you can manage it. The arithmetic is entirely determined by figures this book froze in Chapters 6, 23, and 25.

Section A — The remittance (items 1–9)

A.1 Give the three names for the document and say what distinguishes each.

A.2 Which transaction carries the electronic remittance?

A.3 What is the practical difference between an ERA and an SPR?

A.4 Name the four levels a remittance is organized into, outermost first.

A.5 What must the total of the claim payments plus the provider-level adjustments equal?

A.6 Name the three parts of every adjustment.

A.7 State the line-balancing rule. What does it mean when your posting does not balance?

A.8 (Chapter 26) Which field comes back on the remittance, and what does it make possible?

A.9 (Chapter 27) Distinguish the 835 from the 837.

Section B — The EOB (items 10–16)

B.10 Who receives a remittance advice? Who receives an EOB?

B.11 Give the four reasons the two documents differ.

B.12 What does an EOB explain that a remittance does not?

B.13 Why is the charge prominent on an EOB, and why is that a problem?

B.14 Is "what you may owe" reliable? Name three things the plan does not know.

B.15 Name six fields a typical EOB shows. Which two do you not have, and why do they explain surprising bills?

B.16 A patient says their insurance shows \$17.58 and your statement says \$47.58. State the four things to say, in order, and identify which one resolves the call nine times in ten.

Section C — Group codes (items 17–26)

C.17 Give all four group codes and what each means.

C.18 Which one decides who owes? Which one decides why?

C.19 May you bill a patient for a CO amount? For a PR amount?

C.20 Give the three PR reason codes you will see constantly.

C.21 What does OA most commonly report?

C.22 (Chapter 22) The same medical necessity denial can arrive as CO at one payer and PR at another. What instrument decides which, and which modifiers announced it in advance?

C.23 A PR amount is posted as CO. What has happened, who notices, and why is it invisible even to an audit of the claim?

C.24 A CO amount is posted as PR. What has happened, and why is this worse than C.23 despite being visible?

C.25 Name the usual mechanism behind both errors. Which earlier case study has the same shape?

C.26 State the one-query check that finds both. Why does it work?

Section D — CARCs and RARCs (items 27–36)

D.27 What does a CARC state? A RARC? Which one carries an amount?

D.28 Give the meaning of: CO-45 · CO-97 · CO-16 · CO-18 · CO-29 · CO-151.

D.29 Give the meaning of N19 and MA130.

D.30 Why is CO-16 unactionable alone? What turns it into a work item?

D.31 Many remittance reports suppress RARCs by default. What does that do to your CO-16 workload, and whose problem is it?

D.32 Read together: CO-97 \$128.40 with RARC N19 on a 99214-25. State what the payer asserted, in a sentence.

D.33 Why is that assertion wrong on this claim? Name the two chapters that establish it.

D.34 Distinguish "line 1 denied" from the sentence in D.32. What does each lead to?

D.35 For each, state what the payer asserted and your next action: CO-16 with RARC M76 · PR-204 · CO-29 · CO-151.

D.36 In D.35, how many of the four are appeals? What does that tell you about a practice that works all denials in one queue?

Section E — Posting (items 37–45)

E.37 State the two equivalent forms of the line-posting arithmetic.

E.38 Why post at the line rather than at the claim? Name three later questions that require it.

E.39 "Post what the remittance says, not what you expected." What common system behavior violates this, and what does it destroy?

E.40 Why post zero-payment lines? What is on them?

E.41 (Chapter 25) Item 29 reported \$30.00 collected. What does the payer do with that fact?

E.42 What must the posting do with an existing patient payment, and what happens if it does not?

E.43 Why reconcile the deposit before posting rather than after?

E.44 A line shows charge \$150.00 · allowed \$78.60 · CO-45 \$71.40 · PR-2 \$15.72 · paid \$62.88. Show that it balances. What may you bill the patient?

E.45 The contract for that service says \$85.00. State the finding and the amount. What did not happen on this line?

Section F — Adjustments versus write-offs (items 46–53)

F.46 Define a contractual adjustment. Was it ever collectible?

F.47 Define a write-off. Who decides?

F.48 Why does conflating them make the collection rates uninterpretable?

F.49 A CO-97 for \$128.40 is posted as a contractual adjustment. Describe the account. What appears on an aging report? In a denial log? In a work queue?

F.50 Complete: "Nobody appeals _______."

F.51 Give the five write-off categories.

F.52 Which category pays for itself, and why? Which chapter builds the report it feeds?

F.53 Why must charity and financial assistance never be mixed with bad debt?

Section G — Autoposting and underpayments (items 54–64)

G.54 Name the three things autoposting does well.

G.55 (Chapter 27) What enrollment does autoposting require? What does a practice with paper remittances usually have — a technology problem or an enrollment gap?

G.56 Name the four things autoposting gets wrong.

G.57 What is the exception queue, why does it contain the interesting items, and why is it so often unowned?

G.58 State the two questions to ask about it. Which answer is diagnostic?

G.59 Why is an underpayment harder to detect than a denial? Name three things it does not do.

G.60 (Chapter 23) Explain why a silent underpayment RAISES the net collection rate.

G.61 Give the five steps of the detection method. Which step is the whole difficulty?

G.62 (Chapter 23 §23.6) Why can you not check payments against a blended contract percentage? Give the four Northfield ratios and the blend.

G.63 Name the three classifications of a variance. Which is most common on a first pass? Which produces recovery, and why is it systematic?

G.64 A line is underpaid \$6.40 and the code is billed 40 times a month. Compute the annual figure and the figure over 26 months. What does the duration represent, and what bounds recovery?

Section H — Offsets, reversals, and the balance that moves (items 65–72)

H.65 Define a takeback. Define an offset. Where do they appear on a remittance?

H.66 Name four other things found in the provider-level adjustment section.

H.67 A remittance shows \$4,812.00 of claim payments and an EFT of \$4,199.60. What happened, and what is the correct posting?

H.68 State the three consequences of posting the net instead.

H.69 What does a reversal-and-correction pair look like, and what happens if you post only one half — each way?

H.70 State the sequence by which a primary's PR balance becomes the patient's.

H.71 Name the three things that go wrong in secondary billing. Which produces the most common improper patient bill?

H.72 (Chapter 3) Why is billing a PR-2 coinsurance to a QMB not merely awkward?

Section I — The Encounter's first remit (items 73–80)

I.73 (Chapter 6) On what day does the first remittance arrive, and what is the EFT amount?

I.74 Write out the four lines with their adjustments, and show that each balances.

I.75 Line 1 carries two CO adjustments. Name both, give the amounts, and explain how a payer can price a service and then decline to pay for it.

I.76 (Chapter 23) What is the appealable amount, and why is it not \$185.00?

I.77 Compute the payment posted, the patient responsibility created, and the open denied amount.

I.78 Where does the \$30.00 copay go on this remittance? Why?

I.79 On what day does the copay find its home, and what does the second remittance report?

I.80 State the three things that follow from the \$128.40, and name what a posting process recording "payment received" would have been doing wrong — given that its statement was true.