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AR Analysis - Step 3

In step three its review the AR and details are below how its done.

Step three: Identification of the problem - Review

The analyst then reviews patient account ledgers pertaining to the unpaid claims to analyze why the claims are still outstanding. Analyst reviews patient ledger from all billing angle for possible violation of billing rule.

Following are some of the situations the analyst may encounter & suggested remedial actions:

(a) If the analyst detects a charge entry, cash posting or claim submission error, he/she informs the concerned department. The error is corrected and claim resubmitted, if necessary.

(b) If the claim has been prepared and submitted correctly according to known rules and guidelines, and the usual turnaround time has passed, the analyst either calls insurance carrier or requests AR caller to call insurance carrier. A note is also made to AR caller indicating the type of information that needs to be obtained from representatives of the insurance company or payer.

(c) When claims are underpaid or denied, the analyst establishes the reasons for the denial or low payment by reviewing the explanations of benefits pertaining to the claim, carrier rejection reports, carrier billing guidelines, or initiating a work order to AR Calling to seek clarifications from the insurance company.

Claim denials or underpayments due to billing errors committed by staff are segregated and the concerned staff instructed to take corrective action.

(d) When claims are denied due to lack of documentation or additional information, the analyst requests for such additional documentation from the provider or billing office, and follows up with the insurance through the AR callers.

(e) When the analyst is dissatisfied with the adjudication of a claim he/she may appeal with insurance for a review, with supporting documentation obtained from the provider office. The analyst will have to follow the appeals process and if there is a telephonic appeal facility, analyst should explore the same to appeal. A copy of the patient ledger and copies of the relevant EOB should be available with analyst while executing telephonic appeal.

If there is no telephonic appeal facility, then the analyst must an appeal on paper following the insurance company’s appeals process.

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