Lesson11: Claims Processing

Types of claims

first party claim (patient directly)

3rd party claim (other agencies other than themselves)

Civil service (employee medical benefits --> government officers, pensioners and their dependants)

  • Medical Claims Proration System (MCPS) --> restructured hospitals, SOC, polyclinics
  • Medical Billing System (MBS@Gov) --> GPs and Dialysis Centres

Private organisations/employers/insurance companies of the patients (Letter of Guarantee)

  • manual claim

CPF (patients own) --> Central Claim Processing System (CCPS)/Mediclaim System

  • medisave for hospital bills or CDMP
  • medishield life
  • integrated shield plan

How

bill sent to respective agencies for payment

usually sent electronically via respective healthcare institution's IT systems (LOGs are claimed manually)

BUT: not all can be processed successfully due to various reasons

IF error due to data entry: will rectify and resubmit
IF patient's error (not covered by specific 3rd party payer): institution will charge to patient for payment

Medishield Life:

  • inform hospital staff that you wish to claim from medishield/medishield life
  • hospital submits claims
  • cpf board or the private insurer pays the hospital directly
  • remaining amount can be paid using medisave and/or cash

transmits medical claims through electronical claims system directly to the 3rd party (insurance company, Accountant General's Department, CPFB)

depending on the various schemes patient is entitled to: payment made accordingly

approved payments send back to the healthcare institution

business office staff confirmed that all claims are processed

once full payment received: patient's bill status change from provisional bill to final bill

Various claim issues

Denied claims: claim that has been processed and the insurer has found it to be not payable

  • denied claims can usually be corrected and/or appealed for reconsideration

Billing

Stages

Amendment

Unbilled/interim bill: bill not yet finalised, charges are not confirmed or keyed in, changes to bill is possible

Provisional bill: charges are confirmed and sent for claims, changes to bill not allowed

Final bill: claims processed, any changes to bill will have to raise bill amendment

Staff will raise a bill amendment form to the business office

Needs to be approved by relevant parties:

  • supervisor in-charge
  • business office in-charge
  • higher authority if amount exceeds a certain limit

Once approved: staff proceed to make necessary adjustments

Re-generate the bill and submit the claim

Needed when:

  • changes to the visit information of a billed visit (wrong source of referral, wrong 3rd party payer)
  • changes to the services billed (over or under billed of services)

Flow process:

  • identifies the bills to be amended and raise amendment form
  • seek approval by supervisor
  • Business Office check and seek approval
  • approved by Business Manager/CFO (for large amounts)
  • physical amendment form to be filed for audit purpose

Rejected claims: claim that has not been processed by the insurer due to a fatal error in the information provided

  • causes: inaccurate personal information; errors in information provided
  • has not been processed so it cannot be appealed. Instead, rejected claims need to be researched, corrected and resubmitted

Insufficient information sent: missing claim amount (field is empty)

Wrong information sent: wrong patient information (NRIC, Name, DOB, etc)

Non claimable item sent: not entitled (cosmetic items/services)

Missing out on charging certain items: under claim patient's entitlement (consultation fees that is claimable not keyed)

Bill exceeded claimable amount: double claim (service entered twice)

Not all bills submitted for claim will be approved (10 claims were sent, and only 8 were returned from 3rd party payor --> need to reconcile to ensure all claims are approved)

Claim rejection

Reasons + preventive measures

Patient no longer eligible for 3rd party claims (no longer a civil servant, no longer covered by the insurance)

  • institution's staff to verify patient's entitlement validity
  • check civil service card valid date during registration payment

Plan does not cover the service used (cosmetic surgery)

  • different scheme covers different services. List the services that are not covered (cosmetic services) and communicate with patients

Insufficient amount in account (claim amount exceeds entitlement, claim amount exceeds balance)

  • institution's staff can access patient's Medisave account to check the balance (authorisation and signed approval required to access patient's Medisave account)

Wrong date of birth entered (new requirement by CPF for verification)

  • photocopy patient's NRIC and attach to Medisave authorisation form

Wrong 3rd party payer (selected MCPS instead of CCPS)

  • clear understanding by institution staff on which are the 3rd party payors to use

Rectification

Business office staff need to amend claim message and resubmit

Make necessary adjustments to the bill (cancel provision (open) -> amend details -> rebill (provision))

If patient no longer covered by 3rd party payer, send outstanding bill to patient for payment by other mode (AXS, Cheque)

Payment via claim

Healthcare institutions

Patients

Adv:

  • payments are guaranteed (CCPS, MCPS, LOG) unless patient is no longer covered under scheme
  • direct credits to institution's account

Disadv:

  • longer processing time
  • difficult for staff to keep track of the different schemes available
  • system update needed for any changes to the schemes

Adv:

  • need not pay upfront
  • co-payment by the organisation they belong to

Disadv:

  • does not cover all medical expenses