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Lesson11: Claims Processing (How (bill sent to respective agencies for…
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
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)
Billing
Stages
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
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
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
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
Patients
Adv:
need not pay upfront
co-payment by the organisation they belong to
Disadv:
does not cover all medical expenses