Multi Payor

Yes, the transfer features will be available for both Homecare and Hospice. Although billing requirements are different per each line of business, the functionality is the same.

 

Yes, you can transfer a balance from any type of payor to any other type of payor for both Homecare and Hospice. The list includes, but is not limited to, Medicare, Medicaids, private and commercial insurances, patient invoices, HMOs, Medicare Advantage plans, etc.

No. Upon release, all databases will have the new Transfer screen in Account Summary and transfer functionality. In addition, Homecare users will have the new payor coverage and ‘split claims by discipline’ features. Only users with User Security rights to Billing will be allowed to perform transfers.

 

The ability to split claims by discipline and to check disciplines as covered or not-covered is only available for Homecare as this is not a requirement for Hospice.

 

Go to Master Files | Payors/Plans | Billing Format and see if the covered box is checked for this discipline. If it is unchecked this payor will not appear in the drop down for selection. If this box is checked and you still don’t see the payor, go to the Patient | Insurance screen and see if the covered box is checked on this discipline for this patient. If it is not checked, you will need to check the covered box next to this discipline and save for this payor to become available in the drop down on this discipline. The software will also respect the payor coverage dates. If this box is checked but the visit date is outside the payor coverage dates identified in the patient’s insurance screen, then this payor will not be available for you to select on this visit.

 

1.    Bill the primary payor as you normally would. Once the primary payor has paid its portion of the bill and you have entered that payment into the system, the next step would be to do a transfer. If you need to add any billing codes you can do this prior to or after transferring, but before creating the batch. This can be completed in the Patient | Insurance | Billing Codes screen for that secondary payor.

2.    Go to Accounts | Account Summary | Transfer and in the ‘Payor From’ field select the primary payor and in the ‘Payor To’ field select the secondary payor. Add any group codes and reason codes that may apply. Verify the dollar amount in the ‘Amount to Transfer’ screen is the correct amount and make changes if necessary. Fill out the prior payment fields for each individual visit, if applicable. Click the transfer icon (the save button is not required to be clicked unless you are not intending to click the transfer icon at the same time).

3.    Go to Accounts | Billing | Create Batch. Check the ‘Transfers’ box and create the batch. Save the batch and process the secondary claim as normal.

4.    Once the secondary payor has paid its portion of the bill and the payment has been applied in the system, any remaining balance can be transferred to the patient by going to Accounts | Account Summary | Transfer. In the ‘Payor From’ drop down, select the secondary insurance and in the ‘Payor To’ drop down select the insurance record used to bill patient responsibility. A group code and reason code will be required to be entered prior to transferring. Verify that the transfer amount is correct and all prior payment fields have a dollar amount entered, then click the transfer icon.

5.    Go to Accounts | Billing | Create Batch. Check the ‘Transfers’ box and create the batch for patient responsibility, save the batch and process the claim as normal.

 

The reason code field is where you will enter the Claim Adjustment Reason Code (CARC) that is listed on the primary payor’s remittance advice along with the group code information. The CARC code explains why there is a difference between the total billed amount and the paid amount. There may be times where the remittance advice (explanation of benefits/EOB) does not clearly identify that a number is the CARC, but will most times have the definition and one of the following terms or group codes of Contractual Obligation (CO), Payer Initiated Reductions (PI), Other Adjustment (OA) or Patient Responsibility (PR).

 

Go back to Account | Account Summary for this patient and click on the Transfer tab. Using the ‘Payor From’ drop down, select the payor from which you transferred the amount. At the top right of this screen there is an ‘effective date’ field. This date will need to match the bill thru date used in the Billing | Create Batch screen. For example, if you used an effective date of 7/31/2017 in the transfer screen, on the Create Batch screen you will need to use a bill thru date of 7/31/2017 or after. If you use a bill thru date prior to 7/31/2017, this transferred claim will not populate to the Create Batch screen.

 

The system allows users to enter a total prior payment amount that is less than the payment amount posted on the original claim for those transfers where the ‘Payor From’ is episodic and transferring a remaining balance to a payor that is non-episodic. Since episodic payors are 60 days, versus non-episodic which are billed monthly, there could be payments from the 60 day episode that fall within part of the month you are billing to secondary.

 

Yes, when the ‘Payor From’ is a non-episodic type payor, all prior payment fields must be filled in with a dollar amount prior to clicking transfer and cannot be left blank. If the primary payor did not pay some of the visits, enter $0.00 on that line item.

 

Once a user clicks the transfer icon in the Transfer screen, any charges included in that transfer will then display ‘Yes’ in Charge Entry.

 

For Homecare and Hospice, items entered in Productivity are for reporting purposes only and do not affect the balance of the claim that is being billed. Therefore, these items would not be transferrable. For Hospice, visits entered in Productivity have no effect on the balance of the claim and are only displayed on a claim when there is a checkmark in the discipline specific box in the Billing Format screen of this payor. Due to this existing functionality these visits would not be displayed on the Transfer screen when transferring balances. If the ‘Payor To’ has any disciplines selected on its billing format page, visits corresponding to those disciplines will also be displayed on the resulting secondary claim.

 

Once a user has started a Transfer and saved but has not yet clicked the transfer icon the transferred column status will display as ‘In Process’. Once the transfer icon is clicked the status will remain as ‘In Process’. As soon as that transfer claim has been batched the status will change to be ‘True’.

 

Go to Account Summary, select the Accounts Receivable Reconciliation record for the ‘Payor From’ then scroll to the Batch Details section. In the Transfer column, if the status is ‘True’ this means that the transferred claim has either been batched or billed. Once a transferred claim is batched or billed it will no longer display in the ‘Complete (Not Billed) Transfers’ section. If that transferred claim is deleted from Work With Batches or Post Batches, or it is rebilled out of Account Summary, the Transfer status in the Batch Detail records will display as ‘In Process’ and the entry will show up in the ‘Completed (Not Billed) Transfers’ section. In addition, if a transfer claim has been voided, users will need to click the ‘Include Voided Transfers’ box to display any voided transfer claims.

 

No, users do not have to click Save prior to clicking the Transfer button. Users only need to click ‘save’ if there is no intention of clicking transfer at the same time and users would like to save their current progress prior to leaving the Transfer screen. If there is data that has not been saved and a user leaves the Transfer screen, they will receive a pop up message that there is unsaved data and will be prompted to either click Cancel or OK to save the data.

 

When clicking on the Transfer screen, the screen will always load in ‘New’ mode. Once a payor is selected in the ‘Payor From’ drop down, the system is initiating a transfer. Users can simply click Cancel to the message and it will take them out of the Transfer screen.

 

If you have transferred an amount to a payor but have not billed that transfer claim yet, then you will need to go to the Transfer screen, select your primary payor in the ‘Payor From’ drop down, scroll to the ‘Completed (Not Billed) Transfers’ section and click Void on this transfer record. By voiding the transfer you can now rebill the primary payor claim.

 

If the transferred claim has already been batched, users will need to delete the batch then navigate to the Transfer screen, pick the primary payor in the ‘Payor From’ drop down, scroll to the ‘Completed (Not Billed) Transfers’ section and click the Void button on the transfer record. This will allow the user to rebill the primary payor claim. If the transferred claim has already been billed, users should go to Account Summary and select the secondary payors’ AR and AR Reconciliation records, click the Void/Reverse Charges tab and select the AR record then click ReBill. Users will select the Rebill and Transfer Back option, which will void the transfer automatically, and the primary payor claim can now be rebilled.

 

This error message indicates that the record is an older record without payor coverage effective dates included in the Patient | Insurance screen, or one of the insurances has been deleted. The transfer screen checks for insurances that are currently in effect even though the Account Summary screen will still list the AR for no longer active insurances.

 

As long as the checkbox ‘Include Service Detail overrides on Transfer claims’ is checked in the Billing Formats screen for that payor, the system will use the Service Dtl overrides. The system will pull the revenue code, HCPC code, modifier and unit measures. The system will not pull the billable or price override details. In order to balance out the account properly on the secondary claim, the system will display the visit price on the line items as the price that was sent to the primary payor and the net amount will reflect what the secondary payor owes.

 

No. Contractual Adjustments should not be sent on secondary claims. If the secondary payor has the ‘Post service detail fee overrides as Contractual Allowance’ box checked in Master Files | Payors/Plans | Billing Formats, at the time the secondary transferred claim is created, the system will not post a Contractual Allowance to the secondary payor.

 

Yes. To transfer a balance to self-pay, users would follow the same instructions as transferring to a commercial/private insurance as outlined below.

 

 

No, if a patient is always responsible for a specific dollar amount, you can send that patient responsibility to self-pay before a prior payment is applied. Users can go to the Transfer screen and adjust the ‘Amount to Transfer’ to reflect what the patient owes, and transfer that to the self-pay payor. The balance due on the primary payor will reflect the dollar amount billed minus what was sent to the patient.

 

To ensure the appropriate amount due is reflected on the patient invoice, enter all adjustments and/or discounts that apply to this patient. This will include any sliding fees and discounts that apply to the patient’s bill and contractual adjustments manually added in the Post Payments screen to the primary payor. If the primary payor is set up to receive a contractual adjustment automatically by having the box ‘Post service detail fee overrides as Contractual Allowance’ checked in the Billing Formats screen, then this amount does not need to be added to the Transfer screen and only adjustments, fees, or discounts that apply directly to the patient claim will need to be entered. Users can enter the dollar amount as a lump sum and select the Group Code of OA – Other Adjustment or enter each dollar amount with an individual group code. Users may enter a reason code of 999.

 

Yes. To ensure that the amount due is reflected appropriately on the patient invoice the 2% sequestration adjustment will need to be included in the amount entered in the group/reason code amount field. The system will take what was billed to primary – prior payments – any dollar amount(s) entered in the group/reason code field to equal the patient amount due.

 

If the contractual adjustment was added manually in the Post Payments screen to the primary payor then this amount will need to be added to the Transfer screen along with the sliding fee to get an accurate amount due. Users can add the contractual adjustment applied to primary to the sliding fee that applies to the patient invoice and enter it as a lump sum in the group/reason amount field. Users may also enter them as separate dollar amounts and group codes, but is not required. Users may enter a reason code of 999.

For example, primary payor was billed $800 and they paid $700 with a contractual adjustment of $50. The amount to transfer would be $800 – $700 – $50 = $50. In addition, the patient has a sliding fee of 20% so $50 multiplied by 20% = $10. Therefore, the patient owes $40. When transferring the $50 to secondary self-pay, in the Transfer screen you will need to enter the $50 contractual adjustment as well as the $10 sliding fee. It can be entered with a group code of OA – Other Adjustment with a total amount of $60 and a reason code of 999. The patient invoice report will then display an amount due of $40 to be billed to the patient.

 

Yes. When transferring remaining balances, at the time you click the Create Batch button in the Create Batch screen, the system is looking at the form type selected in the Billing Format screen for that individual payor. If the primary payor was billed on a UB04 and the secondary payor needs to be billed on a HCFA, users will be allowed to transfer a remaining balance form the payor billed on the UB04 to the payor billed on the HCFA. The transfer process will not be any different for this type of scenario.

 

The functionality of the reports remains the same and have been updated to reflect transfers:

1.    Accounts | Revenue: An Adjustments column has been added to the Revenue report to display transfer adjustments only.

●     When the transfer button is clicked, the primary ‘Payor From’ selected in the Transfer screen will display a “Balance Transfer” line with a positive transferred amount in the Adjustments column and $0.00 in the Total Charges column.

●     When the transferred secondary claim is posted to Account Summary, the ‘Payor To’ selected in the Transfer screen will display a “Balance Transfer” line with a negative transferred amount in the Adjustments column and $0.00 in the Total Charges column.

●     If the ‘Rebill/Replace and Transfer Back’ button has been clicked on the transferred ‘Payor To’ claim in Account Summary, the report will display a “Reverse Balance Transfer” line with a positive transferred amount in the Adjustments column and $0.00 in the Total Charges column. The primary ‘Payor From’ claim will show a “Reverse Balance Transfer” line with a negative transferred amount in the Adjustments column and $0.00 in the Total Charges column.

2.    Accounts | Billing: An Adjustments column has been added to the Billing report to display transfer adjustments only.

●     When the transferred claim is saved to Work With Batches the ‘Payor To’ selected in the Transfer screen will display a line with a positive transferred amount in the Adjustments column and $0.00 in the Total Charges column.

●     If the ‘Rebill/Replace and Transfer Back’ button has been clicked on the transferred ‘Payor To’ claim in Account Summary, the report will no longer display this line.

3.    Accounts | A/R Reconciliation: The transferred amounts will be reflected in the Adjustments column of the A/R Reconciliation report.

●     When the transfer button has been clicked, the primary ‘Payor From’ selected in the Transfer screen will display the positive transferred amount in the Adjustments column and decreasing the Ending Balance.

●     When the transferred ‘Payor To’ claim has been posted to Account Summary, the report will display $0.00 in the Charges column and the negative transferred amount in the Adjustments column increasing the Ending Balance.

●     If the ‘Rebill/Replace and Transfer Back’ button has been clicked on the transferred ‘Payor To’ claim in Account Summary, the report will display a “Reverse Balance Transfer” line with a positive transferred amount in the Adjustments column and $0.00 in the Total Charges column. The primary ‘Payor From’ claim will show a “Reverse Balance Transfer” line with a negative transferred amount in the Adjustments column and $0.00 in the Total Charges column.

4.    Billing | Patient Statements: The Patient Statement report will display the transferred amount and reversing balance transfer adjustments.

●     When the transfer button has been clicked, the primary ‘Payor From’ selected in the Transfer screen will display an “Adjustments – Balance Transfer” line with a negative transferred amount decreasing the Total Amount Due.

●     When the transferred ‘Payor To’ claim has been posted to Account Summary, the report will display an “Adjustments – Balance Transfer” line with a positive transferred amount increasing the Total Amount Due.

●     If the ‘Rebill/Replace and Transfer Back’ button has been clicked on the transferred ‘Payor To’ claim in Account Summary, the report will display an “Adjustments – Balance Transfer Back” line on both payor patient statements.

5.    Billing | Patient Invoice: Will display the balance due on each batch detail service line in the Amount column. The gross amount billed to primary will display on each batch detail service line in the Rate column.

 

 

The amount due is reflected by the prior payments and group/reason codes entered in the Transfer screen. Users will want to be sure to enter all group adjustments, discounts and fees with reason codes that apply to the claim and verify the correct prior payments have been entered. The system will take what was billed to primary and subtract any prior payments and group adjustments, discounts, or fees entered (with the exception of PR - Patient Responsibility) to calculate the amount due. If a reason code does not apply, users may use a value of 999 in the Reason Code field. If a group code is not listed for a patient invoice, users may use the OA- Other Adjustments and add all the adjustments, discounts, and fees to enter as the group code amount.

 

Yes. If entering contractual adjustments manually and the primary payor has a contractual adjustment or any other fee/discount, you will want to adjust that in the Post Payments screen to get an accurate amount to transfer to secondary.

 

No. The current process for balancing month end will not change.

 

When the ‘split claims by discipline’ box is checked, at the time a user goes to Accounts | Billing | Create Batch, selects their filter criteria and clicks the ‘Create Batch’ button, the system will split the claim for each discipline. For example, if the patient had three different disciplines, then the user would see three separate claims created in the Create Batch screen for that patient/payor. All three claims will need to be saved to Work With Batches to be billed.

 

If the payor is already attached to the patient’s insurance screen and you uncheck or check the covered box in the Disciplines section on that payor in the Billing Formats screen, then it will not flow back to the patient’s discipline section in their insurance screen. You will need to go back to the patient’s insurance screen and uncheck or check the covered box on that discipline manually. If this is a new patient and this insurance gets added to their Insurance screen, any disciplines checked or unchecked in the Billing Formats screen will flow to the patient’s Insurance screen.

 

First you will want to verify if that discipline is unchecked in the Patient | Insurance screen for that payor. If it is unchecked in the Billing Format screen but still checked in the Patient | Insurance screen, it will still populate to the discipline drop downs. The discipline covered section pulls all disciplines from Reference Files | Discipline Codes.

 

If this discipline has been billed for this payor and patient, it will need to be reversed out of Account Summary. The payor, on any visits attached to this discipline in Charge Entry, orders, authorizations or scheduled in the patient calendar will need to be re-assigned to a different payor prior to unchecking this discipline.

 

When you get to the transfer screen select the ‘Payor From,’ which is the primary/episodic type payor, and select the ‘Payor To,’ which is the secondary/non-episodic type payor. The episode drop down will be grayed out and not selectable. To select a specific month of charges, scroll to the ‘Items with Statement Dates in’ fields, enter the date range of the services you would like to transfer balances and click search.

For example, if the primary payor’s episode ended on 8/15 and the next episode started on 8/16, the secondary payor requires that the entire month of 8/1-8/31 be billed. Type in the date range of 8/1-8/31 in the “Items with Statement Dates in” fields and click search to list August dates of service. If necessary, adjust the ‘Amount to Transfer’ to reflect the entire month of August. Then enter in the prior payments for each individual visit. Once the transfer icon is clicked only the month of August has been transferred to the secondary payor and can be billed.

 

The ‘Episode’ drop down will only become available when an episodic type payor is selected in ‘Payor To.’ The system will then display all available episodes to select in the drop down, excluding any that are inactive.

 

Since an episodic payer is not reimbursed at the individual visit line but rather the entire episode, payments are not received per each visit. When transferring the remaining balance from a payor that is episodic, the system will take the prior payments from the primary payor and divide it equally amongst all visits, excluding the HIPPS, Q code and supply line items in that calculation.

 

Since an episodic payer is not reimbursed at the individual visit line but rather the entire episode, payments are not received for each visit. When transferring the remaining balance from a payor that is episodic, the system will take the prior payments from the primary payor and divide it equally amongst all visits, excluding the HIPPS, Q code and supply line items in that calculation. When transferring episodic to non-episodic, users will transfer to secondary for each month. The ‘Amount to Transfer’ will need to be changed to reflect what to transfer for that individual month. The calculation is Total Remaining balance/total number of visits in episode = per day dollar amount. Take the per day dollar amount X number of visits in that month = amount to transfer.

For example, my payor is Medicare and my secondary payor is BCBS. Medicare paid $1,000 and my remaining balance is $800. My episode goes from 5/23/2017 – 7/21/2017 with a total of 22 visits (excluding supplies and the HIPPS/Q code line items). To bill BCBS I need to transfer and bill May services first. In this example, there are four visits in May. The steps below outline the process:

1.    Go to the Transfer screen and select Medicare in the ‘Payor From’ drop down and select BCBS in the ‘Payor To’ drop down.

2.     Add a group code and reason code

The system will automatically populate the prior payment amounts on the visit line items and the amounts will not be editable. In this example, the prior payment amount was $1000 and I had a total of 22 visits, so each visit line item would show $45.45 (1000/22=45.45) as the prior payment amount.

3.    Scroll to the “Items to be Transferred” section and check only the May visits in the “Batch Details” section.

4.    In the ‘Amount to Transfer’ field the dollar amount will need to be changed to reflect transferring the remaining balance just for May services. Using the calculation above, $800/22 visits = $36.36 per day. $36.36 X 4 visits = $145.44 to enter in the ‘Amount to Transfer’ field.

5.    Click the Transfer button. What will show in AR is that the remaining balance on Medicare is now $654.56

6.    Bill May services to secondary.

7.    Go back into the Transfer screen and perform the same steps for June services and so forth.

 

Yes, according to CMS Medicare Claims Processing Manual you are still required to bill a RAP prior to submitting the Final for a Medicare secondary claim. Users will want to bill the RAP prior to adding any Billing Codes in the Patient | Insurance screen to the secondary payor and prior to performing the transfer. If the RAP has not been billed prior to the Final, in the Create Batch screen users will receive the billing warning “No RAP found” when trying to create a batch for the Final.

 

Yes, the episode will show up in the Transfer page episode drop down prior to the end of the episode date. Users are allowed to transfer any remaining balances to that episodic payor for that episode. However, when going to the Create Batch screen this transfer will not populate in the list of claims to be submitted until the end of that episode date. This prevents any episode from being billed to the payor prior to the episode end date.

 

No, users should wait until all the months included in that episode to secondary have been paid by the primary, prior to performing the transfer. If a user performs a transfer for one month and needs to include additional months to transfer to a secondary episode, the transfer will need to be voided or transferred back (if billed) to transfer the remaining months that fall within the episode date range.

 

This box will only need to be checked when an episodic payor is not marked as primary in the Patient | Insurance screen. If the primary payor is episodic this box does not need to be checked. If the secondary insurance is episodic, this box will need to be checked on any episodes where a RAP claim needs to be generated in the Create Batch screen.