Read the following 4 case studies and respond to the prompts included with each one.

Case Study 1

Charlotte visited her provider for a cough, congestion, and a sinus-type headache. The provider assigned the diagnosis code J01.90 (Acute Sinusitis) for the entire claim. The visit was coded with two procedure codes. The first one was level 3 E/M, 99213 modifier 25 and the second was a B12 injection J3420, due to Charlotte’s pernicious anemia. Charlotte was given the injection on this day, so she did not have to come back in for her regularly scheduled appointment, which was in only two days. The claim was created and submitted to the insurance company the next day.

When the remittance advice was received, office visit 99213 was paid, but the B12 injection was denied. The denial was coded as follows: Claim Adjustment Group Code (CAGC) CO and Claim Adjustment Reason Code (CARC) 50.

Respond to the following in approximately 175–350 words total:

1. What is CAGC CO?

This group code indicates adjustments made in a payer-provider contract, typically for allowed amounts, and CO adjustments are not billable to patients under the contract.

2. What is CARC 50?

The services are not covered by the payer as they are not considered medically necessary.

3. As the medical biller/coder, what would be your next steps? Why might the B12 injection have been denied? If necessary, how would you correct the claim?

The insurance company has determined that they will not cover the cost of the B12 injection, citing their guidelines which do not classify it as medically necessary. Consequently, Charlotte’s healthcare provider may need to appeal this decision or furnish more detailed information to demonstrate the necessity of the B12 injection for her specific medical condition. In support of this process, it is advisable to use the diagnosis code D51.0, which corresponds to pernicious anemia, a condition that could potentially justify the need for B12 supplementation. This code and additional clinical justification could help in overturning the insurance company’s decision.

Case Study 2

You are working in the billing department for a clinic when a patient calls, asking why she was sent a bill for $120. She explains it was her understanding she only had a $30 copay and does not understand why she now owes more. She has her Explanation of Benefits but does not understand it. She asks a series of questions.

You review the patient’s verification of benefits and the claim information. You note the following:

• The patient has an office visit copay of $30. 
• The patient has a deductible of $500, with $400 previously met.
• The patient used an in-network provider, and the plan pays 80% while the patient pays 20%.

The explanation of benefits is shown below:

Claim Number	Date of Service	Patient Name	Service Description	Amount Charged	Allowed Amount	Plan Discount	Patient Copay	Deductible	Coinsurance	Patient Responsibility	Plan Paid
40512	10/5/23	Alexis Hughes	Established office	200	125	75	30	0	0	30	95
40512	10/5/23	Alexis Hughes	Chest X-ray 71045	400	200	200	0	100	20	120	80
						Total: 275	Total: 30	Total: 100	Total: 20	Total: 150	Total: 175

Respond to the following in approximately 175–350 words total:

1. What is meant by a plan discount?

A plan discount refers to the reduced rates negotiated between an insurer and a healthcare provider.

2. Does the patient have to pay the difference between the amount charged and the allowed amount?

The patient inquired about her bill, which reflected charges exceeding her $30 copay. The Explanation of Benefits (EOB)it outlines the breakdown of costs in line with the health insurance policy’s terms. In this case, the patient was billed an extra amount because she had a remaining deductible of $100, calculated from her $500 total deductible minus the $400 she had already paid.

3. If the patient has 20% coinsurance, why does she have to pay $120 for the chest X-ray? Explain in detail.

The insurance covers 80% of the bill, leaving the patient to pay the remaining 20% which is $120.

Case Study 3

You are reviewing the aging report for your office and discover a claim that has been outstanding for 65 days. The patient has insurance through Blue Cross Blue Shield, so you check the claim status online to determine if there is a problem with the claim and notice that the claim has been through adjudication. The claim was denied for reason code PR 27.

Identify the reason code and explain, in 175–350 words, what your next steps would be in the claims follow-up process.

PR 27 is a common reason for insurance company denials, often arising from expenses incurred after a patient’s policy was terminated or was not in force. To successfully appeal such denials, it is crucial to verify the coverage dates and provide proof that the insurance was active at the time the expenses were incurred. If the denial is based on issues of medical necessity or policy exclusions, it is important to seek clarification or correction from the insurance provider. In situations involving complex regulatory changes, it is advisable to consult with experts to ensure compliance, thereby avoiding delays in claim processing and potential legal complications.

Case Study 4

Imagine that you are working as the manager of the collection department. Patient account balances are turned over to your department to manage after they have been unpaid for 31 days. You have several new employees and need to explain to them what their responsibilities will be in the department.

Write a 350- to 525-word summary of when to send out additional statements, how to approach collection phone calls and set up payment plans, and when to send the patient to a collection agency.

New employees in the collections department are responsible for managing overdue patient account balances, a task that involves multiple steps to ensure efficient and empathetic debt recovery. This includes sending out regular statements to keep patients informed about their outstanding balances, making collection calls to remind patients of their dues, negotiating payment plans that take into account the patient’s financial situation, and, as a last resort, referring accounts to collection agencies after 90-120 days of non-payment. As the manager of the collection department, your primary responsibilities will center around overseeing patient account balances that are 31 days overdue. You must ensure that new employees are well-versed in the detailed process of collecting unpaid balances, which encompasses deciding the appropriate intervals for sending additional statements, conducting effective yet empathetic collection calls, establishing viable payment plans, and determining the right time to refer an account to a collection agency.

To maintain clear communication, regular statements should be mailed out on a monthly basis, ensuring that patients are continuously informed of their outstanding balances. If a payment is missed following the due date of the first statement, it’s crucial to initiate collection phone calls promptly. These calls should be conducted with a balance of compassion and professionalism, aiming to negotiate payment plans that accommodate the patient’s financial circumstances. This approach helps in building trust and increasing the likelihood of debt recovery while minimizing conflict.

Referring a patient to a collection agency should be a measure of last resort, considered only after multiple internal attempts to collect the debt have been exhausted, typically after a period of 90-120 days of non-payment. Before reaching this stage, every effort should be made to communicate with the patient and establish a mutually agreeable payment schedule. Such efforts demonstrate the organization’s commitment to working with patients to resolve their debts amicably.

Throughout the entire collection process, maintaining clear and consistent communication with patients is paramount. Every interaction should be handled with the utmost professionalism to achieve the dual goals of collecting the owed amounts and preserving patient relationships. This approach not only aids in smoothing the collection process but also helps uphold the organization’s reputation, ensuring that patients feel respected and valued even in challenging financial situations.