Vikram panel questions

1 introduction of self

What was your roles & responsibilities in your last company?

Answer - A. To cordinate with insurance companies on denials.

B. To task encounters to client if any client intervention required like provider credentialing, provider
capitated.

C. To tasked encounters to coding if any coding conflict required like inclusive, not medically necessity, &
so on

Question - how will your work on no authorization scenario?

Answer - Authorization is required for high dollar services, Arcilary services or any surgery

EnM services POS 11 Clinics - If I am working on EnM services the maximum dollar billed for CPT 99215
would be $600 & when we cordinate with insurance rep we get to know that claim is denied for

authorization bcos your provider is out of network (OON) that means we should get our provider in
network (IIN)

Pos 21 & 22 (inpatient & out patient) if claim gets denied by insurance for Auth I will cordinate with
hospital to cross verify whether they have obtained auth or not because my

provided visited to hospital & performed the service if I get Auth from hospital I will take and will call
insurance and ask rep to reprocess the claim

If no auth obtained by hospital - I will call insurance to verify why they need Auth for CPT depending
upon reply from insurance rep like initial 2 services no Auth required but from 3 visit

Auth is required or based on patient plan Auth is required. I will verify whether insurance retro Auth if
yes maximum TAT is 24 to 72 hours so I will document the information & task to client for next action if
client says appeal with medical records (MR) I will appeal.

Pos 23 Emergency - if claim gets denied for Auth & POS is 23 than I will call insurance to reprocess claim
as Auth is not required for Emergency services.
4) Question - Explain CO 50 Not medically necessity

Answer - Follow up are different on Medicare & Commercial

Medicare - If claim gets denied by Medicare for CO 50 I will check Medicare FSCO, CMS. GOV or NGS
portal on google to cross verify whether DX billed on claim form is listed as per LCD (Local coverage
determination)

if DX is not listed as per LCD I will task to coding department for review to suggest any additional DX

Commercial - If claim gets denied by UHC or Aetna I will call insurance to verify what documents they
need like MR, letter of medical necessity to prove that services were medically necessity & prepare an
appeal with requested documents

& send to insurance claim mailing address or fax number.

Question. How will you work on Inclusive denial

Answer - If more than 2 services billed on claim form so insurance paid 1 CPT and another CPT gets
denied as inclusive.

Steps - Cross verify on encoder pro by putting all CPT to see whether CPT is included with paid CPT

If yes

Will see any modifier is appended or not

If no modifier appended will task to coding

If modifier is already appended will call insurance to reprocess if rep is not reprocessing will appeal with
MR.

6) How will you work on Non covered denial?

Answer - There are types of codes on non covered CO 96 & PR 96

PR 96 steps
I will check my system whether same CPT & DX were paid earlier

If Yes I will call insurance & ask rep to reprocess claim.

If No than I will call insurance to verify whether services are covered under patient plan or not if no than
we will bill claim to patient.

CO 96 Steps

I will call insurance to verify whether services performed by Doctor are eligible or not if no I will task it to
client.

8) Question. Stes of RCM

1. Appointment

2. EVBV ( Eligibility verification & benefits verification)

3. Registration

4. Encounter

5. Medical transcriptionist

6. Medical coding

7. Charge entry

8. Claim preparation & submission

9. Payment posting if claim denied

10. Denial

Mod 76 is used when a particular service is performed by same physician twice in a day

Mod 77 is used when same service performed by two different physician twice in a day

Retro auth

In case of emergency or when provier fails to get prior auth. He can go for retro authorization however
request needs to be initiated within 72 hours from date of service

While working on denial applied towards capitation at first we need to check rendering provider is PCP
or specialist, if provider is PCP than we need to the payer n get capitation period if our DOS is lies under

capitation period so it correct denial if it is not than need to reprocess the claim
Medicare eligibility criteria

Person shud b above 65yrs of age or 65

2yrs of disability or more than that

End stage renal desease person who is on dialysis due kidney failure

Mod 59 is used to describe it is a distinct procedure

Medicaid eligibility criteria

Below poverty line

Blindness

New born baby

Pregnant women

Person who is working in copper mine in USA (black lung programme)

CLIA - Clinical Laboratory improvement Act.

It is a kind of license number for pathology

For an example payer says the provider that for a particular patient they are paying for whole month in
advance, the amount which payer pays in advance is capitation amount n a month is capitation period

COBRA - Consolidate Omnibus Budget Reconsilation Act.

It covers unemployed citizens of USA for period of 3-18 months

What is an LCD in medical billing?

NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) are decisions by
Medicare and their administrative contractors that provide coverage information and determine
whether services are reasonable and necessary on certain services offered by participating providers.

What is MSP
Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have
primary payment responsiility - that is, when another entity has the responsibilit for paying before
Medicare.

1)What are the types of plans

HMO -Hmo health maintance organization where pcp will be there or given by insurance so patient has
to visit PCP only if refers to specialist thn only patient can move

PPO -Ppo plan in this plan patient enjoys more freedom and can visit to any specialist at any time and
patient can go to any OON DRS also

Referal is required in HMO plan not in PPO plan

EPO- In an EPO plan, you have to get treatment from a network of providers on a list. Out-of-network
coverage Not covered (except for emergencies)

POS- This is a hybrid of HMO and PPO plans, covering some of the costs of out-of-network treatment. ou
of network coverage -Cover but at higher costs

2)What is OOP?

Deductible - A deductible is the amount of money that a patient must pay out of their own pocket
before their health insurance coverage starts to kick in.

Coinsurance - Coinsurance is the percentage of the cost of a medical service that a patient is responsible
for paying, after the deductible has been met. Unlike a copay, which is a fixed amount, coinsurance is a
portion of the total cost.

Copay - A copay is a fixed amount that a patient pays for a covered medical service or prescription drug.
It's typically a set fee that you pay at the time of receiving the service.

What and how do you check verify details?

Through website or call, we check the start date and end date of insurance policy, how much OOP is met
and remaining, what type of plan does the patient has. Do they need referral, auth and if yes how to get
the auth,also check OON is covered or not
what is QMB

Qualified Medicare beneficiary

The Qualified Medicare Beneficiary (QMB) Program is one of the four Medicare Savings Programs that
allows you to get help from your state to pay your Medicare premiums.

This Program helps pay for Part A premiums, Part B premiums, and deductibles, coinsurance, and
copayments.

What is SLMB plan

The Specified Low-Income Medicare Beneficiary (SLMB) Program is one of the four. Medicare Savings
Programs that allows you to get help from your state to pay your. Medicare premiums.

This Program helps pay for Part B premiums only.

SSS

Medicaid managed care organizations (MCOs) provide comprehensive acute care and in some cases
long-term services and supports to Medicaid beneficiaries.

MCOs accept a set per member per month payment for these services and are at financial risk for the
Medicaid services specified in their contracts

Modifier 76 - if services performed twice in a day by same physician but timing should be different than
we will append modifier 76

Modifier 77 - if services performed twice in a day by 2 different doctors under same group & timing are
different than we will append modifier 77

Modifier 24 - Used on EnM services when EnM gets denied for global to surgery so we need to cross
verify whether DX for surgery & EnM are same or not if DX are

different than will append modifier 24 if DX are same than we will append modifier 57

Modifier 25 - Used on EnM services when more than 2 services billed on claim form on same day & EnM
gets denied for inclusive we will append modifier 25

EnM CPT 99201 to 99215