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GENETWORx relies on financial data and information to meet its operational, financial, and regulatory requirements. All financial data and information shall be managed to ensure that revenue reporting is correct.
The purpose of this policy is to ensure patient accounts with a negative balance are researched and reconciled in a timely manner. The Billing Department will make adjustments in the billing system to ensure that revenue is consistent with all operational, financial, and regulatory requirements of our Business. The Billing Department will review and document the information obtained as to why credit balances are occurring and will implement corrective measures to prevent continued overpayment trends as appropriate.
Batch: The documentation that supports entries made in the billing system.
Billing system: The computer program which is used to submit bills for services provided to either insurance carriers or patients.
Cash Control Specialist (CCS): Responsible for reconciling patient accounts by applying payments received and recognizing when an overpayment and has been made and then initiating a refund.
Billing Department: the unit in the Corporate Office that is responsible for managing the revenue cycle.
Credit Balance Report: a report that will display patient accounts with a negative balance which are in the billing system.
Payor (Insurance and other financially obligated entities or person(s): Financial classifications are abbreviations in the billing system, in which like payors are grouped.
Patient Account: The term used to describe the entry in the billing system that holds patient, charge, and financial data pertaining to services performed on a specific date(s).
Remittance Advice: The documentation that accompanies payments made by insurance carriers, which provides patient names as well as the amount they are paying.
A credit balance report will be generated from information in the billing system on a monthly basis and will be a tool for resolving those balances including any refunds due. In addition, to comply with State unclaimed property laws and escheat reporting guidelines, credit balances remaining unresolved will be remitted in accordance with State guidelines by the Finance Department.
Any request for a refund check will be in accordance with RCA’s check request procedure.
There will be three results to all credit balance investigations: No overpayment was made, a patient made the overpayment or an insurance company made the overpayment.
No Overpayment Was Made
If after investigation the Billing Department, by its CCS determines that no refund is necessary, shall perform the necessary adjustments to correct the patient account following established procedures.
Patient refunds occur once all claims have been paid and payment(s) have been posted to the patient’s account. Once it has been determined that a refund to a patient is due, a request should be generated within thirty days (30) of the refund recognition. The CCS will submit all refund approval requests to the Billing Department supervisor and Director respectively along with printed copies of all supporting documents including but not limited to printed patient ledger, any explanation of benefits, all receipts from patient payments, and if a self-pay the original agreement made with the patient upon admission.
The Director will in turn submit the request to the Financial Analyst for the first review, then the Controller and then the SVP, Finance and Administration, or their designee for final approval. Once the approval is returned from the Finance, the CCS should make the appropriate adjustment to the billing system to remove the negative amount from the billing system. The method of the payment will drive how the overpayment is refunded whenever applicable.
The CCS should enter the check number and/or reference number, the date and the amount to be refunded in the billing system and a copy of the check or refund transaction should be included with the batch that the entries were made.
Once it has been determined that an insurance company made an overpayment Genetworx will contact the payer to resolve the matter. All correspondence with the payer will be documented in the billing system. The credit balance will be transferred to a refund guarantor to clearly identify that the insurance company has been made aware of this overpayment. The insurance company will inform us as to how they would like to resolve the credit balance. Some payers will off-set the credit on future payments others may request a check.
On a monthly basis all outstanding insurance overpayments which were reported approximately one year before, should be reviewed and if appropriate, the Billing Department should complete a check request and mail it to the insurance carrier along with an explanation including a copy of the remittance advice. The Billing Department will document the check number, the date of the check, and the dollar amount into the billing system and a copy of the check should be included in the batch in which the entries were made. If an insurance carrier either states that the refund is not necessary or if the check is returned, then RCA shall consider the amount of miscellaneous income. The account in the billing system shall be adjusted to the correct adjustment code and a copy of the adjustment shall be given to the finance department for re-classification.
Medicare and Medicaid Exception – where applicable
If any Medicare, Medicaid or any Federal payer is found to have a credit balance, the amount must be refunded to the payer within sixty (60) days either by check or by completing an adjustment form required by the payer. If an adjustment form is sent, the patient account should be transferred into the appropriate FSC, which will clearly identify that a form was sent. If an account is still open one year after the form was submitted, a check should be requested and send to the payer. The Billing Department should also enter the check number, the date of the check and the amount into billing system and a copy of the check should be included with the batch that the entries were made.
Any exceptions to this Policy or its procedures must be approved by the SVP, Finance, and Administration or their designee.