ERA Posting of Optima Issue

OpenEMR Development
1

juggernautsei wrote on Wednesday, October 05, 2011:

Hi,

I have a client that is having a problem with ERA’s for just one carrier which is Optima being counted twice. Below is what the billing person Donna wrote me. Any help would be greatly appreciated. It would be nice to have this fixed before upgrading to version 4.1 of if someone can tell me this issue has been resolved in version 4.1. Thanks ahead of time.

(And Donna Wrote)

Sherwin
I successfully posted 1 Anthem, 1 Aetna & 3 Optima ERA’s.  I verified the payments & adjustments that posted automatically with those listed on the 835 file I printed from Payerpath.  Everything looks great with the exception to Optima adjustments.  This is the same issue we had prior to upgrade so it’s not a new issue & you may have already started your research in resolving this issue.  Here’s an example of what is being posted automatically per report that followed when you hit SUBMIT:

Virginia Hobbs 1262.10065 93350:26 2011-04-28 Service Item 118.00 118.00
  Allowed amount is 85.49
      2011-05-12 Ins1/13#434303 payment -85.49 32.51
      2011-05-12 45: Charges exceed your contracted/ legislated fee arrangement -32.51  0.00
      2011-05-12 A2: Contractual adjustment -32.51  -32.51

Here’s what the patients acct shows in OpenEmr:

Ins1/ePay - 13#434303 2011-05-12 32.51 Adjust code 45
  Ins1/ePay - 13#434303 2011-05-12 32.51 Adjust code A2
  Ins1/ePay - 13#434303 2011-05-12 85.49
  -32.51 

As you see above, adjustment code 45 is subtracting $32.51 from the patients total charge AND adjustment code A2 is subtracting $32.51 which leaves a credit balance on the patients account of -$32.51 which is incorrect.  The balance should be $0.  This two adjustments codes mean the same thing & I’m not sure why it’s duplicated.  I’ve attached the PDF file of this 835 Remittance which is what I use to post manual adjustments/payments.  A2 code is not listed on the PDF so I’m not sure why its on the RPT.  These duplicate adjustments are only found on claims processed as Primary…Secondary claims auto post correctly.  Is there a way to make A2 codes post as “for informative purposes only” like the COPAY amount does in the following?:

  Claim status 1: Processed as Primary
  AMT segment at claim level ignored.
George Easter 662.9745 99211 2011-04-28 Service Item 29.00 29.00
  Allowed amount is 21.68
      2011-05-12 45: Charges exceed your contracted/ legislated fee arrangement -7.32 21.68
  3: Co-payment Amount 21.68 
      2011-05-12 A2: Contractual adjustment -7.32 14.36
    CO-PAY 2011-04-28 Pt Paid -30.00 -15.64

As you can see here, adjustment code 3 is $21.68 & that amount is not subtracted from the balance.

I have been deleting these duplicate adjustments after they have been “auto posted” but I’ve left these patient accounts alone so that you had something to refer to.

This is not of highest priority but it does take me extra, unnecessary, time to delete all of the duplicate adjustments on every Optima claim processed as Primary.  Without deleting the duplicate adjustments, the patient’s balance & any subsequent bill/statement would be incorrect.

2

cverk wrote on Wednesday, October 05, 2011:

I will second the idea that the ERA module needs a little work.  I download 835 EOB’s directly from Unitedhealthcare and they will not run at all.  I receive 835 EOB’s from a number of other carriers through officeally and they run with seamingly random issues.  On some claims they will insert a duplicate of the CPT code or codes and pay and adjust against those codes, while leaving the original codes in place and thus a balance when their is none. You then have to manual adjust off that balance.  You also have to go to authorizations and authorize those codes, pull them up under billing and mark them as cleared to prevent them from being rebilled. I thought this was something about the authorizations for my front desk person coding in these visits from a superbill, but it doesn’t seem to matter even if she is authorized at all levels.

3

juggernautsei wrote on Friday, October 07, 2011:

There is one thing that the can be added to the billing wish list and it has to do with insurance.

The problem is that the system only has three spots for insurance. The billing person needs this to happen. She needs to be able to put in up to 5 or more insurance companies and be able to assign which one is primary and which one is secondary. This needs to be assignable because the way it is now when the patient has a new carrier that will start on the next month. She has to delete all the insurance information and then type it in again but when the work was done under the old carrier. She has to delete the new carrier and put the old one back to bill against. This is costing a lot of time. The AllScripts allow her to keep multiple insurances in a patients record and assign which one is needed to be used to bill again.

What would be to cost on sponsoring the work for these modificaiton to the billing module?

Sherwin

Sherwin

4

bradymiller wrote on Saturday, October 08, 2011:

Hi Sherwin,

If nobody contacts you regarding these mods for the billing module, then send me an email at brady@sparmy.com ; I could send you some recs of pros/developers for you to contact whom should be able to do this (and they should be able to ensure it is also committed to the official codebase).

-brady

5

juggernautsei wrote on Saturday, October 08, 2011:

Mr. Brady,

Thanks for the response. I will keep you informed. I will wait few more days to see if anyone will pick this up.

Regards,

Sherwin

6

sritel wrote on Saturday, October 08, 2011:

Hi,

We would be interested in taking this up.

Please feel free to reach me at srikant@emrtsolutions.com
www.emrtsolutions.com
(EMR Technical Solutions LLC)

Regards,

Srikant

7

yehster wrote on Saturday, October 08, 2011:

Sherwin,
It’s hard to accurately determine a cost without understanding the full scope of the issues and your desired time frame. There is certainly more to it than simply adding quaternary, quinary insurance carriers (allowing up to 5 carriers…).

It would be relatively easy to add additional tabs on the demographics_full.php page for the additional insurance information, and then maybe add a couple of controls to allow copying the info back and forth between the entries. Not sure that’s the way to go though.

Where it gets difficult is making sure the additional fields are all available as choices elsewhere, or if it would just be sufficient to be able to have the additional fields on the demographics_full page and copy them back and forth.

Anyway, I’m thinking aloud here trying to determine how hard this problem really is.
-Kevin Yeh

8

juggernautsei wrote on Sunday, October 09, 2011:

Kevin,

thanks for thinking out loud. I have looked at the code and since I am a rookie programmer. I am in over my head. I have learned from other things that i have broken in the software that things are more connected than I know. I do know that it would not just be as simple as adding fields.

But what you discribed is close to the working model I have in mind. The addition of two more insurances would help. The obsticle that would l have to be over come is being able to switch the insurances at random. Lets say that insurance1 is primary and insurance2 is secondary and there is an insurance3. Now insurance4&5 are no active. They are just place holders. The ideal thing that the user wants to happen is that insurance4 now needs to be primary because the patient is switching carriers. So, she will drag the tab of insurance4 over to the primary position and then it will become insurance1 and that which was primary becomes insurance4. The other thing that happens is that the billing company will need to bill a proceedure that was done under what is now insurance4 when it use to be insurance1. Now it has to be put back as insurance1 to write out the claim. Now theoreticlly on the coding side the only thing that happens is that in the database insurance1 is erased and replaced with insurance4 and vice versa. This happens when the patient data is saved thus not having to change any of the other references. This is my pseudo working code.

I was looking at this code http://tool-man.org/examples/edit-in-place.html to see if I could figure out how this works and see if it could work for OEMR. The part on the page where there is the slide show sorter is what I think will work. There is no hurry because they have been working with the system the way it is deleting and re-entering the insurance information.

I hope this helps clear up the picture. Think out loud some more, pls

Sherwin

9

yehster wrote on Sunday, October 09, 2011:

Sherwin,
How do billing folks know/keep track of the fact that they need to bill the old insurance provider or the new provider?

Here’s what I’m thinking as a potential solution. 
1. Add three additional tabs to the insurance entry called Historical1, Historical2 and Historical3
2. Add a mechanism to swap any of the historical insurance information with Primary, Secondary or Tertiary
3. (Optional)Add a mechanism to easily “clean out”  historical data

Then the use case is a follows.
Established patient comes in with a new primary insurance carrier.
The front office person can then move the current entry into one of the historical entries (hopefully blank still)
They can then enter the new information in to the now blank primary tab.
Alternately, the user could enter the new information into one of the historical tabs.  When done, they can swap with primary.  Old info in primary is moved to historical and the new information entered in historical is moved to primary.

Now when it is time to bill, the biller can swap between any of the historical fields and the primary, secondary or tertiary as needed.
How the biller knows he needs to swap at this point is not clear to me though.

-Kevin Yeh

10

juggernautsei wrote on Sunday, October 09, 2011:

Kevin,

I spoke with the billing person today. She shared that it is just by happen stance that they come across this.

Billing runs a claim and it is rejected and the reason is that the carriers policy was not enforce at the time of the encounter. Billing has to call the patient to get the new billing information but there may be new claims in the system that have not been billed yet. So, billing has to figure out under which policy was the proceedure done and bill it accordingly.

Second reason is that claims get kicked back for any reason the the client has move do a new insurance. billing still needs the historical information to rerun that claim.

I spoke with billing about the proposed setup and she said that is perfect.

Let me know if you need any more information.

Sherwin

11

juggernautsei wrote on Sunday, October 09, 2011:

Kevin,

The billing person sent me the message below to further explain why.

See patient, Peter Kane #534.  I orginally sent claim to Optima for 12/2010 claims (Optima coverage ended 12/31/2010).  Beginning Jan 2011 the patient had Medicare & Anthem BCBS.  No payment had been received from Optima for Dec 2010 claims…said they did not have claims on file so I had to refile to Optima for Dec 2010 claims.  We had already updated the patients account to reflect his insurance effective for 2011 so I had to remove Medicare & Anthem & re-enter Optima info so that when I re-opened 2010 encounters, it would be listed under the correct insurance for that date of service…therefore leading to EDI tranmission to the correct insurance co.  I put a “billing note” on the account so that if the patient came back in for services in 2011, it would alert the front desk that the insurance info would have to changed back to medicare & anthem BCBS before anymore 2011 claims could be filed.  Notice that when I changed insurance info to Optima for 2010 claims re-filing, the insurance listed for 2011 encounter is listed with Optima as well…luckily Medicare & Anthem BCBS  had already paid so changing the patients insurance back to Optima didn’t mess up filing for 2011 encounter.

Is there a way to add a coverage end date?  Would that help the situation with patients like Mr. Kane?  Currently, the systems says "Primary Insurance from 2010-01-01 until Present " just below the “PRIMARY” insurance tab……the effective date I entered for the insurance company is 1/1/2010 but there is no place for me to enter an “until” date to replace "“Present”.  See Secondary “OLD”, “Old Secondary Insurance from 2011-01-01 until 2011-10-09”…the “until” date was auto-populated because that’s the day I made the change of insurance on the patients account…that isn’t the true “until” date.  In Mr Kane’s situation, is it possible for OPEN EMR to allow me to put in Optima as primary insurance effective 1/1/10 until 12/31/2010 AND to enter Medicare primary effective 1/1/11 until present & Anthem secondary effective 1/1/11 until present, so that when I look at VISIT HISTORY to view my encounters, 2010 encounters are listed under Optima AND at the same time 2011 encounters are listed under Medicare  & Anthem BCBS?  That way if I re-open an encounter, it’ll recognize which insurance co. the encounter should go to based on effective/end dates of coverage as it relates to the date of the encounter?

Hope this helps.

Sherwin

12

jcahn2 wrote on Monday, October 10, 2011:

Each payor need to be identified with and “active” date when it is placed in the insurance demographic.  When it stops it needs an “inactive” terminate date.  Encounters generated during the active period are associated  with only active primary and secondary insurance etc.  One should not be able to generate a claim for an inactive insurance.  Also there needs to be a “manual” selection to override primary and secondary for “cash”, “disallowed”, and “Workers Comp” claims and statement generation.
Jack Cahn MD
OEMR Board

13

sunsetsystems wrote on Monday, October 10, 2011:

Currently, insurance termination is considered to be the next effective date.  So if you want to record a period of no insurance, the way to do that is to enter “Unassigned” as the insurer, with the effective date set to the desired termination date.

Just wanted to make sure y’all are aware of that.  I agree that an explicit termination date would be nicer.

Rod
www.sunsetsystems.com

14

nursejeff wrote on Monday, October 10, 2011:

I second the suggestion above by Dr. Cahn.

We have many patients that have insurance but also come in for services not covered by their insurance.  We consider these “cash” visits.  In our former Medisoft program we were able to label that days encounter as a “cash” encounter and a claim was not made to send on to the clearinghouse.

I do not know of a way that OpenEmr can differentiate between a “cash” visit and a visit that should complete a claim.

Thank you for the consideration.

Jeff Guillory Jr.
Family Nurse Practitioner

15

jcahn2 wrote on Monday, October 10, 2011:

And again, the problem with Workers Comp is that WC needs to be an active insurance overlapping the same time span as the patient’s primary insurance.  Could be a WC visit on Monday and a Diabetes recheck on Wednesday.  The biller has to be able to select the correct payor when both must be active.  Not sure how folks are presently working around this problem.
Jack Cahn MD
OEMR board

16

juggernautsei wrote on Friday, December 23, 2011:

Hello!

Reviving this thread… I hope.

Here is an update since I have upgraded Dr. East to the 4.1 with a great success and very little brakage.

Donna the billing person wrote me this:

"I wanted to update you guys on ERA posting which is #8 on Sugar’s list.  I’ve auto-posted an Optima remit……no more duplicate adjustment posting since upgrade…that’s GREAT!  However, I still have to touch accounts with balances remaining because the system doesn’t move the remaining amount to the next responsible party automatically.  "

Those that have worked on the billing side kudos. I hope these posting will help guide the next development of the billing section. Is there a quick fix for the asignement  of the remaining balance?

Sherwin