Chapter 4, Problem 17R

The difference between a remittance advice (RA) and an explanation of benefits (EOB) is:   The RA goes to the provider only and includes payment information.    The EOB goes to the provider.   The RA is sent to the patient and includes payment information.   The EOB contains payment information.

To process claims accurately and effectively, billing professionals must understand how a clean claim is prepared and what issues can contribute to a dirty claim. When managing a team of billing professionals, it is important to understand how internal and external factors contribute to a smooth process vs. a rejection or denial. Summarize internal factors (within your organization/facility) that can positively or negatively influence the life cycle of a claim. Summarize external factors (outside of your organization/facility) that can positively or negatively influence the life cycle of a claim. From a leadership perspective, how can you ensure your team is effectively trained and confident in navigating internal and external challenges with claim processing? Please be sure to validate your opinions and ideas with citations and references in APA format.

A physician asks the medical biller to change the date of service on a Medicare claim because it has passed the timely filing limit and was not previously submitted for payment. Is this fraud or abuse if the claim is then submitted? Why?