User Guide — Insurance Refund Workflow
This page describes the insurance refund workflow.
Features and workflows
The insurance refund workflow begins when you identify a claim that requires a refund. You can use the Manage Refunds page to generate a list of claims that may need insurance refunds.
Use the Issue Insurance Refund page to post the refund. Behind the scenes, athenaOne opens (and closes) your refund payment batches automatically.
Reconcile these refund payment batches to deposit batches via the Batch Refunds tab of the Manage Refunds page. athenaOne automatically closes the deposit batches that you create using the Batch Refunds tab of the Manage Refunds page.
You can record payee information during the insurance refund posting process so that your practice's check writer or A/P department can easily find the payee to whom the refund check needs to be sent on the Assign Check Numbers tab of the Manage Refunds page.
You can also add new payees as follows:
- When you post a refund to a patient claim via the Issue Insurance Refund page.
- When you reconcile payment batches to deposit batches via the Batch Refunds tab of the Manage Refunds page.
- Directly from the Payee Addresses page.
Capturing payee address information is not required to complete the refund posting process. A payee address provides additional information to your practice's A/P department or check writer about where an insurance refund should be sent.
Notes:
- You must use the Refund Checks In Process page for any "in process" refunds (refunds without check numbers) that you posted prior to Release 14.2; only refunds posted after Release 14.2 appear on the Assign Check Numbers tab of the Manage Refunds page.
- You can post patient refunds manually using the Issue Patient Refund page or in batches using the Patient Refund Policies page and the associated Patient Refund Worklist. However, patient refunds will appear on the Assign Check Numbers tab of the Manage Refunds page.
Best practice
Insurance refunds should be processed on a weekly basis.
Where do I find the claims that need insurance refunds?
You can identify claims that require insurance refunds using these pages:
- On the Workflow Dashboard, the MGRHOLD work queue contains claims denied with the legacy REFUND kick code and with the SENDREFUND or SENDREFUNDINTEREST kick codes. SENDREFUND indicates that the payer will not take back the amount, so a refund should be issued; SENDREFUNDINTEREST indicates that interest will be charged if the amount requested is not refunded in a timely manner.
- On the Approve Insurance Refunds list.
- On the View Overpaid Claims worklist. To generate this list, click Show Overpaid Claims on the Billing Worklists page. The Task Bar lists overpaid claims and claims kicked with a REFUND kick code.
Who is responsible for follow-up on overpaid claims?
Beginning in November 2017, athenahealth intercepts and reviews overpaid claims in HOLD, MGRHOLD, or OVERPAID status sent with any of these kick codes:
- OVERPYMT
- OVERPY1MRY
- OVERPY2NDY
- OVERPYEOBPOST
After reviewing the claim, we either:
- Resolve the overpayment issue on the claim.
- Provide next steps for how you or the payer can resolve the overpayment (we may contact the payer on your behalf to determine the next steps).
When athenahealth is working a claim for overpayment, the kick code OVERPYMTATHENACALLPAYER or OVERPYMTATHENARVW appears in the claim notes within 3 days. These kick codes move the claim to CBOHOLD status.
Note: athenahealth does not resolve overpaid claims with service restrictions that you may have applied or overpaid claims that were already in your worklists prior to your practice's rollout date for this service.
athenahealth may need to send a claim back to you under these circumstances:
- We cannot reach the payer.
- The payer cannot or will not provide us with the necessary information.
- The claim must be voided from the payer's portal.
- You must coordinate benefits with the patient or the patient must do so with the payer.
- A refund check is required to resolve the overpayment with the payer.
- A determination from you is required to accept an overpaid balance.
- You changed something on the claim that caused the overpayment.
What is the refund checks in process list?
The Refund Checks In Process page displays all refunds — both to patients and payers — that have been posted, but do not have check numbers associated with them (assuming that a refund will be issued as soon as a check is cut).
For insurance refunds, if you do not have the check number at the time that the refund is posted (if it was not entered from the Payment Batch or Issue Insurance Refund page), the refund appears listed on the Refund Checks In Process page.