Waiver Of Liability

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A waiver of liability can protect either the patient or the healthcare provider from financial risk, depending on who signs it, what it's intended for, and whether it’s initiated by the provider or the insurance company. There are two main types of waiver of liability commonly used in medical billing:

1. Patient-Signed Waiver of Liability
2. Provider-Signed Waiver of Liability

1. Patient-Signed Waiver of Liability:
  • This waiver is similar to an Advance Beneficiary Notice (ABN) but is used for non-Medicare payers.
  • It is a written agreement provided by the healthcare provider to inform the patient that they may be financially responsible if the insurance denies the claim.
  • By signing this waiver, the patient acknowledges and agrees to pay for the service in the event of a denial.

2. Provider-Signed Waiver of Liability:
  • This is a written agreement initiated by the insurance company and the provider must sign to confirm that the patient will not be billed for the service if the claim is denied.
  • Insurance companies typically request this waiver when the provider submits a final appeal for a denied claim.
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Hospital Billing Codes

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Revenue Codes: 
  • These codes describe the type & the location of the service.
  • For example: 0450 - Emergency Room General Services, 0300 – Laboratory General Services, etc.
  • These are 4 digis codes.
  • It is used in locator 42 on UB-04 form.

Condition Codes:
  • These codes describe specific circumstances or situations of patient's care.
  • For example: 02 - Condition is employment related, 17 - Patient is homeless, etc.
  • These are 2 digits codes.
  • It is used in locators 18-28 on UB-04 form.

Occurrence Codes:
  • These codes describe specific dates & events that occurred during patient treatment.
  • For example: 01 - Auto Accident Date, 02 - Date of illness or injury, etc.
  • These are 2 digits codes.
  • It is used in locators 31-34 on UB-04 form.

Occurrence Span Codes:
  • These codes describe the span of the particular service or events provided to the patient.
  • For example: 77 - Hospital stay start date, 78 - Hospital stay end date, etc.
  • These are 2 digits codes.
  • It is used in locators 35-36 on UB-04 form.

Value Codes:
  • These codes provide additional monetary information related to a patient's care or services.
  • For example: 01 - Patient's age, 18 - Number of covered days, etc.
  • These are 2 digits codes.
  • It is used in locators 39-41 on UB-04 form. 

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How to work on Medicare denial - 22, 24 & 109

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When working on these denials, it may create confusion sometimes because when you check eligibility on the Medicare portal or Medicare IVR, you find 2 options - MCO/HMO & MSP and it may be possible that the insurance is available in both tabs then it is difficult to find the correct primary insurance to bill the claim. This post will help to resolve the confusion. Please go through the complete post to have a clear understanding.

1. Denial 24 (Covered under managed care plan) & 109 (Not covered by this payer):

Scenario 1: On these denials, you need to refer to the MCO/HMO tab and the insurance available under this tab will be the primary insurance. After updating this insurance as primary, you do not need to keep the Medicare insurance as a secondary payer because the MCO/HMO plan pays on behalf of Medicare.

Scenario 2: On denial 109, there is another possibility that you will not find any insurance under the MCO/HMO tab. In that case, there may be a possibility of the patient enrolled in Railroad Medicare then you will need to submit the claim to Railroad Medicare (Palmetto Railroad) with the same policy ID.

2. Denial 22 (Other Payer Primary):

Scenario 1: On this denial, you need to refer to the MSP tab and the insurance available under this tab will be the primary insurance. Once you find the primary insurance information then update it as primary insurance and keep Medicare insurance as a secondary payer. Note: Whenever you are making Medicare as secondary, always update the MSP code. Please visit the below link to learn more about the MSP code,

https://www.arlearningonline.com/2020/01/msp-medicare-secondary-payer.html

Scenario 2: There is another possibility that you will not find any insurance under the MSP tab. In that case, you can resubmit the claim to Medicare.

Scenario 3: You may find multiple insurances in the MSP tab, in that case under each insurance name, you will find the MSP code of the insurance. This MSP code will help to identify insurance types. 

MSP Codes:
12 - Commercial insurance with health coverage for beneficiary with age 65 or above
 13 - Commercial insurance with Health coverage for End-Stage Renal Disease beneficiary
 14 - Auto Insurance
 15 - Worker Compensation
 41 - Black Lung Insurance
 43 - Commercial insurance with health coverage for beneficiary under age 65
 47 - Liability Insurance

Example - You find 2 insurances under the MSP tab with MSP code 12 (Commercial insurance) & 14 (Auto insurance). In that case, you will need to identify the service whether it is related to health coverage or Auto injury. If it is related to health coverage then you will need to make primary insurance to an insurance that has MSP code as 12 and keep Medicare as secondary with MSP code 12. In the same way, if the service is Auto related injury then you will need to make Auto insurance as primary which is mentioned with MSP code 14 and Medicare as secondary with MSP code 14.

3. Other Possible Scenarios:

Sometimes, while checking the eligibility you can find a scenario where insurance is available in both MCO/HMO & MSP tabs. In that case, identifying the correct primary and secondary insurance is a little bit tricky. The below examples will help to identify the correct primary and secondary insurance.

Example 1 - There is an insurance in the MSP tab with MSP code 43 (Commercial insurance) and another insurance is under the MCO/HMO tab.

In such a scenario, you can make the insurance as primary which is available under the MSP tab and keep the insurance on secondary position which is available under the MCO/HMO tab. (No need to update the MSP code, it is needed when the original Medicare is updated as secondary)

Example 2 - There is an insurance in the MSP tab with MSP code 15 (Worker Compensation) and another insurance is under the MCO/HMO tab.   

In such a scenario, you need to identify whether a service is related to a work-related injury or not. If it is not then you do not need to bill the claim to WC, you can directly make the MCO/HMO plan as primary insurance. Do not need to keep Medicare as secondary and submit the claim to the MCO/HMO plan.

If the service is related to work-related injury then you can make WC as primary and keep the MCO/HMO plan as secondary and submit the claim to worker comp. (No need to update the MSP code, it is needed when the original Medicare is updated as secondary)
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Interview Questions - Part I

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Tricare & VA Coverage

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TRICARE (CHAMPUS):

  • It covers active and retired military personnel and their dependents, survivors and certain former spouses.

VETERANS AFFAIRS / ADMINISTRATION (VA) (CHAMPVA):

  • Veteran - Veteran is a person who has served in the army, navy or air force, especially during a war.
  • It covers the spouse or child of a veteran who died on the duty or who has been rated permanently and totally disabled for a service-connected disability by a VA regional office.

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B20: Procedure/service was partially or fully furnished by another provider

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Denial Occurrence:
  • This denial occurs when multiple providers billed the same service on the same date of service.
  • The providers can be part of same or different Group/Facility/Hospital.

On Call Scenario:

                                         Claim denied as it is already paid to another provider
                                                                              ↓
                                                            May I get the denial date?
                                                                              ↓
                                     Check in system if the same service on the same DOS
                                     has already been billed and paid to another provider
                                                   ↙                                                    ↘
                                             Yes                                                         No
                                          ↙                                                                    ↘
                         What is the time                                    Could you please provide the name
                       frame for  to submit                                  and NPI of the provider to whom
                       the corrected claim?                                     the payment has been made?
                                     ↓                                                                           ↓
                          May I have the                                                 What is the Fax# or
                       claim# & call ref#?                                              Mailing address to
                                                                                                      send an appeal?      
                                                                                                                  ↓
                                                                                                      How much is the
                                                                                                           time limit?
                                                                                                                  ↓
                                                                                                       May I have the
                                                                                                   Claim# & Call ref#?

Important Notes & Actions:
  • Please take action as per your process update. Below actions can be different from your process update.
  • If you find the same service on the same DOS under a different provider in your system then you can submit corrected claim after appending 77 modifier.
  • If the payer is Medicare then do not need to submit corrected claim, you can append 77 modifier and resubmit the claim.
  • If you do not find the same service on the same DOS under a different provider in your system and it is part of different group then you can send an appeal to insurance.
  • Sometimes, clients wants to write off such claims. So, work as per client instructions.
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TFL & AFL Calculator

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