Written Communication Skills - Essay Example

e) Explain in detail your written communication skills to obtain needed information to respond to inquiries and provide information. My work involves processing requests and inquiries from providers and beneficiaries to CPD thus my written communication skills are used through a “reprocessing worksheet” and in drafting letters to the respondents requesting for additional information. In most cases, the requests contain insufficient information that requires on my part further research and investigation to be able to process their request. I receive correspondence that are in STELLENT, these correspondence are sent by providers, sponsors, or beneficiaries who inquiries about a denied claim, an approved claim, or just a correspondence of general inquiry. Another means that I process requests are the correspondence between PCDUO’s and other Customer Service. The bulk of the correspondences are requests for processing claims and reviewing and or verifying of claims if processed correctly. The tasks also involve me having to write sent back letters to an inquisitor regarding balance billing, letter of credible coverage, or explaining to a provider why a claim is either denied correctly or paid correctly, and to submit an appeal if it’s an appealable denial. Be it a correspondence in STELLENT or PCDUO, I would carefully analyze each requests and cross reference it to the CHAMPVA policy manual and CSC/CPD desk procedures to determine whether to do a send back letter to the inquisitor, or to have the claim reprocessed. If a claim needs to be reprocessed, I would place the request through the “reprocessing worksheet” to inform CPD why the claim was denied, how much to pay the provider, whether to over ride timely filing because evidence exist of timely submission, and give the specific instructions on how to reprocess the claim. My dedication to effective communication speaks well during my tenure since all my written correspondence, not once did I received a send back letter from a Supervisor or a “reprocessing worksheet” from CDP due to inaccurate or incomplete data. I always make sure that I check the policy manual and or CSC/CPD desk procedures and reference it to my correspondence to ensure efficacy and factualness of my judgment. Another example wherein I used my written communication skills to obtain needed information to respond to inquiries and provide information was when I was on active duty as a Guardsman in the Air Force. Being part of the chain of command, I would respond to daily inquiries through email from senior commanders and from junior personnel that involves critical matters pertaining to deployments, reenlistments, trainings, career job reservations, and accountability. It is crucial that all correspondence is heeded to in a timely manner and contains correct and accurate information. Also, when I was assigned as the UTM and UDM for my unit, I was responsible for all written correspondence and reports that are anchored on Air Force standards and regulations, staff members’ recommendations, past performances, and present requirements. It was also part of my responsibility to provide the quarterly report for the commander regarding the unit’s ability for deployment. My reports are based on analyzing unit funds, manning, and equipment availability. Upon my recommendation to senior leadership and the commander on whether the unit is fully compliant or partially compliant for deployment, the results are then forwarded to the wing commander then to the MAJCOM. Accuracy and correctness of data is crucial less I get reprimanded which I never did. I never delayed a deployment and I have completed all reenlistment and member training on time. f) Explain in detail you knowledge of claims processing system to specifically address how a claim adjudicates through benefit calculation, and the hierarchy of system work flow and reimbursement controls. Having worked in SSD prior to working in CSC, I have completed over 205 hours of SSD training; 306 hours of CSC training; and 96 hours of CPD training; all of which has given me technical knowledge on how a claim adjudicates through benefit calculation and the hierarchy of system work flow. The process of claim adjudication through benefit calculation starts when a claim is received by the Claim Processing Department (CPD).When CPD receives a claim by OCR or EDI, they input and verify all the pertinent information that is present in order for a claim to be processed—i.e. beneficiary information that includes SSN and the complete name of the beneficiary; claim information that includes valid diagnosis code, procedure code, date of service, and billed amount; and vendor information. After a claim is generated at CPD, benefits calculation is determined whether the claim is valid for paying primary or paying patient responsibility when Other Health Insurance is present. If a claim is processed as primary for outpatient services, beneficiary has a cost share of an individual annual deductible of $50 or family deductible of $100 (ASC and Inpatient claims do not have deductibles), and a 25% coinsurance with an annual catastrophic cap of $3000. For Inpatient medical claim the beneficiary’s cost share will be lesser of the three (25% of the billed amount, base DRG amount, or per diem rate of $535 times the number of days inpatient) up to an annual catastrophic cap of $3000. For outpatient and inpatient services, CHAMPVA pays deductible, co-pay, and coinsurance up to the allowable ceiling amount when Other Health Insurance (OHI) is present. Initial determination is made by Artificial Intelligence (AI). If a claim cannot be determined by AI, it goes to Suspense I or goes to QMD (Nurses queue) for review. Timely filling will always be the first denial; next denial is for missing an Explanation of Benefits (EOB) from primary insurance. The end product of this process is called the initial determination. ClaimCheck is an automated “code editing software” that ensures proper coding of outpatient and inpatient claims. The following edits are considered during ClaimCheck which are integral procedure, mutually exclusive procedures, duplicate claims, assistant surgeons, cosmetic procedures, unlisted procedures, obsolete procedures, and age and sex conflict. The following are claims that are not subject to ClaimCheck: pharmacy, dental, DME, inpatient mental health, and E&M that is part of the overall surgical plan. The hierarchy of system work flow starts when a claim is generated at CPD. The second process is when the initial determination is made whether the claim would be approved or denied. Third, the claim goes to PMD for first level appeal. Lastly, PMD makes appeal determination whether denial is upheld or over turned. If the appeal is upheld ,then a written request to the HAC Director can be made for a second level appeal within 90 days from first level appeal determination. At the second level appeal the Director or designee will review the claims and any other supporting documents. The decision of the Director is final with regards to “benefit coverage and computation of benefits”. As an Appeals Specialist, I will be dealing with all sections in PMD (Policy, PMPAY, and Program Integrity) as well as all other departments (CPD, RU, SSD). g) Explain in detail your ability to conduct extensive research of the assigned subject matter, organize information, and formulate sound conclusions and recommendations based on findings. As a Customer Service Representative I conduct extensive research on claims that have been denied due to timely filing, duplicate denials, corrected claims that were submitted to add or change a modifier that denied a procedure code for mutually exclusive or integral to major procedure, researching CHAMPVA CMAC rate with TRICARE’s rates, researching ASC claims to verify that it processed correctly, and researching and reviewing sponsor’s Rating Decision and Award Letter to determine if they are CHAMPVA eligible. My research is conducted through phone or written correspondence through PCDUO or STELLENT. When a claim is denied for timely filing, it is my responsibility to determine if the claim was submitted in a timely manner or if the claim falls under the 180 day Grace Period for beneficiary to submit claims back dating to effective date. When I find evidence that the claim was initially filed in a timely manner with CHAMPVA, I either send a claims reprocessing worksheet to CPD stating my findings that is backed with the CHAMPVA policy manual or CSC/CPD desk procedures for reference. In terms of duplicate denials and research claims it denied off of, I research both claims to determine if the appropriate modifiers were used to signify Technical Component (TC), Professional Fees (26), RT, LT, etc. A PCDUO to RU or a claims reprocessing to CPD would be generated stating my findings. I also look at CHAMPVA’s CMAC rates with TRICARE’s rates, especially when it comes to ASC claims. I would also double-check TRICARE’s ASC rate on their website, and review the ASC claim to verify if it was processed correctly. I also check the sponsor’s Rating Decision and Award Letter to verify if it does not state that the sponsor is Permanently and Totally (P/T) disabled, and whether if they are Dependent Education Assistance (Chapter 35) eligible. In some cases, the inquisitor would present Rating Decisions to show they are Permanently and Totally Disable to qualify them for state benefits. I would provider sponsor’s and beneficiary’s sound conclusion on how to get it resolved, and how to apply for Chapter 35 and the P/T status. As a Supervisor in the US Air Force, stationed in Kadena AB and Mountain Home AFB, I was designated as team leader and am thus responsible for overseeing the unit’s annual inspections. I submit my reports and pertinent information to my commanders and senior officers through the chain of command on how to improve results based on past performances. As team leader, I would seek guidance from Air Forces Instructions and manuals to ensure the unit was within Air Force standards. I gave written and verbal recommendations to leadership from my investigation on identifiable policy violations and required steps needed to make corrections. Another responsibility that I have to perform as Supervisor in the Air Force, was writing the quarterly and annual Enlisted Performance Reports on subordinates based on performances. To do so, I would conduct background check on personnel’s personal profile. I would also research local laws and Air Force Instructions to make recommendations to commanders on how to discipline a subordinate when a crime has been committed which would be used as basis for his ruling. Read More