Reference no: EM133166244

You are a newly hired health insurance specialist at a small medical practice, and you are responsible for completing and submitting CMS-1500 claims. Toward the end of your second day on the job, you are asked to take a phone call from a patient who has questions about a submitted claim.

The patient tells you that they just received an explanation of benefits (EOB) from the third-party payer, and it makes no sense because the bottom part of the form that is supposed to include a tear-off check is blank. The patient tells you that the EOB states the patient agreed to the assignment of benefits. The patient is upset because that money is needed to buy groceries.

You use the medical practice's electronic health record system to quickly access the patient's record, submitted CMS-1500 claim, and remittance advice that the practice received from the payer. You explain to the patient that the physician accepts assignment from this payer and that the patient authorized the assignment of benefits from the payer directly to the physician. You further explain that according to your file, the account is considered paid in full because the patient paid the $20 copayment at the time of the encounter.

The patient argues that the medical practice owes them money because they were supposed to receive a check from the payer.

What is causing confusion for the patient? How should this be resolved for the patient?