Bioventus Inc. · NASDAQ:BVS
Bioventus — Investor Presentation (September 2017)
20 slides from Bioventus's investor presentation, Sep 14, 2017
Slide 1: Explanation of Benefits "EOB 101"
Explanation of Benefits “EOB 101” Confidential 9/14/2017
Slide 2: What is an EOB?
What is an EOB? • An explanation of benefits (commonly referred to as an EOB) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and services were paid for on their behalf. • It contains the date of service, the code used to bill a particular
Slide 3: Your Responsibility re: EOBs
Your Responsibility re: EOBs • Unlike with EXOGEN®, Bioventus is not a healthcare provider for our HA products. – Thus, HIPAA prevents you from accessing or sharing HA patients’ PHI. – You may not solicit or accept HA patients’ PHI. – If you do receive a communication from a customer, you should che
Slide 4: Reading and Understanding an EOB
Reading and Understanding an EOB • Elements of an EOB – Payer – Policy – HCPCS/CPT Codes & Modifiers – HA Units – Allowable Costs – Coinsurance – Group Reason Code
Slide 5: Explanation of Benefits - Payer
Explanation of Benefits - Payer 1. Determine the Payer, e.g. Palmetto GBA (Medicare MAC)
Slide 6: Explanation of Benefits - Policy
Explanation of Benefits - Policy 2. Determine Policy Type, e.g. Medicare
Slide 7: Explanation of Benefits – HCPCS/CPT Codes & Modifiers
Explanation of Benefits – HCPCS/CPT Codes & Modifiers 3. Verify HCPCS Code, e.g. J7328 Hyaluronan or derivative, gel-syn, for intra-articular injection, 0.1 mg 4. Determine CPT codes, e.g. 20610 Arthrocentesis 5. Identify Modifiers RT, LT, 50-bilateral
Slide 8: Explanation of Benefits - Units
Explanation of Benefits -Units 6. Confirm number of units, e.g. 168.0 Note: If Modifier 50 is used to indicate bilateral, the number of units will be doubled 168 x 2 = 336.0
Slide 9: Explanation of Benefits – Allowable
Explanation of Benefits – Allowable 7. Identify CMS Allowable e.g. $365.74 (WAC +6%)
Slide 10: Explanation of Benefits – Allowable
Explanation of Benefits – Allowable 8. Is there a deductible? If any deductible is applied, the amount will show in this field. The internal control number will also appear in this column. ICNs are not PHI.
Slide 11: Explanation of Benefits - Coinsurance
Explanation of Benefits -Coinsurance 9. ID the coinsurance, e.g. $73.15 represents 20% of the Medicare allowable. For Commercial plans, this will vary depending on the patient’s benefit. The provider bills the patient and collects the coinsurance. 10. This represent 80% of the allowable fee (WAC+6%)
Slide 12: Explanation of Benefits - Group Reason Code
Explanation of Benefits- Group Reason Code 11. Group Reason Code (GRP/RC), Group codes represent the financially responsible party. Reason codes explain denials and payments. These combinations of codes are defined in the glossary at the bottom of the Standard Provider Remittance, and may vary by pa
Slide 13: Explanation of Benefits - Group Reason Code
Explanation of Benefits - Group Reason Code • CO-45 indicates claim amount that must be written off based on payer contracted fee schedule. • CO-253 Sequestration - reduction in federal payment.
Slide 14: Examples of GELSYN-3 Denials
Examples of GELSYN-3 Denials • Not a covered benefit under the patient’s plan • Incorrect coding, e.g., units, J-code, modifiers, NDC, place of service code… • Did not meet Payer’s guidelines – Did not meet “medical necessity” – Prior Authorization was required, not completed – No medical notes atta
Slide 15: EOB Scenarios
EOB Scenarios Scenario I: An account tells you they received an EOB from xyz health plan and they did not cover GELSYN-3, could you take a look at it? Response: Tell the account that you can look at the EOB if it is redacted of PHI. If you cannot figure out the coding error, tell the account to cont
Slide 16: EOB Scenarios
EOB Scenarios Scenario II: An account sends you an unsolicited EOB that contains PHI. What should you do? Response: Reply to your customer, This email contains patient information and Bioventus cannot accept or communicate protected health information. Ask that the customer resend the EOB with all P
Slide 17: EOB Scenarios
EOB Scenarios Scenario III: An account sends you an unsolicited EOB that does not contain PHI. What should you do? Response: If the account sends an unsolicited EOB, please forward the communication to Dan Rindner, dan.rindner@bioventusglobal.com. John Nosenzo is the only person who will communicate
Slide 18: EOB Example
EOB Example Provider coded correctly, J7328, 168 units, was allowed $365.760 = WAC +6%. Why was the Provider only paid $219.42? In this instance, the patient’s coinsurance is 40% or $146.28. If the provider collected the coinsurance and was paid $219.42 by BCBS IL, the total would be $365.70.
Slide 19: EOB Example
EOB Example In this example, the provider billed $400. for J7328, and the allowable is $2.18. Is there an error and what do you tell the account. The account only submitted for 1 unit, instead of 168 units. $2.18 x 168 units = $366.24, ~WAC +6%=ASP. Tell the account to contact its provider represent
Slide 20: EOB Example
EOB Example ‘COMPANY AND ITS AFFILIATES: ‘9900 Bran Road ‘Minnotonka MN 653439584 Phone: (677) 842-3210 Payment Date: 04/62/2017 TIN: ""8a17 NU cntoationtonte ) UNTEOHEALTHCARE INSURANCE 326090158 SSE TET: Electronic Provider Remittance Advice evmmont eumber soczemente “Aseount Pationt Namo / “Subsc