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Issues and Trends in HBI Ch 3
 

Issues and Trends in HBI Ch 3

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  • Teaching Notes: <br /> Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material. <br />   <br />
  • . <br />
  • Teaching Notes: <br />   <br /> Ask students to describe why it is important for healthcare providers to follow the same financial accounting practices. <br /> Ask students to define cash flow and to explain why it is important. <br />
  • Learning Outcome: 3.1 Explain the method used to classify patients as new or established. <br /> Teaching Notes: <br />   <br /> Examine Figure 3.1 with the class and ask students to identify and describe the differences between NP and EP. <br /> Ask students to describe the required forms for NP intake, noting why.a NP requires additional time. <br />
  • Learning Outcome: 3.2 Discuss the five categories of information required of new patients. <br /> Teaching Notes: <br />   <br /> Ask students to describe why each of the five categories of information for a new patient is necessary to collect. <br />
  • Learning Outcome: 3.2 Discuss the five categories of information required of new patients. <br /> Teaching Notes: <br />   <br /> Examine Figures 3.2 and 3.3 with the class and ask students to discuss the contents of the forms. <br /> Ask students to discuss strategies for collecting the patient’s information accurately. <br /> Optional Assignment: <br /> Ask students to write a paragraph that describes the differences between PAR and nonPAR providers. <br />
  • Learning Outcome: 3.2 Discuss the five categories of information required of new patients. <br /> Teaching Notes: <br />   <br /> Ask students if there are differences between insured, subscriber, and guarantor. <br /> Ask students to describe assignment of benefits. <br />
  • Learning Outcome: 3.2 Discuss the five categories of information required of new patients. <br /> Teaching Notes: <br />   <br /> Examine the contents of the sample Acknowledgment of Receipt of Notice of Privacy Practices (Figure 3.6) with the class. <br /> Ask students to explain how the Acknowledgment of Receipt of Notice of Privacy Practices protects the patient and provider. <br /> Note that physicians must make a good faith effort to have patient read the privacy practices and sign the notice. <br />
  • Learning Outcome: 3.3 Explain how information for established patients is updated. <br /> Teaching Notes: <br />   <br /> Ask students why it is important to verify pertinent EP’s personal and insurance information at the time of the appointment or visit. <br /> Ask students how they can verify accuracy and update the EP’s new information. <br />
  • Learning Outcome: 3.4 Verify patients’ eligibility for insurance benefits. <br /> Teaching Notes: <br />   <br /> Discuss the three steps used to establish a patient’s financial responsibility with your students: (1) verify the patient’s eligibility for insurance benefits; (2) determine preauthorization and referral requirements; and (3) determine the primary payer if more than one insurance plan is in effect. <br /> Ask students why financial responsibility is important and how they can ensure accuracy when verifying the patient’s identification. <br /> Optional Assignment: <br /> Ask students to write a paragraph that provides strategies for ensuring accuracy during the three-step process used to establish a patient’s financial responsibility. <br />
  • Learning Outcome: 3.4 Verify patients’ eligibility for insurance benefits. <br /> Teaching Notes: <br />   <br /> Ask students to provide an example of how they would verify a patient’s eligibility in an emergency situation. <br /> Optional Assignment: <br /> Ask students to write a paragraph about why some websites allow a medical biller to check eligibility for coverage, get information on copayments and deductibles, process claims, and submit preauthorization requests. <br />
  • Learning Outcome: 3.4 Verify patients’ eligibility for insurance benefits. <br /> Teaching Notes: <br />   <br /> The HIPAA Eligibility for a Health Plan transaction is also referred to as X12 270/271. <br /> 270 is the transaction number assigned to the inquiry sent, and 271 is assigned to the response by the insurance plan. <br /> Have students describe the purpose and advantage of using the X12 270/271. <br /> Ask students to define and describe the advantage of using trace numbers. <br />
  • Learning Outcome: 3.5 Discuss the importance of requesting referral or preauthorization approval. <br /> Teaching Notes: <br />   <br /> Ask students to explain why third-party payers may require preauthorization before a patient sees a specialist, is admitted to the hospital, or has a particular procedure. <br /> Ask students to describe how the preauthorization process can help improve healthcare. <br /> Discuss the way in which patients benefit from a preauthorization process. <br />
  • Learning Outcome: 3.5 Discuss the importance of requesting referral or preauthorization approval. <br /> Teaching Notes: <br />   <br /> Examine the contents of Figure 3.10 (a) and (b) with your students. <br /> Ask students to describe how a referral waiver can help ensure payment to the provider. <br /> Optional Assignment: <br /> Ask students why patients may decide to self-refer. <br />
  • Learning Outcome: 3.6 Determine primary insurance for patients who have more than one health plan. <br /> Teaching Notes: <br />  Many patients will have more than one insurance plan. <br /> It is the responsibility of the medical insurance specialist to determine which is primary, secondary, and (in rare cases) tertiary. <br /> It is important to determine the primary insurance because this is the first plan to be billed for the service. <br /> Ask students to identify and explain the billing process for primary, secondary, and tertiary insurance (primary insurance is billed first, then a second bill is sent to the secondary insurance after payment is received from the primary insurance, etc.). <br /> Optional Assignment: <br /> Ask students to write a paragraph that describes how the Explanation of Benefits (EOB) and Remittance Advice (RA) are used when coordinating benefits between multiple insurance payers. <br />
  • Learning Outcome: 3.6 Determine primary insurance for patients who have more than one health plan. <br /> Teaching Notes: <br />   <br /> Ask students to explain how they can confirm which payer is the primary, secondary, or tertiary insurance. <br /> Ask students to describe why contacting the payer is the best way to identify and establish primary, secondary, or tertiary insurance. <br />
  • Learning Outcome: 3.6 Determine primary insurance for patients who have more than one health plan. <br /> Teaching Notes: <br />   <br /> Provide a scenario for your students in which they must determine which parent’s insurance would be primary under the birthday and gender rules. <br />
  • Learning Outcome: 3.6 Determine primary insurance for patients who have more than one health plan. <br /> Teaching Notes: <br />   <br /> Discuss the importance of being detail-oriented and accurate in maintaining databases. <br /> Ask students to provide examples of strategies that can help keep databases up-to-date. <br /> Present examples of how outdated information can impact a physician’s office. <br />
  • Learning Outcome: 3.6 Determine primary insurance for patients who have more than one health plan. <br /> Teaching Notes: <br />   <br /> Discuss the importance of professional and accurate communications with third-party payers. <br /> Ask students why it is important to be prepared with all required documents when contacting the payer. <br /> How can accurate documentation of the exchange of information with a payer help later with following up on the case? <br />
  • Learning Outcome: 3.7 Summarize the use of encounter forms. <br /> Teaching Notes: <br /> Traditionally, the encounter form was a paper form completed by the provider as he/she examined the patient. <br /> Offices that have integrated EHR or PMPs may use an electronic version that is completed by the provider using a laptop, tablet, or PDA. <br /> Encounter forms or electronic databases must be updated each year when the procedure codes are updated. <br />
  • Learning Outcome: 3.8 Identify the eight types of charges that may be collected from patients at the time of service. <br /> Teaching Notes: <br />   <br /> Ask students to provide examples of the eight types of charges that can be collected in a medical office. <br /> Ask students to explain how a medical billing specialist can ensure that patients pay their required bills in full at the time of service. <br />
  • Learning Outcome: 3.8 Identify the eight types of charges that may be collected from patients at the time of service. <br /> Teaching Notes: <br />   <br /> Ask students to discuss why practices sometimes collect partial payments during the checkout process. <br /> What situations might self-pay patients present in terms of ability to pay? <br />
  • Learning Outcome: 3.9 Explain the use of real-time claims adjudication tools in calculating time-of-service payments. <br /> Teaching Notes: <br />   <br /> Ask students to explain why real-time claims adjudication is the ideal tool for calculating charges due at the time of service. <br /> Ask students to discuss why financial policies can help ensure the financial success of a medical office. <br />

Issues and Trends in HBI Ch 3 Issues and Trends in HBI Ch 3 Presentation Transcript

  • CHAPTER 3 Patient Encounters and Billing Information © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
  • Learning Outcomes When you finish this chapter, you will be able to: 3.1 3.2 3.3 3.4 3.5 Explain the method used to classify patients as new or established. Discuss the five categories of information required of new patients. Explain how information for established patients is updated. Verify patients’ eligibility for insurance benefits. Discuss the importance of requesting referral or preauthorization approval. 3-2
  • Learning Outcomes (continued) 3-3 When you finish this chapter, you will be able to: 3.6 Determine primary insurance for patients who have more than one health plan. 3.7 Summarize the use of encounter forms. 3.8 Identify the eight types of charges that may be collected from patients at the time of service. 3.9 Explain the use of real-time claims adjudication tools in calculating time-of-service payments.
  • 3-4 Key Terms • accept assignment • Acknowledgment of Receipt of Notice of Privacy Practices • assignment of benefits • birthday rule • cash flow • certification number • charge capture • chart number • coordination of benefits (COB) • direct provider • encounter form • established patient (EP) • financial policy • gender rule • guarantor • HIPAA Coordination of Benefits • HIPAA Eligibility for a Health Plan
  • 3-5 Key Terms (continued) • HIPAA Referral Certification and Authorization • indirect provider • insured • new patient (NP) • nonparticipating provider (nonPAR) • participating provider (PAR) • partial payment • patient information form • primary insurance • prior authorization number • real-time claims adjudication (RTCA) • referral number • referral waiver • referring physician • secondary insurance
  • Key Terms (continued) • • • • • self-pay patient subscriber supplemental insurance tertiary insurance trace number 3-6
  • Patient Encounters and Billing Information3-7 • Healthcare is business – Big business! • Financial health of a practice depends on billing and collection of fees • Regular cash flow – monies moving in and out – must be maintained • Standardized billing procedures assist in success of practice
  • 3.1 New Versus Established Patients • New patient (NP)—patient who has not seen a provider within the past three years • Established patient (EP)—patient who has seen a provider within the past three years 3-8
  • 3.2 Information for New Patients • When a patient is new to the practice, five categories of information are important: 1. Preregistration and scheduling information 2. Medical history 3. Patient/guarantor and insurance data 4. Assignment of benefits 5. Acknowledgment of Receipt of Notice of Privacy Practices 3-9
  • 3.2 Information for New Patients (continued) 3-10 • Referring physician—physician who refers a patient to another physician • Participating provider (PAR)—provider who agrees to provide medical services to a payer’s policyholders according to a contract • Nonparticipating provider (nonPAR)—provider who does not join a particular health plan • Patient information form—form that includes a patient’s personal, employment, and insurance company data
  • 3.2 Information for New Patients (continued) 3-11 • Other terms for the policyholder of a health plan include: – Insured – Subscriber – Guarantor • Assignment of benefits—authorization allowing benefits to be paid directly to a provider
  • 3.2 Information for New Patients (continued) • Acknowledgment of Receipt of Notice of Privacy Practices—form accompanying a covered entity’s Notice of Privacy Practices • Direct provider—clinician who treats a patient face-to-face • Indirect provider—clinician who does not interact face-to-face with the patient 3-12
  • 3.3 Information for Established Patients • When EPs arrive for appointments, they are asked if any pertinent personal or insurance information has changed • EPs should review their information forms for accuracy at least once per year • Any changes to an EP’s information should be entered in the practice management program (PMP) • Chart number—unique number that identifies a patient 3-13
  • 3.4 Verifying Patient Eligibility for Insurance Benefits 3-14 • First step is to verify patients’ eligibility for benefits • Next contact the payer to verify three points: 1. Patient’s general eligibility for benefits 2. Amount of the copayment or coinsurance required at the time of service 3. Determine that the planned encounter is for a covered service considered medically necessary under the payer’s rules
  • 3.4 Verifying Patient Eligibility for Insurance Benefits (continued) • Check out-of-network benefits if the practice does not participate with the insurance plan presented by the patient • Verify amounts for copayment and coinsurance because these could have changed over time • Contact the payer for verification of coverage on unusual or unfamiliar services 3-15
  • 3.4 Verifying Patient Eligibility for Insurance Benefits (continued) • HIPAA Eligibility for a Health Plan— transaction in which a provider asks for and receives an answer about a patient’s eligibility for benefits (X12 270/271) • Trace number—number assigned to a HIPAA 270 electronic transaction 3-16
  • 3.5 Determining Preauthorization and Referral Requirements • Preauthorization is requested before a patient is given certain types of medical care – Prior authorization number—identifying code assigned when preauthorization is required (also called a certification number) – HIPAA Referral Certification and Authorization— transaction in which a provider asks a health plan for approval of a service and gets a response (X12 278) – Referral number—authorization number given to the referred physician • Providers must handle these situations correctly to ensure that services are covered if possible 3-17
  • 3.5 Determining Preauthorization and Referral Requirements (continued) 3-18 • Referral waiver—document a patient signs to guarantee payment when a referral authorization is pending – Used if a patient does not have the required referral document – Patient may have chosen to “self-refer” and signing the waiver provides documentation of that situation
  • 3.6 Determining the Primary Insurance • Primary insurance—health plan that pays benefits first • Secondary insurance—second payer on a claim • Tertiary insurance—third payer on a claim • Supplemental insurance—health plan that covers services not normally covered by a primary plan 3-19
  • 3.6 Determining the Primary Insurance (continued) • To determine a patient’s primary insurance, medical insurance specialists: – Examine the patient information form and insurance card – Follow coordination of benefits guidelines – Follow any rules that may apply – Communicate with the patient as needed 3-20
  • 3.6 Determining the Primary Insurance (continued) 3-21 • Coordination of benefits (COB)—explains how an insurance policy will pay if more than one policy applies – HIPAA Coordination of Benefits—transaction sent to a secondary or tertiary payer (X12 837) • Birthday rule—guideline to determine which parent has the primary insurance for a child • Gender rule—coordination of benefits rule for a child insured under both parents’ plans
  • 3.6 Determining the Primary Insurance (continued) • Entering Insurance Information in the Practice Management Program – Database of payers is maintained to reflect changes in participation agreements or contact information – Database is kept up-to-date to assist with information on secondary payers, policy numbers, effective dates and referral numbers 3-22
  • 3.6 Determining the Primary Insurance (continued) • Communications with payers – – – – Checking on eligibility Receiving referral certification Resolving billing disputes Documenting all communication with payer into patient’s financial record 3-23
  • 3.7 Working with Encounter Forms • An encounter form (electronic or paper) is completed by a provider to summarize billing information for a patient’s visit – Lists medical practice’s most frequently performed procedures with associated procedure codes – Blank spaces for diagnosis codes, and often includes other various information – Paper forms may be preprinted or computergenerated • Charge capture—procedures that ensure billable services are recorded and reported for payment 3-24
  • 3.8 Understanding Time-of-Service (TOS) Payments • Practices routinely collect these charges at the time of service: 1. 2. 3. 4. 5. 6. 7. 8. Previous balances Copayments Coinsurance Noncovered or overlimit fees Charges of nonPAR providers Charges for self-pay patients Deductibles for patients with CDHPs Charges for supplies and copies of medical records 3-25
  • 3.8 Understanding Time-of-Service (TOS) Payments (continued) • Accept assignment—participating physician’s agreement to accept allowed charge as full payment • Self-pay patient—patient with no insurance • Partial payment—payment made during checkout based on an estimate 3-26
  • 3.9 Calculating TOS Payments • Real-time claims adjudication—process used to generate the amount owed by a patient at the time of service • Financial policy—practice’s rules governing payment from patients • Credit and debit cards usually accepted 3-27
  • Summary
  • Summary
  • Summary