Survey of Medical Insurance pp ch03

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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 3.1 Explain the method used to classify patients as new and or established. Page: 86 Teaching Notes:   Ask students to think about the patient information forms that they may have filled out when visiting a medical office.
  • Learning Outcome: 3.2 List the five types of information that new patients provide before their encounters. Pages: 86-95 Teaching Notes:   Have students discuss the reason(s) why each of the five types of information for a new patient is necessary to obtain.
  • Learning Outcome: 3.2 List the five types of information that new patients provide before their encounters. Pages: 86-95 Teaching Notes:   Discuss the contents of the forms in Figures 3.2 and 3.3 with the class.
  • Learning Outcome: 3.2 List the five types of information that new patients provide before their encounters. Pages: 86-95 Teaching Notes:   Examine the contents of the sample Assignment of Benefits Form (Figure 3.5) with the class.
  • Learning Outcome: 3.2 List the five types of information that new patients provide before their encounters. Pages: 86-95 Teaching Notes:   Examine the contents of the sample Acknowledgment of Receipt of Notice of Privacy Practices(Figure 3.6) with the class.
  • Learning Outcome: 3.3 Discuss the procedures that are followed to update established patient information. Pages: 95-98 Teaching Notes:   Ask students why they think it is a good idea to have established patients review their pertinent personal and insurance information at least once per year.
  • Learning Outcome: 3.4 Explain the process for verifying patients’ eligibility for insurance benefits. Pages: 98-101 Teaching Notes:   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; (3) Determine the primary payer if more than one insurance plan is in effect.)
  • Learning Outcome: 3.4 Explain the process for verifying patients’ eligibility for insurance benefits. Pages: 98-101 Teaching Notes:   Ask your students to describe the purpose of the X12 270/271.
  • Learning Outcome: 3.5 Discuss the importance of requesting referral or preauthorization approval. Pages: 101-104 Teaching Notes:   In their own words, ask your students to explain the reason(s) why payers often require preauthorization before a patient sees a specialist, is admitted to the hospital, or has a particular procedure.
  • Learning Outcome: 3.5 Discuss the importance of requesting referral or preauthorization approval. Pages: 101-104 Teaching Notes:   Examine the contents of Figure 3.10 (a) and (b) with your students.
  • Learning Outcome: 3.6 Explain how to determine the primary insurance for patients who have more than one health plan. Pages: 104-106 Teaching Notes:   Ask your students to explain the timelines for billing primary, secondary, and tertiary insurance. (Primary insurance is billed first, then a second bill is sent to the secondary insurance after it is received from the primary insurance, etc.)
  • Learning Outcome: 3.6 Explain how to determine the primary insurance for patients who have more than one health plan. Pages: 104-106 Teaching Notes:   Have your students name and discuss some instances in which they think communications with payers would be necessary.
  • Learning Outcome: 3.6 Explain how to determine the primary insurance for patients who have more than one health plan. Pages: 104-106 Teaching Notes:   Create a scenario for your students in which they must determine which parent’s insurance would be primary under the birthday rule.
  • Learning Outcome: 3.7 Summarize the use and typical formats of encounter forms. Pages: 106-109 Teaching Notes:   Ask your students to explain why they think practices sometimes use paper encounter forms.
  • Learning Outcome: 3.8 Identify the seven types of charges that may be collected from patients at the time of service. Pages: 109-111 Teaching Notes:   Have your students discuss the reason(s) that medical practices may require self-pay patients to pay their bills in full at the time of service.
  • Learning Outcome: 3.8 Identify the seven types of charges that may be collected from patients at the time of service. Pages: 109-111 Teaching Notes:   Ask your students to discuss the reason(s) why they think practices sometimes collect partial payments during the checkout process.
  • Learning Outcome: 3.9 Explain the use of real-time claims adjudication tools in calculating time-of-service payments. Pages: 111-114 Teaching Notes:   Ask your students to explain the reason(s) why real-time claims adjudication is the ideal tool for calculating charges due at the time of service.
  • Learning Outcome: 3.10 Describe the billing procedures and transactions that occur during patient checkout. Pages: 114-117 Teaching Notes:   Have your students discuss the advantages a medical practice receives by offering multiple payment methods.
  • Learning Outcome: 3.10 Describe the billing procedures and transactions that occur during patient checkout. Pages: 114-117 Teaching Notes:   Examine the contents of the sample walkout receipt (Figure 3.15) with your students.

Transcript

  • 1. 3 Patient Encounters and Billing Information
  • 2. Learning Outcomes
    • When you finish this chapter, you will be able to:
    • 3.1 Explain the method used to classify patients as new and or established.
    • 3.2 List the five types of information that new patients provide before their encounters.
    • 3.3 Discuss the procedures that are followed to update established patient information.
    • 3.4 Explain the process for verifying patients’ eligibility for insurance benefits.
    • 3.5 Discuss the importance of requesting referral or preauthorization approval.
    3-2
  • 3. Learning Outcomes (Continued)
    • When you finish this chapter, you will be able to:
    • 3.6 Explain how to determine the primary insurance for patients who have more than one health plan.
    • 3.7 Summarize the use and typical formats of encounter forms.
    • 3.8 Identify the seven 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.
    • 3.10 Describe the billing procedures and transactions that occur during patient checkout.
    3-3
  • 4. Key Terms
    • accept assignment
    • Acknowledgment of Receipt of Notice of Privacy Practices
    • adjustment
    • assignment of benefits
    • birthday rule
    • cash flow
    • certification number
    • charge capture
    • chart number
    3-4
    • 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
  • 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
    3-5
    • primary insurance
    • prior authorization number
    • real-time claims adjudication (RTCA)
    • referral number
    • referral waiver
    • referring physician
    • revenue cycle management (RCM)
    • secondary insurance
  • 6. Key Terms (Continued)
    • self-pay patient
    • subscriber
    • supplemental insurance
    • tertiary insurance
    • trace number
    • walkout receipt
    3-6
  • 7. Chapter 3 Introduction
    • Cash flow— movement of monies into or out of a business
    • Revenue cycle management (RCM)— the actions that ensure the provider receives the maximum appropriate payment
    3-7
  • 8. 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
  • 9. 3.2 Information for New Patients
    • When the patient is new to the practice, five types 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
  • 10. 3.2 Information for New Patients (Continued)
    • 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
    3-10
  • 11. 3.2 Information for New Patients (Continued)
    • 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
    3-11
  • 12. 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
  • 13. 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
  • 14. 3.4 Verifying Patient Eligibility for Insurance Benefits
    • First step is to verify patients’ eligibility for benefits
    • Then contact the payer to verify three points:
      • Patient’s general eligibility for benefits
      • Amount of the copayment or coinsurance required at the time of service
      • That the planned encounter is for a covered service that is medically necessary under the payer’s rules
    3-14
  • 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
    3-15
  • 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
    3-16
  • 17. 3.5 Determining Preauthorization and Referral Requirements (Continued)
    • 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
    3-17
  • 18. 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
    3-18
  • 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 the coordination of benefits guidelines
      • Follow any rules that may apply
      • Communicate with the patient as needed
    3-19
  • 20. 3.6 Determining the Primary Insurance (Continued)
    • 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 that determines which parent has the primary insurance for a child
    • Gender rule— coordination of benefits rule for a child insured under both parents’ plans
    3-20
  • 21. 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 the medical practice’s most frequently performed procedures with their procedure codes
      • Blank spaces for diagnoses codes, and often includes other various information
      • Paper forms may be preprinted or computer-generated
    • Charge capture— procedures that ensure billable services are recorded and reported for payment
    3-21
  • 22. 3.8 Understanding Time-of-Service (TOS) Payments
    • Practices routinely collect these charges at the time of service:
      • Previous balances
      • Copayments
      • Coinsurance
      • Noncovered or overlimit fees
      • Charges of nonPAR providers
      • Charges for self-pay patients
      • Deductibles for patients with CDHPs
    3-22
  • 23. 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
    3-23
  • 24. 3.9 Calculating TOS Payments
    • Real-time claims adjudication —process used to generate the amount owed by a patient at the time of service
    • Real-time benefit information— process used to generate information about a patient’s benefits at the time of service
    • Financial policy— practice’s rules governing payment from patients
    3-24
  • 25. 3.10 Collecting TOS Payments and Checking Out Patients
    • The PMP is used to record the financial transactions from patients’ visits:
      • Charges—amounts providers bill
      • Payments—monies the practice receives
      • Adjustments —changes to patients’ accounts
    • Information from the encounter form is entered into the PMP to calculate charges and compute balances
    • Payment methods may include cash, check, and a credit or debit card
    3-25
  • 26. 3.10 Collecting TOS Payments and Checking Out Patients (Continued)
    • Walkout receipt— report that lists the diagnoses, services provided, fees, and payments received and due after an encounter
    3-26