Survey of Medical Insurance pp ch03

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Survey of Medical Insurance pp ch03

  1. 1. 3 Patient Encounters and Billing Information
  2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>3.1 Explain the method used to classify patients as new and or established. </li></ul><ul><li>3.2 List the five types of information that new patients provide before their encounters. </li></ul><ul><li>3.3 Discuss the procedures that are followed to update established patient information. </li></ul><ul><li>3.4 Explain the process for verifying patients’ eligibility for insurance benefits. </li></ul><ul><li>3.5 Discuss the importance of requesting referral or preauthorization approval. </li></ul>3-2
  3. 3. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>3.6 Explain how to determine the primary insurance for patients who have more than one health plan. </li></ul><ul><li>3.7 Summarize the use and typical formats of encounter forms. </li></ul><ul><li>3.8 Identify the seven types of charges that may be collected from patients at the time of service. </li></ul><ul><li>3.9 Explain the use of real-time claims adjudication tools in calculating time-of-service payments. </li></ul><ul><li>3.10 Describe the billing procedures and transactions that occur during patient checkout. </li></ul>3-3
  4. 4. Key Terms <ul><li>accept assignment </li></ul><ul><li>Acknowledgment of Receipt of Notice of Privacy Practices </li></ul><ul><li>adjustment </li></ul><ul><li>assignment of benefits </li></ul><ul><li>birthday rule </li></ul><ul><li>cash flow </li></ul><ul><li>certification number </li></ul><ul><li>charge capture </li></ul><ul><li>chart number </li></ul>3-4 <ul><li>coordination of benefits (COB) </li></ul><ul><li>direct provider </li></ul><ul><li>encounter form </li></ul><ul><li>established patient (EP) </li></ul><ul><li>financial policy </li></ul><ul><li>gender rule </li></ul><ul><li>guarantor </li></ul><ul><li>HIPAA Coordination of Benefits </li></ul><ul><li>HIPAA Eligibility for a Health Plan </li></ul>
  5. 5. Key Terms (Continued) <ul><li>HIPAA Referral Certification and Authorization </li></ul><ul><li>indirect provider </li></ul><ul><li>insured </li></ul><ul><li>new patient (NP) </li></ul><ul><li>nonparticipating provider (nonPAR) </li></ul><ul><li>participating provider (PAR) </li></ul><ul><li>partial payment </li></ul><ul><li>patient information form </li></ul>3-5 <ul><li>primary insurance </li></ul><ul><li>prior authorization number </li></ul><ul><li>real-time claims adjudication (RTCA) </li></ul><ul><li>referral number </li></ul><ul><li>referral waiver </li></ul><ul><li>referring physician </li></ul><ul><li>revenue cycle management (RCM) </li></ul><ul><li>secondary insurance </li></ul>
  6. 6. Key Terms (Continued) <ul><li>self-pay patient </li></ul><ul><li>subscriber </li></ul><ul><li>supplemental insurance </li></ul><ul><li>tertiary insurance </li></ul><ul><li>trace number </li></ul><ul><li>walkout receipt </li></ul>3-6
  7. 7. Chapter 3 Introduction <ul><li>Cash flow— movement of monies into or out of a business </li></ul><ul><li>Revenue cycle management (RCM)— the actions that ensure the provider receives the maximum appropriate payment </li></ul>3-7
  8. 8. 3.1 New Versus Established Patients <ul><li>New patient (NP)— patient who has not seen a provider within the past three years </li></ul><ul><li>Established patient (EP)— patient who has seen a provider within the past three years </li></ul>3-8
  9. 9. 3.2 Information for New Patients <ul><li>When the patient is new to the practice, five types of information are important: </li></ul><ul><ul><li>1. Preregistration and scheduling information </li></ul></ul><ul><ul><li>2. Medical history </li></ul></ul><ul><ul><li>3. Patient/guarantor and insurance data </li></ul></ul><ul><ul><li>4. Assignment of benefits </li></ul></ul><ul><ul><li>5. Acknowledgment of Receipt of Notice of Privacy Practices </li></ul></ul>3-9
  10. 10. 3.2 Information for New Patients (Continued) <ul><li>Referring physician— physician who refers a patient to another physician </li></ul><ul><li>Participating provider (PAR)— provider who agrees to provide medical services to a payer’s policyholders according to a contract </li></ul><ul><li>Nonparticipating provider (nonPAR)— provider who does not join a particular health plan </li></ul><ul><li>Patient information form— form that includes a patient’s personal, employment, and insurance company data </li></ul>3-10
  11. 11. 3.2 Information for New Patients (Continued) <ul><li>Other terms for the policyholder of a health plan include: </li></ul><ul><ul><li>Insured </li></ul></ul><ul><ul><li>Subscriber </li></ul></ul><ul><ul><li>Guarantor </li></ul></ul><ul><li>Assignment of benefits— authorization allowing benefits to be paid directly to a provider </li></ul>3-11
  12. 12. 3.2 Information for New Patients (Continued) <ul><li>Acknowledgment of Receipt of Notice of Privacy Practices— form accompanying a covered entity’s Notice of Privacy Practices </li></ul><ul><li>Direct provider— clinician who treats a patient face-to-face </li></ul><ul><li>Indirect provider— clinician who does not interact face-to-face with the patient </li></ul>3-12
  13. 13. 3.3 Information for Established Patients <ul><li>When EPs arrive for appointments, they are asked if any pertinent personal or insurance information has changed </li></ul><ul><li>EPs should review their information forms for accuracy at least once per year </li></ul><ul><li>Any changes to an EP’s information should be entered in the practice management program (PMP) </li></ul><ul><li>Chart number— unique number that identifies a patient </li></ul>3-13
  14. 14. 3.4 Verifying Patient Eligibility for Insurance Benefits <ul><li>First step is to verify patients’ eligibility for benefits </li></ul><ul><li>Then contact the payer to verify three points: </li></ul><ul><ul><li>Patient’s general eligibility for benefits </li></ul></ul><ul><ul><li>Amount of the copayment or coinsurance required at the time of service </li></ul></ul><ul><ul><li>That the planned encounter is for a covered service that is medically necessary under the payer’s rules </li></ul></ul>3-14
  15. 15. 3.4 Verifying Patient Eligibility for Insurance Benefits (Continued) <ul><li>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) </li></ul><ul><li>Trace number— number assigned to a HIPAA 270 electronic transaction </li></ul>3-15
  16. 16. 3.5 Determining Preauthorization and Referral Requirements <ul><li>Preauthorization is requested before a patient is given certain types of medical care </li></ul><ul><ul><li>Prior authorization number— identifying code assigned when preauthorization is required (also called a certification number ) </li></ul></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>Referral number— authorization number given to the referred physician </li></ul></ul><ul><li>Providers must handle these situations correctly to ensure that services are covered if possible </li></ul>3-16
  17. 17. 3.5 Determining Preauthorization and Referral Requirements (Continued) <ul><li>Referral waiver— document a patient signs to guarantee payment when a referral authorization is pending </li></ul><ul><ul><li>Used if a patient does not have the required referral document </li></ul></ul>3-17
  18. 18. 3.6 Determining the Primary Insurance <ul><li>Primary insurance— health plan that pays benefits first </li></ul><ul><li>Secondary insurance— second payer on a claim </li></ul><ul><li>Tertiary insurance— third payer on a claim </li></ul><ul><li>Supplemental insurance— health plan that covers services not normally covered by a primary plan </li></ul>3-18
  19. 19. 3.6 Determining the Primary Insurance (Continued) <ul><li>To determine a patient’s primary insurance, medical insurance specialists: </li></ul><ul><ul><li>Examine the patient information form and insurance card </li></ul></ul><ul><ul><li>Follow the coordination of benefits guidelines </li></ul></ul><ul><ul><li>Follow any rules that may apply </li></ul></ul><ul><ul><li>Communicate with the patient as needed </li></ul></ul>3-19
  20. 20. 3.6 Determining the Primary Insurance (Continued) <ul><li>Coordination of benefits (COB)— explains how an insurance policy will pay if more than one policy applies </li></ul><ul><ul><li>HIPAA Coordination of Benefits— transaction sent to a secondary or tertiary payer (X12 837) </li></ul></ul><ul><li>Birthday rule— guideline that determines which parent has the primary insurance for a child </li></ul><ul><li>Gender rule— coordination of benefits rule for a child insured under both parents’ plans </li></ul>3-20
  21. 21. 3.7 Working with Encounter Forms <ul><li>An encounter form (electronic or paper) is completed by a provider to summarize billing information for a patient’s visit </li></ul><ul><ul><li>Lists the medical practice’s most frequently performed procedures with their procedure codes </li></ul></ul><ul><ul><li>Blank spaces for diagnoses codes, and often includes other various information </li></ul></ul><ul><ul><li>Paper forms may be preprinted or computer-generated </li></ul></ul><ul><li>Charge capture— procedures that ensure billable services are recorded and reported for payment </li></ul>3-21
  22. 22. 3.8 Understanding Time-of-Service (TOS) Payments <ul><li>Practices routinely collect these charges at the time of service: </li></ul><ul><ul><li>Previous balances </li></ul></ul><ul><ul><li>Copayments </li></ul></ul><ul><ul><li>Coinsurance </li></ul></ul><ul><ul><li>Noncovered or overlimit fees </li></ul></ul><ul><ul><li>Charges of nonPAR providers </li></ul></ul><ul><ul><li>Charges for self-pay patients </li></ul></ul><ul><ul><li>Deductibles for patients with CDHPs </li></ul></ul>3-22
  23. 23. 3.8 Understanding Time-of-Service (TOS) Payments (Continued) <ul><li>Accept assignment— participating physician’s agreement to accept allowed charge as full payment </li></ul><ul><li>Self-pay patient— patient with no insurance </li></ul><ul><li>Partial payment— payment made during checkout based on an estimate </li></ul>3-23
  24. 24. 3.9 Calculating TOS Payments <ul><li>Real-time claims adjudication —process used to generate the amount owed by a patient at the time of service </li></ul><ul><li>Real-time benefit information— process used to generate information about a patient’s benefits at the time of service </li></ul><ul><li>Financial policy— practice’s rules governing payment from patients </li></ul>3-24
  25. 25. 3.10 Collecting TOS Payments and Checking Out Patients <ul><li>The PMP is used to record the financial transactions from patients’ visits: </li></ul><ul><ul><li>Charges—amounts providers bill </li></ul></ul><ul><ul><li>Payments—monies the practice receives </li></ul></ul><ul><ul><li>Adjustments —changes to patients’ accounts </li></ul></ul><ul><li>Information from the encounter form is entered into the PMP to calculate charges and compute balances </li></ul><ul><li>Payment methods may include cash, check, and a credit or debit card </li></ul>3-25
  26. 26. 3.10 Collecting TOS Payments and Checking Out Patients (Continued) <ul><li>Walkout receipt— report that lists the diagnoses, services provided, fees, and payments received and due after an encounter </li></ul>3-26

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