Mary Claire Cuthbert RN, CLTC              INTRODUCTION         TO HEALTH CARE CAREERS
PERCEPTION
ROAD TO NOWHERE
CAREERS IN HEALTHCARE
DO YOU THINK YOU ARE INVISIBLE?
A PIECE OF THE PUZZLE!
DETAILED
COMMUNICATE
HONEST AND ETHICAL
BE ADAPTABLE
YOU MAY HAVE TO PUT FIRES OUT
AGGRESSIVELY PATIENT
DON’T TAKE IT PERSONALLY
DOING THINGS THAT ARE IMPOSSIBLE
FOLLOW MY LEAD
ARE YOU SCARED?
TERRIFIED
WILL YOU FIND YOUR WAY?
THERE IS A WAY
CLARITY AND PURPOSE
BACK AND FRONT OFFICE   Typical medical office has two main areas:     Back office     Front office   Back office    ...
BACK AND FRONT OFFICE   Back office (cont’d)       Typical personnel:          Health   care professionals            ...
FRONT OFFICE   Front office       Also known as        administrative area       Hub of medical facility       Staff p...
APPOINTMENT SCHEDULING PRINCIPLESFront office staff usually have first contact with  patients when they request appointmen...
THE PROCESS   Patient registration     Registration information/form     Encounter form   Clinical assessment and trea...
PATIENT REGISTRATION   Receptionist       Registers patient       Obtains authorizations       Copies/Scans insurance ...
PATIENT REGISTRATION FORM Demographic information Insurance information Authorization/Assignment of benefits Electroni...
PATIENT REGISTRATION   Electronic health (medical) record       New patient          Create patient database          ...
ENCOUNTER FORM Also called charge slip, routing form, or superbill Type of visit Lab tests and treatments Diagnoses C...
CLINICAL ASSESSMENT AND TREATMENT                     Physician/Provider                         Examines patient       ...
DEPARTURE PROCEDURES   Schedule another appointment       If necessary Compute charges for services Collect copayment...
POSTING CHARGES AND PAYMENTSCharges:  Encounter forms are “source documents”Payments:  Checks, receipts, and insurance sta...
POSTING CHARGES AND PAYMENTSElectronic billing  Charges and payments entered into patient database              Billing Sp...
DIAGNOSTIC AND PROCEDURE CODES   Remember Source Documents are     Encounter form     Medical record   Medical coder  ...
INSURANCE CLAIM FORM   CMS-1500       Patient and insurance information          CMS-1500   blocks 1-13       Treatmen...
INSURANCE CLAIM FORM   Billing specialist       Submits claim          Paper               Completes claim form using ...
INSURANCE CARRIER/COMPANY   Reviews claim for errors       “Clean” claim          Provider   (or patient) receives paym...
DENIED CLAIMS   Technical (data entry) errors     Missing or incorrect information     Transposed numbers     Incomple...
RESOLVING DENIED CLAIMS   Technical errors     Billing specialist corrects errors     Claim resubmitted   Coverage    ...
OTHER CLAIMS PROBLEMS   Delinquent or pending     Payment from insurance carrier overdue     Claim lost or misplaced  ...
STATE INSURANCE COMMISSION   Responsibilities     Monitor financial strength of insurance companies     Protect interes...
STATE INSURANCE COMMISSION   Referrals     Pattern of problems with payment for services     Unresolved primary payer s...
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Introduction to Health Care Careers Medical Office Receptionist Insurance Billing

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An Introduction to a career in Health Care as a Medical Receptionist and Insurance Billler

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  • Welcome to Medical Receptionist and Insurance Billing Class.
  • I would like to begin by asking each of you “What do you see when you look at this picture?” Let some people answer…“You see everyone’s perception is different; the way you see something the first time can also be very different the next time you get to look at it…and this is why learning and meeting standards in the medical field is very important…everyone needs to be on the same page, looking at things the same way, and practicing to meet the same standards of care.”
  • Have you ever felt as if you were on a road to nowhere?Not knowing exactly what to do or where to go?
  • Lets take a moment to look at all of the different positions within a medical office.As you can see at the very top of the pyramid is the Physician and then the Nurse and then possibly the Therapist..these positions are considered the Clinical Staff of the office..these individuals provide the “hands on” with the patients.Now lets look at the positions called Support Staff…the office manager, Insurance billing Specialist, Medical coder, Medical secretary, Unit coordinator, receptionist, transcriptionist, medical record clerk, and file clerk…depending upon the size of the office or department or clinic or hospital you may find that you will be doing more than one position duties and then again there may be whole departments comprised of duties related just for medical record keeping.
  • When you look at this iceberg…two thirds of it is not even visible below the water, what stands out of the water is beautiful and gets most of the recognition …just like the pyramid before, doctors, nurses, and therapists standout the most in the publics eye; but below the surface and behind the scenes are the core components of people and duties that can make an office or department shine like this iceberg.
  • You will become a very important piece of the puzzle!But first..let’s talk about the necessary traits and qualities that you must possess and develop to the highest standard to be able to work in the medical field.
  • You must be detailed oriented!Why do you think…
  • You must be able to read, write, and speak…in different languages!When you learn a new language you must learn vocabulary…Medical vocabulary as it relates to disease processBusiness vocabulary as it relates to accounting and office management, telephone and office etiquetteComputer literacy as it relates to electronic medical health records, scheduling, mailings,Excel spreadsheets or power point presentations and typing speed and accuracy.
  • You must be honest and ethical…the rules and procedures regarding confidential information, the reason why malpractice and fraud occur; you need to keenly aware of
  • You need to be adaptable..because things are always changing.
  • You may have to put fires out
  • You will need to be aggressively patient with yourself…otherwise you will find that you will frustrated and discouraged.
  • You will need to learn how to not take things personally
  • And soon enough…you will find yourself doing things that you thought were impossible.
  • You will find people following your lead…because you are a leader.
  • Are you scared?
  • Or just terrified.
  • As we begin this process of learning you will find your way.
  • Because there is always a way…even if at first you can quite see it…you journey will take you over a bridge that was not visible and lead you on a path to your future.
  • Let’s talk about logistics..How is a medical office set up..
  • You may not know this, but the front and back office willingly need to work together as a team.
  • Lets start to discuss the front office…
  • “First contact” is the key to a successful office!
  • The work flow process..
  • Two of your projects are related to completing the Sims Claims forms that are provided with your book.
  • For every professionally licensed practice there are public agencies that oversee the process and procedures.
  • These agencies are there to protect the public.
  • Introduction to Health Care Careers Medical Office Receptionist Insurance Billing

    1. 1. Mary Claire Cuthbert RN, CLTC INTRODUCTION TO HEALTH CARE CAREERS
    2. 2. PERCEPTION
    3. 3. ROAD TO NOWHERE
    4. 4. CAREERS IN HEALTHCARE
    5. 5. DO YOU THINK YOU ARE INVISIBLE?
    6. 6. A PIECE OF THE PUZZLE!
    7. 7. DETAILED
    8. 8. COMMUNICATE
    9. 9. HONEST AND ETHICAL
    10. 10. BE ADAPTABLE
    11. 11. YOU MAY HAVE TO PUT FIRES OUT
    12. 12. AGGRESSIVELY PATIENT
    13. 13. DON’T TAKE IT PERSONALLY
    14. 14. DOING THINGS THAT ARE IMPOSSIBLE
    15. 15. FOLLOW MY LEAD
    16. 16. ARE YOU SCARED?
    17. 17. TERRIFIED
    18. 18. WILL YOU FIND YOUR WAY?
    19. 19. THERE IS A WAY
    20. 20. CLARITY AND PURPOSE
    21. 21. BACK AND FRONT OFFICE Typical medical office has two main areas:  Back office  Front office Back office  Also known as “clinical” area  Where all examinations, diagnostic testing, and medical procedures conducted
    22. 22. BACK AND FRONT OFFICE Back office (cont’d)  Typical personnel:  Health care professionals  e.g., doctors, nurses, physicians assistants, medical assistants, X-ray technicians  Even though primary focus is patient care, work closely with those in front office  Sometimes sharing responsibilities
    23. 23. FRONT OFFICE Front office  Also known as administrative area  Hub of medical facility  Staff play key role in proper management of medical office  e.g., administrative medical assistants, medical transcriptionists, medical insurance billers, office managers
    24. 24. APPOINTMENT SCHEDULING PRINCIPLESFront office staff usually have first contact with patients when they request appointments Partial patient information collected over phone
    25. 25. THE PROCESS Patient registration  Registration information/form  Encounter form Clinical assessment and treatment  Physician/Provider visit Patient departure  Scheduling and billing
    26. 26. PATIENT REGISTRATION Receptionist  Registers patient  Obtains authorizations  Copies/Scans insurance card  Generates encounter form
    27. 27. PATIENT REGISTRATION FORM Demographic information Insurance information Authorization/Assignment of benefits Electronic or paper format
    28. 28. PATIENT REGISTRATION Electronic health (medical) record  New patient  Create patient database  Enter registration information  Scan insurance card  Established patient  Update database
    29. 29. ENCOUNTER FORM Also called charge slip, routing form, or superbill Type of visit Lab tests and treatments Diagnoses Charges, payment, and balance due Patient signature/authorization
    30. 30. CLINICAL ASSESSMENT AND TREATMENT  Physician/Provider  Examines patient  Orders lab tests and treatments  Completes clinical sections on encounter form
    31. 31. DEPARTURE PROCEDURES Schedule another appointment  If necessary Compute charges for services Collect copayment Post charges and payments
    32. 32. POSTING CHARGES AND PAYMENTSCharges: Encounter forms are “source documents”Payments: Checks, receipts, and insurance statements are “source documents” Charges and Payments posted to patient account ledger and day sheet
    33. 33. POSTING CHARGES AND PAYMENTSElectronic billing Charges and payments entered into patient database Billing Specialist generates: Statements Receipts Claim forms Transaction journals b
    34. 34. DIAGNOSTIC AND PROCEDURE CODES Remember Source Documents are  Encounter form  Medical record Medical coder  Reviews encounter form and medical record  Assigns codes  Enters codes into database
    35. 35. INSURANCE CLAIM FORM CMS-1500  Patient and insurance information  CMS-1500 blocks 1-13  Treatment and provider information  CMS-1500 blocks 14-33  Charges  CMS-1500 blocks 24F, 28, 29, and 30
    36. 36. INSURANCE CLAIM FORM Billing specialist  Submits claim  Paper  Completes claim form using source documents  Electronic  Generates claim form using patient database
    37. 37. INSURANCE CARRIER/COMPANY Reviews claim for errors  “Clean” claim  Provider (or patient) receives payment  “Dirty” (denied) claim  Payment withheld  Provider and patient notified
    38. 38. DENIED CLAIMS Technical (data entry) errors  Missing or incorrect information  Transposed numbers  Incomplete codes Coverage  Service not covered by health insurance  Patient not covered by policy at time of service
    39. 39. RESOLVING DENIED CLAIMS Technical errors  Billing specialist corrects errors  Claim resubmitted Coverage  Billing specialist may contact patient  Charges billed to patient
    40. 40. OTHER CLAIMS PROBLEMS Delinquent or pending  Payment from insurance carrier overdue  Claim lost or misplaced Billing specialist  Contacts insurance company  Phone, e-mail, or written inquiry  May resubmit claim
    41. 41. STATE INSURANCE COMMISSION Responsibilities  Monitor financial strength of insurance companies  Protect interest of insured and policyholders  Maintain complaint records  Resolve insurance conflicts
    42. 42. STATE INSURANCE COMMISSION Referrals  Pattern of problems with payment for services  Unresolved primary payer status conflicts Provider or patient may submit complaint Billing specialist may assist patient

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