Patient Encounters and Billing Information

1. 3 Patient Encounters and Billing Information

2. 3-2 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. 3-3 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.

4. 3-4 Key Terms • 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 • accept assignment • Acknowledgment of Receipt of Notice of Privacy Practices • adjustment • assignment of benefits • birthday rule • cash flow • certification number • charge capture • chart number

5. 3-5 Key Terms (Continued) • primary insurance • prior authorization number • real-time claims adjudication (RTCA) • referral number • referral waiver • referring physician • revenue cycle management (RCM) • secondary insurance • HIPAA Referral Certification and Authorization • indirect provider • insured • new patient (NP) • nonparticipating provider (nonPAR) • participating provider (PAR) • partial payment • patient information form

6. 3-6 Key Terms (Continued) • self-pay patient • subscriber • supplemental insurance • tertiary insurance • trace number • walkout receipt

7. 3-7 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

8. 3-8 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 • Figure 3-1, page 77

9. 3-9 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

10. 3-10 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

11. 3-11 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

12. 3-12 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 • HIPAA requirement • Direct vs. Indirect • clinician who treats a patient face-to-face • clinician who does not interact face-to-face with the patient • Not required for TPO • Patients must be informed once • Signed or not kept in file

13. 3-13 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) • Check for current Notice of Privacy Practices • Make sure one in file hasn’t expired • Existing patients get new cases or records for new cc • Chief complaint • Chart number—unique number that identifies a patient

14. Communications w/Patients • Most important – document EVERYTHING OT 232 Ch 3 lecture 1

15. 3-14 3.4 Verifying Patient Eligibility forInsurance Benefits • 1st step in establishing financial responsibility • Abstract info from PIF & insurance card • Patient information form • Then contact the payer to verify • Patient’s general eligibility for benefits • Amount of copay • Whether the visit is for a covered service that is medically necessary • All must be checked before patient sees provider

16. Verify Patient Eligibility for Insurance Benefits (cont’d.) • Factors affecting general eligibility • Premiums • Income • Employment • PCP • Checking Out-of-Network Benefits • Additional charge or 100% responsible? • Verifying the amount of copayment • Usually listed on card, but January appointments? OT 232 Ch 3 lecture 1

17. 3-15 3.4 Verifying Patient Eligibility forInsurance Benefits (Continued) • Determine whether the planned encounter is for a covered service • Electronic benefit inquiries & responses • HIPAA standard forms can be used (pg 59?) • 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 • PMPs log transactions • Be careful of info sent

18. 3-16 3.5 Determining Preauthorization and Referral Requirements • Preauthorizationis requested before a patient is given certain types of medical care • Usually required • Controls access to specialists • HIPAA standard transaction • Prior authorization number—identifying code assigned when preauthorization is required (also called a certification number) • Referrals • Often required • HIPAA standard transaction • 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 • Procedures when patient is not covered • Inform patient prior to increase odds of pmt

19. 3-17 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

20. 3-18 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

21. 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 the coordination of benefits guidelines • Follow any rules that may apply • Communicate with the patient as needed

22. 3-20 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

23. Establishing Financial Responsibility (cont’d.) • Entering insurance info in the PMP • Communications with payers • All communications with payers should be documented in the patient’s… • FINANCIAL (not medical/clinical) record OT 232 Ch 3 lecture 2

24. 3-21 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 • Aka ‘Superbill’ • 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

25. 3-22 3.8 Understanding Time-of-Service (TOS) Payments • HIPAA tip – page 97 • 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

26. 3-23 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

27. Collecting Time-of-Service (TOS) Payments • Other TOS Collection Considerations • Due to circumstances, funds can be delayed to practice • Adjudicated amounts • Annual deductible payments • Differences in participation contracts • So increase TOS collections • Deductibles • Partial payment • % of estimated amount owed OT 232 Ch 3 lecture 2

28. 3-24 3.9 Calculating TOS Payments • Real-time claims adjudication—process used to generate the amount owed by a patient at the time of service • Wave of the future • Must be coded first • Get paid within 24 hours • 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

29. 3-25 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

30. Financial Policy • Usually displayed in reception area or in new patient info packet • Should explain • Unassigned claims • Assigned claims • Copayments • Estimating what the patient will owe • Based on deductible & allowed charges • Financial arrangement for large bills • Payment plan • Interest or not? OT 232 Ch 3 lecture 2

31. 3-26 3.10 Collecting TOS Payments and Checking Out Patients (Continued) • Payment Methods • Some sort of receipt is given as proof of payment • Insurance questionable • Patient or provider handles after patient pays in full • Walkout receipt—report that lists the diagnoses, services provided, fees, and payments received and due after an encounter • Insurance questionable • Patient or provider handles after patient pays in full