Computers in the Medical Office

1. Computers inthe Medical Office Chapter 1: The Medical OfficeBilling Process

2. The Billing Process • The key to the financial health of a medical practice is billing for services and collecting payments • The billing process consists of ten steps

3. The Billing Process • Preregister patients • Establish financial responsibility • Check in patients • Check out patients • Review coding compliance

4. The Billing Process • Check billing compliance • Prepare and transmit claims • Monitor payer adjudication • Generate patient statements • Follow up payments and collections

5. Preregister Patients • The billing cycle begins when a patient requests an appointment • Obtain information from patient including name, address, telephone, reason for visit, and insurance coverage

6. Establish FinancialResponsibility for Visit • Determine whether the physician participates in the patient’s insurance plan • Explain financial responsibility to patient

7. Types of Medical Insurance • Most patients are covered by some type of health insurance plan • These plans can include: • Government plans • Private payer plans

8. Government Plans • Medicare • Medicaid • TRICARE • CHAMPVA • Workers’ Compensation

9. Private Payer Plans • Fee-for-service • Preferred provider organization (PPO) • Health maintenance organization (HMO) • Consumer-driven health plan (CDHP)

10. Private Payer Plans • Fee-for-service • Policyholder is reimbursed for covered medical expenses

11. Private Payer Plans • Preferred Provider Organization (PPO) • Managed care network of health care providers who contract to provide services to members at discounted fees • Patient may be treated by a provider outside the network at a higher fee

12. Private Payer Plans • Health maintenance organization (HMO) • Managed care network of health care providers who contract to provide services to members of an insurance plan in exchange payment from the plan • Providers receive fixed payments at regular intervals from the plan

13. Private Payer Plans • Consumer-driven health plan (CDHP) • Low premium/high deductible plan combined with a pretax savings accountto cover out-of-pocket expenses • Members have access to informational tools, such as plan-sponsored websites, to help make educated health-care decisions

14. Check In Patients • Patient completes a patient information form, which contains personal, employment, and insurance information required to collect payment for services • Photocopy patient’s insurance identification card • Collect any payment or copayment that is due

15. Check Out Patients • Record procedure and diagnosis • Collect any payment or copayment that is due • Schedule follow-up appointment

16. Recording Diagnoses and Procedures • Diagnostic and procedural codes for treatment of a patient are recorded on an encounter form

17. Recording Diagnoses • Diagnosis codes provide health plans with specific information about a patient’s illness, signs, and symptoms • Diagnosis codes are listed in ICD-9-CM International Classification of Diseases

18. Recording Procedures • Procedure codes specifies which procedures and tests were performed • Procedure codes are listed in CPT-Current Procedural Terminology

19. Review Coding Compliance • Coding compliance • American Medical Association • American Hospital Association • Medical necessity

20. Check Billing Compliance • Physician’s standard fee schedule • Discounted contracts with third-party payers • Determining whether code is billable

21. Prepare and Transmit Claims • When patients receive services from a healthcare provider, the fees are paid by health insurance plans and/or patients • To obtain payment from an insurance plan, a claim must be filed

22. Prepare and Transmit Claims • Claims contain information about the patient, the procedures and diagnoses, and the provider • Information required to create claim found on patient information form and encounter form

23. Monitor Payer Adjudication • The process of claim review by the payer is known as adjudication • Results of the review are sent to the physician in a remittance advice (RA, transfer of the money) or explanation of benefits (EOB)

24. Monitor Payer Adjudication • Remittance advice reviewed for accuracy • All procedures on claim included on RA • Unpaid charges are explained • Codes match those on the claim • Payment for each procedure is as expected

25. Monitor Payer Adjudication • If no problems are found, the payment or adjustment is recorded in the practice management program • If a problem is found, a review of the claim is requested

26. Generate Patient Statements • Once payments from insurance plans are recorded, statements are printed and mailed to patients • Statements list the balance on the account that is owed by the patient

27. Follow Up Patient Paymentsand Handle Collections • The accounting cycle is the flow of financial transactions in a business • A number of reports are created on a daily basis to monitor the financial activity in the practice • Monthly and annual reports also provide important data on the financial health of the practice

28. Follow Up Patient Paymentsand Handle Collections • Follow up with patients who have outstanding balances • Follow up on insurance claims not paid in a timely manner