1. Patient Encounters and Billing Information Chapter 3
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2. Learning Outcomes After studying this chapter, you should be able to:
3.1 Explain the method used to classify patients as new and or established.
3.2 Describe the information that new and returning patients provide before their encounters.
3.3 Discuss the purpose of the Assignment of Benefits.
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3. Learning Outcomes (Continued)
3.4 Explain the purpose of the HIPAA Acknowledgment of Receipt of Notice of Privacy Practices.
3.5 Describe the procedures for verifying patients’ eligibility for insurance benefits and for requesting referral or preauthorization approval.
3.6 Explain how to determine the primary insurance for patients who have more than one health plan.
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4. Learning Outcomes (Continued)
3.7 Discuss the use and typical formats of encounter forms.
3.8 List the four types of charges that are collected from patients at the time of service.
3.9 Describe the billing procedures and transactions that follow patients’ encounters.
3.10 Explain the importance of communication skills in working with patients, payers, and providers.
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5. Key Terms Accept assignment
Acknowledgment of Receipt of Notice of Privacy Practices
Adjustment
Assignment of benefits
Birthday rule
Certification number
Charge capture
Chart number
Coordination of benefits (COB)
Direct provider
Encounter form
Established patient (EP)
Financial policy
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6. Key Terms (Continued) Gender rule Guarantor
HIPAA Coordination of Benefits
HIPAA Eligibility for a Health Plan
HIPAA Referral Certification and Authorization
Indirect provider
Insured
New patient (NP)
Nonparticipating provider (nonPAR)
Partial payment
Participating provider (PAR)
Patient information form
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7. Key Terms (Continued) Primary insurance Prior authorization number
Real –time claims adjudication (RTCA)
Referral number
Referral waiver
Referring physician
Secondary insurance
Self-pay patient
Subscriber
Supplemental insurance
Tertiary insurance
Trace number
Walkout receipt
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8. Gathering Patient Information
Information to collect from new patients:
Preregistration and scheduling information
Medical history
Patient/guarantor information and insurance information
Assignment of benefits
Acknowledgment of Receipt of Notice of Privacy Practices
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9. Gathering Patient Information (Continued)
Information to collect from established patients:
Updated personal demographics
Updated insurance information
Signed Acknowledgment of Receipt of Notice of Privacy Practices on file?
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10. Patient Information Patient Health Plans
• Full name • Social Security Number
• Gender • Employer information
• Marital status • Spouse’s name and employer
• Birth date • Contact person
• Address
Health Plans
• Policyholder name and personal information, identification number
• Other health plan
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11. Patient Information Processing patient information
Scan or photocopy insurance card
Double-check the information on the patient information form
Group identification number
Effective date
Member name – exact match
Member identification number
Health plan information
Process assignment of benefits form
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12. Acknowledgment of Receipt of Notice of Privacy Practices
A patient must be given a direct provider’s Notice of Privacy Practices once
The patient is asked to sign an acknowledgment of receipt of this notice
Provider must document in the medical record whether patient has signed
Shows good-faith effort of office to inform patients of privacy practices
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13. Communication Skills Communication skills are critical!
Medical insurance specialists handle patient interactions effectively.
They also frequently communicate with payers’ representatives.
Communicating appropriately with providers and other team members contributes to a successful practice.
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14. Establishing Financial Responsibility
The financial policy should be posted.
Three steps to establish financial responsibility:
Verify patients’ insurance coverage prior to non-emergency services.
Determine preauthorization and referral requirements
Determine primary payer if applicable
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15. Verification of Patient Eligibility for Insurance Benefits
Current enrollment and benefit eligibility
Copayment information
Plan provisions: Is the planned service medically necessary?

16. Determining Preauthorization and Referral Requirements
Preauthorization: if required, secure preauthorization number
Referral: if required, secure referral number/document
HIPAA Referral Certification and Authorization transaction – X

17. Determining the Primary Insurance
Coordination of Benefits:
If the patient has one policy, it is primary
If the patient has coverage under two plans, the patient’s longest running plan is primary and the other plan is secondary. A third, or tertiary, plan or a supplemental plan may also be in effect.
A patient’s plan is also primary if the patient is:
Listed as a dependent on another person’s plan
Covered under a government-sponsored plan, that is in addition to an employer’s plan
Retired, but covered under a working spouse’s plan
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18. Determining the Primary Insurance (continued)
If the patient is a dependent child covered by both parents’ plans, the “birthday rule” usually determines primary coverage
If the patient is a dependent child of divorced or separated parents, primary insurance is determined in the following order:
plan of custodial parent
plan of spouse of custodial parent if remarried
plan of parent without custody
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19. HIPAA Transactions Electronic verification under HIPAA:
HIPAA Eligibility for a Health Plan transaction
HIPAA Referral Certification and Authorization transaction
HIPAA Coordination of Benefits transaction
Electronic format used to verify benefits
A referral document that describes the services a patient is certified to receive
When a patient has more than 1 policy, the primary carrier must be determined
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20. Updating Patient Diagnoses, Procedures, and Charges
Medical services provided by physician
Diagnosis(es) determined
Treatment documented
Encounter form completed
Compiles data for each office visit
Details dx and procedure codes and charges
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21. Updating Patient Diagnoses, Procedures, and Charges
Coding
The completed encounter form and the patient medical records are used to code or verify the assigned codes.
Charges Calculated
The charges for the services are calculated, based on the current fee schedule.
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22. Collecting Time-of-Service Payments
Potential patient responsibility: review
Copayments
Coinsurance
Deductibles
Excluded services
Overlimit usage
Set dollar amount payable for encounter
Percentage of charges set as patient responsibility
Amount insured pays before insurance benefits begin
Services not covered by insured’s benefit plan
Dollar/number of services
exceed plan benefits
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23. Collecting Time-of-Service Payments
Practices collect:
Copayments
Noncovered or overlimit fees
Charges of nonparticipating providers
Charges for services to self-pay patients
Practices may also collect:
Partial payments
Full payment when real-time claim adjudication tool is available from the payer
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24. Checking Out Patients Estimating Patients’ Bills
Verify the amount and status of the deductible.
Check required coinsurance or other payments.
Calculate charges based on the fee schedule.
Determine payer’s allowed amounts.
Charges – (patient deductible/TOS payments) – (payer’s payment) = Estimated Bill
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25. Checking Out Patients Processing Payments – Payment Methods:
Cash: A receipt is issued.
Check: The payment amount and check number are entered on the encounter form, and a receipt is offered.
Credit or Debit Card: The card slip is filled out, and the card is passed through the card reader. The approved card slip is signed by the payer, and a receipt may be offered.
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