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BILLING, REIMBURSEMENT, AND COLLECTIONS Chapter 7 © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED.

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Presentation on theme: "BILLING, REIMBURSEMENT, AND COLLECTIONS Chapter 7 © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED."— Presentation transcript:

1 BILLING, REIMBURSEMENT, AND COLLECTIONS Chapter 7 © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED

2 LEARNING OUTCOMES: WHEN YOU FINISH THIS CHAPTER YOU WILL BE ABLE TO 7.1 Recognize and calculate charges for medical services and process patient statements based on the patient encounter form and the physician’s fee schedule. 7.2 Compare and contrast the process of completing and transmitting insurance claims using both hardcopy and electronic methods. 7.3 Describe the different types of billing options used by medical practices for billing patients. 7.4 Paraphrase the procedures and options available for collecting delinquent accounts. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-2

3 clearinghousecycle billing clean claimdependent CMS-1500electronic claims claim formEOB collection agencyERA collection at the time of service fee adjustment collection ratiofee schedule guarantor monthly billing patient information form patient statement scrubber program terminated account third-party liability write-off © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED KEY TERMS 7-3

4 KEY TERMS (CONTINUED) clearinghouse –a service bureau that collects electronic claims from many different medical practices and forwards the claims to the appropriate insurance carriers clean claim -- a claim that is accepted by the insurance payer for adjudication CMS which is filled out or updated by the patient, and the patient encounter form claim form -- is one of the most important steps in successful claim reimbursement collection agency -- for collecting unpaid bills, as most agencies work on a contingency basis © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-4

5 KEY TERMS (CONTINUED) collection at the time of service -- Patients pay at the time of the visit by cash, check, debit card, or credit card collection ratio -- (total collections divided by net charges of the practice cycle billing -- is designed to avoid once-a-month peak workloads and to stabilize the cash flow dependent -- children usually children under the age of 18 (or children under 21 who are full-time students) © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-5

6 KEY TERMS (CONTINUED) electronic claims -- are prepared on a computer and transmitted electronically (from one computer to another) to an insurance carrier for processing EOB -- explanation of benefits ERA -- electronic remittance advice fee adjustment -- Should the need arise, the physician can adjust the cost of any procedure © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-6

7 KEY TERMS (CONTINUED) fee schedule -- which lists the usual procedures the office performs and the corresponding charges guarantor -- guarantees payment of the account charges monthly billing -- bills are sent out once a month and are timed to reach the patient no later than the last day of the month patient information form -- which is filled out or updated by the patient © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-7

8 KEY TERMS (CONTINUED) patient statement -- is sent to the patient for billing purposes on the next billing date scrubber program – used to check for errors on insurance claim forms before they are submitted terminated account -- A physician who finds it impossible to extract payment from a patient may decide to terminate the physician- patient relationship third-party liability -- Sometimes a person other than the patient assumes liability, or responsibility, for the charges write-off -- One type of fee adjustment a medical office makes regularly with certain health plans © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-8

9 Administrative medical assistants keep track of the services rendered and any payments made during a visit to the physician. After the patient completes the office visit, the administrative medical assistant updates the patient ledger to show the financial information for the encounter.  Patient Encounter Form  Fee Schedule  Patient Statements  Computerized Billing © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED RECOGNIZE AND CALCULATE CHARGES FOR MEDICAL SERVICES AND PROCESS PATIENT STATEMENTS BASED ON THE PATIENT ENCOUNTER FORMS AND THE PHYSICIAN’S FEE SCHEDULE.

10 7.2 COMPARE AND CONTRAST THE PROCESS OF COMPLETING AND TRANSMITTING INSURANCE CLAIMS USING BOTH HARDCOPY AND ELECTRONIC METHODS.  Complete the insurance claim form, either electronic or on paper,  Verify patient demographic, encounter, and insurance information.  Transmit, electronically or by postal mail, the claim form to the insurance company, which decides to pay the fee, deny the claim, or pay a certain portion of the claim.  Verify the accuracy. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-10

11 7.3 DESCRIBE THE DIFFERENT TYPES OF BILLING OPTIONS USED BY MEDICAL PRACTICES FOR BILLING PATIENTS.  Methods of Payments  Sending Statements  Payment Plans  Fee Adjustment  Health Insurance  Third-Party Liability © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-11

12 7.4 PARAPHRASE THE PROCEDURES AND OPTIONS AVAILABLE FOR COLLECTING DELINQUENT ACCOUNTS  Communicating with Patients  Guidelines for Payment  The Office Collection Policy  Laws Governing Collections  Course of Action  Statute of Limitations  Credit Arrangements and the Truth in Lending Act  Writing Off Uncollectible Accounts © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 7-12


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