Patient Encounters and Billing Information Chapter 3 © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

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. Chapter 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. Chapter 3

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. Chapter 3

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 Chapter 3

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 Chapter 3

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 Chapter 3

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 Chapter 3

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? Chapter 3

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 Chapter 3

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 Chapter 3

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 Chapter 3

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. Chapter 3

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 Chapter 3

Verification of Patient Eligibility for Insurance Benefits Current enrollment and benefit eligibility Copayment information Plan provisions: Is the planned service medically necessary?

Determining Preauthorization and Referral Requirements Preauthorization: if required, secure preauthorization number Referral: if required, secure referral number/document HIPAA Referral Certification and Authorization transaction – X12 278.

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 Chapter 3

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 Chapter 3

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 Chapter 3

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 Chapter 3

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. Chapter 3

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 Chapter 3

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 Chapter 3

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 Chapter 3

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. Chapter 3