The Medical Billing Cycle

Slides:



Advertisements
Similar presentations
Medical Insurance Chapter 18 ICBS 120.
Advertisements

Posting Insurance Payments and Creating Patient Statements
Patient Encounters and Billing Information Chapter 3
Chapter 6 Insurance and Coding
Billing, reimbursement, and collections
REIMBURSEMENT FOLLOW-UP AND COLLECTIONS Chapter 7.
CHAPTER © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 2 The Use of Health Information Technology in Physician Practices.
Certified Medical Coders (CMC) translate clinical data from patient health records and assign appropriate medical codes. Their work is submitted to.
© 2009 by The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Career Education Computers in the Medical Office Chapter 1: The Medical Office.
CHAPTER © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 1 The Medical Billing Cycle.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved. 1 McGraw-Hill Insert Cover Here The Hospital Billing Environment PART ONE Chapter 2 The Hospital.
From Prescription to Payment: Becoming a Pharmacy Technician Insurance Specialist Chapter 1 © 2010 The McGraw-Hill Companies, Inc. All rights reserved.
Copyright © 2008 Delmar Learning. All rights reserved. Chapter 4 Life Cycle of an Insurance Claim.
Overview Clinical Documentation & Revenue Management: Capturing the Services Prepared and Presented by Linda Hagen and Mae Regalado.
The Medical Billing Cycle
PAYMENT METHODS: Managed Care and Indemnity Plans
© 2011 The McGraw-Hill Companies, Inc. All rights reserved. Step 7 in the Medical Billing Cycle: Prepare and Transmit Claims 1-16 Medical practices produce.
3 Patient Encounters and Billing Information Lecture 2.
7 Creating Claims. Learning Outcomes When you finish this chapter, you will be able to: 7.1 Describe the role of claims in the billing process. 7.2 Discuss.
Patient Encounters and Billing Information
1 Introduction to the Medical Billing Cycle Chapter One lecture 2 OT 232.
Posting Insurance Payments and Creating Patient Statements
2 The Use of Health Information Technology in Physician Practices.
The Blue Plans, Private Insurance, and Managed Care Plans
The Health Care Industry Part 2 - Medical Insurance Karen F. Nichols, MSA School of Allied Health Professions University of Nebraska Medical Center.
Chapter 28 Medical Office
Introduction to the Medical Billing Cycle Chapter One lecture 3 OT 232
CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 1 Introduction to the Medical Billing Cycle.
CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 9 Checkout Procedures.
4 Scheduling.
CHAPTER © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 8 Posting Payments and Creating Patient Statements.
CHAPTER © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7 Creating Claims.
Introduction to Health Information Technology and Medical Billing
CHAPTER © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in.
PrimeSUITE’s Practice Management and Electronic Health Record Software
 Indemnity or Fee-for-Service coverage- -allow you go to the doctor of your choice and pay for services at the time of the visit. -The amount that your.
CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 1 Introduction to the Medical Billing Cycle.
Component 1: Introduction to Health Care and Public Health in the U.S. 1.5: Unit 5: Financing Health Care (Part 2) 1.5b: Reimbursement Methodologies and.
Copyright © 2009 by The McGraw-Hill Companies, Inc. All Rights Reserved. McGraw-Hill Chapter 5 Personal Health Records Electronic Health Records for Allied.
DOCUMENTATION GUIDELINES FOR E/M SERVICES
1.3 Health Care Plans (Continued) 1-14 Managed care offers a more restricted choice of providers and treatments in exchange for lower premiums, deductibles,
Insurance Terms and Concepts Medical Insurance involves a contract in which a business agrees to pay a portion of a patient’s medical expenses in exchange.
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 11 The Blue Plans, Private Insurance, and Managed Care Plans Insurance.
RCMS (Revenue Cycle Management System) Flow chart model
The Use of Health Information Technology in Physician Practices
FROM PATIENT TO PAYMENT
Chapter 15 HOSPITAL INSURANCE.
CHAPTER © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 8 Posting Insurance Payments and Creating Patient Statements.
1 Chase Smith Health Insurance. 2 Health Insurance Facts 85 of 100 Americans are currently covered by a government based health insurance or private health.
Health Care Costs. How we pay for health care: Private pay Private pay Group health insurance Group health insurance Government sponsored plans Government.
2 Understanding Managed Care: Insurance Plans.
Chapter 15 HOSPITAL INSURANCE.
Insurance Payment Posting
Component 1: Introduction to Health Care and Public Health in the U.S. 1.4: Unit 4: Financing Health Care (Part 1) 1.4 c: Insurance and Third-Party Payers.
1.03 Healthcare Finances Understand healthcare agencies, finances, and trends Healthcare Finances Government Finances Private Finances 2.
Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 14 Health Insurance.
Health Insurance Plans 2.4 Cost is a major concern Health care is over 15% of the gross national product Without insurance the cost of an illness can become.
1:5 Health Insurance Plans Health care costs are rising faster than other costs of living Most people rely on health insurance plans to pay for health.
Seminar Unit 2. Managed Care Causes Creation Goals Guidelines.
1 Introduction to the Medical Billing Process Chapter 1 © 2010 The McGraw-Hill Companies, Inc. All rights reserved.
Managed Health Care Manar alramli
Patient Encounters and Billing Information Chapter 3
Superbills.
Introduction to the Medical Billing Process Chapter 1
Processing an Insurance Claim
Introduction to the Revenue Cycle
Chapter 3: Basics of Health Insurance
3 Understanding Managed Care: Medical Contracts and Ethics.
The Medical Billing Cycle
Presentation transcript:

The Medical Billing Cycle 1 The Medical Billing Cycle

When you finish this chapter, you will be able to: Learning Outcomes 1-2 When you finish this chapter, you will be able to: 1.1 Identify four types of information collected during preregistration. 1.2 Compare fee-for-service and managed care health plans, and describe three types of managed care approaches. 1.3 Discuss the activities completed during patient check-in. 1.4 Discuss the information contained on an encounter form at check-out. 1.5 Explain the importance of medical necessity.

Learning Outcomes (Continued) 1-3 When you finish this chapter, you will be able to: 1.6 Explain why billing compliance is important. 1.7 Describe the information required on an insurance claim. 1.8 List the information contained on a remittance advice. 1.9 Explain the role of patient statements in reimbursement. 1.10 List the reports created to monitor a practice’s accounts receivable.

Key Terms accounting cycle accounts receivable (A/R) adjudication 1-4 accounting cycle accounts receivable (A/R) adjudication capitation coding coinsurance consumer-driven health plan (CDHP) copayment deductible diagnosis diagnosis code documentation electronic health records (EHRs) encounter form explanation of benefits (EOB) fee-for-service health maintenance organization (HMO) health plan managed care Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.

Key Terms (Continued) medical coder medical necessity medical record 1-5 medical coder medical necessity medical record modifier patient information form payer policyholder practice management program (PMP) preferred provider organization (PPO) premium procedure procedure code remittance advice (RA) statement Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.

Step 1 in the Medical Billing Cycle: Preregister Patients 1-6 Patient information gathered via phone or Internet before visit: Name Contact information Reason for the visit Whether patient is new to practice Learning Outcome: 1.1 Identify four types of information collected during preregistration. Pages: 4-5 Information for preregistration can also be obtained by mailing the patient paperwork before the actual visit. The patient can bring it in on the day of the appointment or mail it back prior to the appointment . All these ways help speed up the process of registering a new patient. It lessens the patient’s time in the waiting room. It keeps your day from getting backed up if patients do not arrive a little before their actual appointment time.

Step 2 in the Medical Billing Cycle: Establish Financial Responsibility for Visit 1-7 Many patients have medical insurance, which is an agreement between a policyholder and a health plan To secure medical insurance, policyholders pay premiums to payers, which are health plans such as government plans and private insurance Learning Outcome: 1.2 Compare fee-for-service and managed care health plans, and describe three types of managed care approaches. Pages: 5-7 Show examples in your state of fee-for-service and managed care health plans. (Try United Health Group, WellPoint, Aetna, Humana, or Cigna—some of the largest.) Have students describe plans in which they have participated.

Fee-for-Service Health Plans Step 2 in the Medical Billing Cycle: Establish Financial Responsibility for Visit (Continued) 1-8 Fee-for-Service Health Plans Policyholders are repaid for medical costs Requires payment of coinsurance Usually a deductible must be paid before benefits begin Managed Care Health Plans Managed care organizations control both financing and delivery of health care Have contracts with both patients and providers Learning Outcome: 1.2 Compare fee-for-service and managed care health plans, and describe three types of managed care approaches. Pages: 5-7 Show examples in your state of fee-for-service and managed care health plans. (Try United Health Group, WellPoint, Aetna, Humana, or Cigna—some of the largest.) Have students describe plans in which they have participated. Fee-for-service plans (also called indemnity plans) are more expensive than managed care plans. Fee-for-service plans usually have deductibles and are more flexible than managed care plans.

Types of managed care health plans Step 2 in the Medical Billing Cycle: Establish Financial Responsibility for Visit (Continued) 1-9 Types of managed care health plans Preferred provider organization (PPO): provider network for plan members; discounted fees Health maintenance organization (HMO): pays fixed amounts called capitation payments to contracted providers; patients must pay a small fixed fee called a copayment per visit Consumer-driven health plan (CDHP): combines a health plan with a high deductible with a policyholder's savings account Learning Outcome: 1.2 Compare fee-for-service and managed care health plans, and describe three types of managed care approaches. Pages: 5-7  Provide students with examples of both types of plans in area. Discuss some of the largest companies.  Kaiser Foundation Health Plan/Northern California is the largest HMO with 2,722,738 enrollees; followed by Kaiser Foundation Health Plan/Southern California with 2,591,555 enrollees; then PacifiCare of California with 2,260,334 enrollees.   Total HMO enrollment in the US reached 670 million for the first time while eight plans passed the million-member mark, according to a study by The Interstate Competitive Edge HMO Industry Report.   Some of the largest PPO’s are Blue Cross and Blue Shield of California, Pacific Foundation for Medical Care, Aetna US Healthcare, Cigna.   Some of the largest CDHP’s are UnitedHealth Group, Inc. , Aetna Inc., Cigna Healthcare, Humana, Inc., Meritain Health.   Have students visit major industry websites and compare.

Step 3 in the Medical Billing Cycle: Check In Patients 1-10 Patients complete the patient information form that contains personal, employment, and medical insurance information Patient identity is verified Time-of-service payments due before treatment are collected Learning Outcome: 1.3 Discuss the activities completed during patient check-in. Pages: 8-10 Have students fill in the patient information form in Figure 1-2 using their own information. If they do not have insurance information, have them pick a company from one of the sources documents. Ask students if they would like to discuss their personal experiences regarding check-in at their doctor’s office. They have probably never really thought about the check-in procedure, so this will give them some insight. Ask them if their copay was collected before or after the visit. This helps engage the students early in the course.

Step 4 in the Medical Billing Cycle: Check Out Patients 1-11 Every time a patient is treated by a health care provider, a record, known as documentation, is made of the encounter This chronological medical record, or chart, includes information that the patient provides Learning Outcome: 1.4 Discuss the information contained on an encounter form at check-out. Pages: 10-13 Have students discuss items that are filled in on an encounter form at check-out.

Step 4 in the Medical Billing Cycle: Check Out Patients (Continued) 1-12 Diagnoses and Procedures A diagnosis is the physician’s opinion of the nature of the patient’s illness or injury Procedures are the services performed Coding is the process of translating a description of a diagnosis or procedure into a standardized code A patient’s diagnosis is communicated to a health plan as a diagnosis code A procedure code stands for a particular service, treatment, or test A modifier is a two-digit character that is appended to a CPT code to report special circumstances Learning Outcome: 1.4 Discuss the information contained on an encounter form at check-out. Pages: 10-13 Show the class examples of the ICD-9 coding book and the CPT coding book. Read them a few of the common codes and their descriptions so they have an idea of what the coding process is about. Refer to the figures in the book also. Actual copies of ICD-9 and CPT will help clarify Figures 1.4 and 1.5.

Step 4 in the Medical Billing Cycle: Check Out Patients (Continued) 1-13 The diagnosis and procedure codes are recorded on an encounter form, also known as a superbill A practice management program (PMP) is a software program that automates the administrative and financial tasks required to run a medical practice Learning Outcome: 1.4 Discuss the information contained on an encounter form at check-out. Pages: 10-13 Get a blank superbill from a practice in your area to show students that the most common codes are on the superbill.

Step 5 in the Medical Billing Cycle: Review Coding Compliance 1-14 A physician, medical coder, or medical insurance specialist assigns codes The documented diagnosis and medical services should be logically connected, so that the medical necessity of the charges is clear to the insurance company Medical necessity is treatment by a physician for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in an appropriate manner Learning Outcome: 1.5 Explain the importance of medical necessity. Pages: 13-15 Discuss how medical necessity is related to payment.

Step 6 in the Medical Billing Cycle: Check Billing Compliance 1-15 Each charge, or fee, for a visit is represented by a specific procedure code The provider’s fees for services are listed on the medical practice’s fee schedule Medical billers use their knowledge to analyze what can be billed on health care claims Learning Outcome: 1.6 Explain why billing compliance is important. Page: 15 Show an example of a bill that is not in compliance. Explain why an insurance company will not pay for a strep test performed on a patient with a diagnosis of urinary tract infection. Have the students fill out the Encounter Form in Figure 1.6.