1. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Chapter 3 An Introduction to Medical Informatics and the Administrative Applications of Computers

2. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Medical Informatics The use of computers to organize and apply medical information. The information includes patient information, administrative information, and the use of computers in education and pharmacy. It is traditional to divide computer applications in health care into three categories Clinical Administrative Specia lpurpose Telemedicine includes all three categories.

3. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Administrative Applications of Computer Technology in the Medical Office Office management Scheduling Billing (bucket or balance billing) Filing insurance claims

4. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 The Patient Information Form Personal information Name Address and phone number Date of birth Social Security number Family information Medical information Allergies Medical history Current medicaltions Insurance information

5. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 The Electronic Medical Record (EMR) Encouraged by Health Insurance Portability and Accountability Act of 1996 (HIPAA) Complete medical history and current information in electronic form Advantages: continuity of care Disadvantages: lack of privacy

6. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Coding and Grouping Systems CPT—(current procedure terminology)—codes procedures ICD—(international classification of disease)— codes diseases DRG—(diagnosis related group)—used to determine reimbursement by government and private insurers

7. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Accounting, Using MediSoft Transactions organized around cases Charges—amount patient is billed for provider’s service Payments—made by patients or insurance carrier Adjustments—a positive or negative change to a patient’s account

8. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Insurance Fee-for-service (indemnity) plans Schedule of benefits Deductibles Choose own providers Preferred provider plans (PPO) Assignment Copayment Some coverage for out-of-network providers

9. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Insurance (cont.) Federal Insurance Plans (administered by CMS formerly HCFA) Medicaid serves low-income people Medicare serves people 65 and over and disabled people with chronic renal disorders CHAMPVA for military personnel TRICARE for military personnel Workers’ compensation for people injured on the job

10. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Insurance (cont.) Managed care Health maintenance organization (HMO) Care is determined by insurance company. Must use in-network providers.

11. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Insurance (cont.) Claims are submitted to insurance carriers requesting payment HCFA-1500 (CMS-1500)—widely accepted claim form EOB—explanation of benefits EMC—electronically processed claim Clearinghouse ERA—electronic remittance advice

12. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Insurance (cont.) Bucket billing Bill first insurer When EOB or ERA is received, bill second insurer. When EOB or ERA is received, bill third insurer. Bill patient.

13. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Accounting Superbill (encounter form) lists commonly performed services of a practice. Utilized in several accounting reports.

14. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Accounting Reports Patient Day Sheet Lists day’s patients Lists chart numbers Lists procedures Used for daily reconciliation

15. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Accounting Reports Procedure Day Sheet Grouped report Organized by procedure All patients who underwent a particular procedure are listed together. Used to see what procedures a health care provider is performing

16. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Accounting Reports Payment Day Sheet Report grouped by providers Each patient is listed under his or her provider. Shows amounts received from each patient to each provider.

17. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Accounting Reports Practice Analysis Report Generated monthly Summary total of all procedures, charges, and transactions

18. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Accounting Reports Patient Aging Report Used to show patient’s outstanding payments Current and past-due balances are listed based on the number of days late (30–60 days, 60–90 days, over 90 days)

19. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Other Systems Resource utilization groups (RUGs) used as basis of payment in skilled nursing facilities. Ambulatory patient classification (APC) used as basis of payment for hospital outpatient services. Healthcare Common Procedure Coding Systems (HCPCS) developed to standardize claims processing for government and private insurers

20. Information Technology for the Health Professions, 2/e By Lillian Burke and Barbara Weill ©2005 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Other Systems HHRG (Home Health Resource Group) determines prospective payment for home health care for Medicare patients OASIS (Outcome and Assessment Information Set) data collection instrument.