3

Patient Encounters and Billing Information

Learning Outcomes

When you finish this chapter, you will be able to: 3.1

Explain the method used to classify patients as new and or established.

3.2

3.3

List the five types of information that new patients provide before their encounters.

Discuss the procedures that are followed to update established patient information.

3.4

Explain the process for verifying patients’ eligibility for insurance benefits.

3.5

Discuss the importance of requesting referral or preauthorization approval.

3-2

Learning Outcomes (Continued)

3-3

When you finish this chapter, you will be able to: 3.6

Explain how to determine the primary insurance for patients who have more than one health plan.

3.7

3.8

3.9

3.10

Summarize the use and typical formats of encounter forms.

Identify the seven types of charges that may be collected from patients at the time of service.

Explain the use of real-time claims adjudication tools in calculating time-of-service payments.

Describe the billing procedures and transactions that occur during patient checkout.

Key Terms

• • • • • • • • • accept assignment Acknowledgment of Receipt of Notice of Privacy Practices adjustment assignment of benefits birthday rule cash flow certification number charge capture chart number • coordination of benefits (COB) • direct provider • encounter form • established patient (EP) • financial policy • gender rule • guarantor • • HIPAA Coordination of Benefits HIPAA Eligibility for a Health Plan

3-4

Key Terms (Continued)

• • • • • • • • HIPAA Referral Certification and Authorization indirect provider insured new patient (NP) nonparticipating provider (nonPAR) participating provider (PAR) partial payment patient information form • primary insurance • prior authorization number • real-time claims adjudication (RTCA) • • • • • referral number referral waiver referring physician revenue cycle management (RCM) secondary insurance

3-5

Key Terms (Continued)

• • • • • • self-pay patient subscriber supplemental insurance tertiary insurance trace number walkout receipt

3-6

Chapter 3 Introduction

• • Cash flow—movement of monies into or out of a business Revenue cycle management (RCM)—the actions that ensure the provider receives the maximum appropriate payment

3-7

3.1 New Versus Established Patients

3-8

• • • New patient (NP)—patient who has not seen a provider within the past three years Established patient (EP)—patient who has seen a provider within the past three years Figure 3-1, page 77

3.2 Information for New Patients

3-9

• When the patient is new to the practice, five types of information are important: 1. Preregistration and scheduling information 2. Medical history 3. Patient/guarantor and insurance data 4. Assignment of benefits 5. Acknowledgment of Receipt of Notice of Privacy Practices

3.2 Information for New Patients (Continued)

3-10

• • • • Referring physician—physician who refers a patient to another physician Participating provider (PAR)—provider who agrees to provide medical services to a payer’s policyholders according to a contract Nonparticipating provider (nonPAR)—provider who does not join a particular health plan Patient information form—form that includes a patient’s personal, employment, and insurance company data

3.2 Information for New Patients (Continued)

3-11

• • Other terms for the policyholder of a health plan include: –

Insured

–

Subscriber

–

Guarantor

Assignment of benefits—authorization allowing benefits to be paid directly to a provider

3.2 Information for New Patients (Continued)

•

Acknowledgment of Receipt of Notice of

Privacy Practices—form accompanying a covered entity’s Notice of Privacy Practices • HIPAA requirement • Direct vs. Indirect – clinician who treats a patient face-to-face – clinician who does not interact face-to-face with the patient • Not required for TPO • Patients must be informed once • Signed or not kept in file

3-12

• • • • • •

3.3 Information for Established Patients

3-13

When EPs arrive for appointments, they are asked if any pertinent personal or insurance information has changed EPs should review their information forms for accuracy at least once per year Any changes to an EP’s information should be entered in the practice management program (PMP) Check for current Notice of Privacy Practices – Make sure one in file hasn’t expired Existing patients get new cases or records for new cc – Chief complaint Chart number—unique number that identifies a patient

Communications w/Patients

• Most important – document EVERYTHING OT 232 Ch 3 lecture 1 14

3.4 Verifying Patient Eligibility for Insurance Benefits

• • • • 1 st step in establishing financial responsibility Abstract info from PIF & insurance card – Patient information form Then contact the payer to verify – Patient’s general eligibility for benefits – Amount of copay – Whether the visit is for a covered service that is medically necessary All must be checked before patient sees provider

3-14

Verify Patient Eligibility for Insurance Benefits (cont’d.) • • • Factors affecting general eligibility – Premiums – Income – Employment – PCP Checking Out-of-Network Benefits – Additional charge or 100% responsible?

Verifying the amount of copayment – Usually listed on card, but January appointments?

OT 232 Ch 3 lecture 1 16

• •

3.4 Verifying Patient Eligibility for Insurance Benefits (Continued)

Determine whether the planned encounter is for a covered service

3-15

Electronic benefit inquiries & responses – HIPAA standard forms can be used (pg 59?) • HIPAA Eligibility for a Health Plan—transaction in which a provider asks for and receives an answer about a patient’s eligibility for benefits (X12 270/271) • Trace number—number assigned to a HIPAA 270 electronic transaction – PMPs log transactions – Be careful of info sent

• • • •

3.5 Determining Preauthorization and

3-16

Referral Requirements

Preauthorization is requested before a patient is given certain types of medical care – Usually required – Controls access to specialists – HIPAA standard transaction – Prior authorization number—identifying code assigned when preauthorization is required (also called a certification number) Referrals – Often required – – HIPAA standard transaction HIPAA Referral Certification and Authorization: transaction in which a provider asks a health plan for approval of a service and gets a response (X12 278) – Referral number—authorization number given to the referred physician Providers must handle these situations correctly to ensure that services are covered if possible Procedures when patient is not covered – Inform patient prior to increase odds of pmt

3.5 Determining Preauthorization and

3-17

Referral Requirements (Continued)

• Referral waiver—document a patient signs to guarantee payment when a referral authorization is pending – Used if a patient does not have the required referral document