Transcript 3 - Walla Walla Community College

3
Patient Encounters and
Billing Information
Lecture 2
3-18
3.6 Determining the Primary Insurance
• Primary insurance—health plan that pays
benefits first
• Secondary insurance—second payer on a
claim
• Tertiary insurance—third payer on a claim
• Supplemental insurance—health plan that
covers services not normally covered by a
primary plan
3.6 Determining the Primary Insurance3-19
(Continued)
• To determine a patient’s primary insurance,
medical insurance specialists:
– Examine the patient information form and
insurance card
– Follow the coordination of benefits guidelines
– Follow any rules that may apply
– Communicate with the patient as needed
3.6 Determining the Primary Insurance3-20
(Continued)
• Coordination of benefits (COB)—explains how an
insurance policy will pay if more than one policy
applies
– HIPAA Coordination of Benefits—transaction sent to
a secondary or tertiary payer (X12 837)
• Birthday rule—guideline that determines which
parent has the primary insurance for a child
• Gender rule—coordination of benefits rule for a
child insured under both parents’ plans
Establishing Financial Responsibility
(cont’d.)
• Entering insurance info in the PMP
• Communications with payers
– All communications with payers should be
documented in the patient’s…
• FINANCIAL (not medical/clinical) record
OT 232 Ch 3 lecture 2
5
3.7 Working with Encounter Forms
3-21
• An encounter form (electronic or paper) is completed
by a provider to summarize billing information for a
patient’s visit
– Aka ‘Superbill’
– Lists the medical practice’s most frequently performed
procedures with their procedure codes
– Blank spaces for diagnoses codes, and often includes other
various information
– Paper forms may be preprinted or computer-generated
• Charge capture—procedures that ensure billable
services are recorded and reported for payment
3.8 Understanding Time-of-Service (TOS)
3-22
Payments
• HIPAA tip – page 97
• Practices routinely collect these charges at the
time of service:
1.
2.
3.
4.
5.
6.
7.
Previous balances
Copayments
Coinsurance
Noncovered or overlimit fees
Charges of nonPAR providers
Charges for self-pay patients
Deductibles for patients with CDHPs
3.8 Understanding Time-of-Service (TOS)
3-23
Payments (Continued)
• Accept assignment—participating physician’s
agreement to accept allowed charge as full
payment
• Self-pay patient—patient with no insurance
• Partial payment—payment made during
checkout based on an estimate
Collecting Time-of-Service (TOS)
Payments
• Other TOS Collection Considerations
• Due to circumstances, funds can be delayed to
practice
– Adjudicated amounts
– Annual deductible payments
– Differences in participation contracts
• So increase TOS collections
– Deductibles
– Partial payment
• % of estimated amount owed
OT 232 Ch 3 lecture 2
9
3.9 Calculating TOS Payments
• Real-time claims adjudication—process used to
generate the amount owed by a patient at the
time of service
• Wave of the future
• Must be coded first
• Get paid within 24 hours
• Real-time benefit information—process used to
generate information about a patient’s benefits
at the time of service
• Financial policy—practice’s rules governing
payment from patients
3-24
3.10 Collecting TOS Payments and
Checking Out Patients
3-25
• The PMP is used to record the financial
transactions from patients’ visits:
– Charges—amounts providers bill
– Payments—monies the practice receives
– Adjustments—changes to patients’ accounts
• Information from the encounter form is entered
into the PMP to calculate charges and compute
balances
• Payment methods may include cash, check, and a
credit or debit card
Financial Policy
• Usually displayed in reception area or in new
patient info packet
• Should explain
– Unassigned claims
– Assigned claims
– Copayments
• Estimating what the patient will owe
– Based on deductible & allowed charges
• Financial arrangement for large bills
– Payment plan
– Interest or not?
OT 232 Ch 3 lecture 2
12
3.10 Collecting TOS Payments and
Checking Out Patients (Continued)
• Payment Methods
– Some sort of receipt is given as proof of payment
– Insurance questionable
• Patient or provider handles after patient pays in full
• Walkout receipt—report that lists the diagnoses,
services provided, fees, and payments received
and due after an encounter
– Insurance questionable
• Patient or provider handles after patient pays in full
3-26