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Medical Insurance

Medical Insurance. Lisa H. Young, RN, BSN MA Ed. Working with Medical Insurance and Billing Chapter 1. Three ways that medical insurance specialist help ensure the financial success of physician practices. (pages 3-7) Following all procedures carefully Communicating effectively

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Medical Insurance

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  1. Medical Insurance Lisa H. Young, RN, BSN MA Ed

  2. Working with Medical Insurance and BillingChapter 1 • Three ways that medical insurance specialist help ensure the financial success of physician practices. (pages 3-7) • Following all procedures carefully • Communicating effectively • Using health information technology

  3. Working with Medical Insurance and Billing • Covered and Uncovered services under medical insurance policies (pages 7-8) • Covered: primary care, emergency care, medical specialists’ services and surgery; eligible for members; listed under the schedule of benefits of an insurance policy • Non-covered: are identified by the insurance policy as services for which it will not pay

  4. Working with Medical Insurance and Billing • Indemnity and Managed Care Approaches to Health Plan Organizations (pages 9 – 11) • Indemnity: the payer protects the member against loss form the costs of medical services and procedures • Managed: Restricted choice of providers and treatments in exchange for lower premiums, deductibles, and other charges

  5. Working with Medical Insurance and Billing • Health maintenance organizations (HMO) control healthcare costs by: • Creating a restricted number of physicians for members • Controlling the use of services • Controlling drug costs • Using cost-sharing methods (pages 11 – 14)

  6. Working with Medical Insurance and Billing • Preferred provider organization (PPO) • Create a network of hospitals and other providers for members to use at negotiated, reduced fees • Are the most popular type of healthcare • Generally require the payment of premium and copayments from patients (pages 14 – 15)

  7. Working with Medical Insurance and Billing • Consumer-driven health plan (page 16) • CDHPs combine a high-deductible, low-premium PPO with a pretax savings account to cover out-of-pocket medical expenses up to the amount of the deductible • Comparison of Health Plan Options Table 1.2 on page 16

  8. Working with Medical Insurance and Billing • Three major types of medical insurance payers: • Private payers • Employer sponsored • Government-sponsored (pages 17 – 18)

  9. Working with Medical Insurance and Billing • Ten steps in Medical Billing Cycle (pages 18-24) • Preregister patients • Establish financial responsibility • Check in patients • Coding compliance • Billing compliance • Check out patients • Prepare and Transmit claims • Generate patient statements • Follow up payments and collections

  10. Working with Medical Insurance and Billing • Professionalism and etiquette contribute to career success • Vital quality for all office personnel • Develop skills and attributes to perform work successfully • Strong code of ethics • Correct etiquette (pages 25-27)

  11. Working with Medical Insurance and Billing • Professional certification for career advancement (pages 27-28) • Membership in a professional organization • Certification for a professional organization • Certification through education, experience, and an exam

  12. EHR, HIPAA, and HITECHChapter 2 • Accurate documentation with medical records (pages 36- 43) • Electric health records (EHRs) • Immediate access to health information • Computerized physician order management • Automated alerts and reminders • Electronic communication and connectivity • Patient support • Administration and report • Error reduction http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  13. Documentation of Patient Encounters • Patient’s name • Encounter date and reason • Appropriate history and physical examination • Review of all tests that were ordered • Diagnosis • Plan of care, or notes on procedures or treatments that were given • Instructions or recommendations that were given to the patient • Signature of the provider who saw the patient

  14. Patient Medical Record • Biographical and personal information • Records of all communications • Records of prescriptions • Scanned records • Drug & environmental allergies • Up-to-date immunization record • Previous & current diagnoses • Records of referral letters • Hospital admissions • Records of missed or canceled appointments • Requests for information about the patient.

  15. EHR, HIPAA, and HITECH • HIPAA is a law designed to: • Protect people’s private health information • Health insurance coverage for employees with a change or lose of their jobs • Uncover fraud and abuse • Standards for electronic transmission of healthcare transactions (pages 44 - 47)

  16. EHR, HIPAA, and HITECH • ARRA of 2009 includes rules in the HITECH Act: • Provisions concerning the standards for electronic transmission of healthcare data • Guides the use of federal stimulus money to promote the adoption and meaningful use of health information technology, mainly using EHRs.

  17. EHR, HIPAA, and HITECH • Covered entities and business associates • Covered entity is a health plan, healthcare clearinghouse, healthcare provider who transmits health information in electronic form • Business associates, such as a law firm or billing service, work for the covered entity and agree to follow HIPAA regulations to safeguard PHI • Electronic data interchange is used to facilitate transaction of information (pages 47-49)

  18. EHR, HIPAA, and HITECH • HIPAA Privacy Rule (pages 49 - 57) • Regulates the use and disclosure of patients’ PHI • Use and disclosure of PHI is permitted for patients’ treatment, payment, and healthcare operations (TPO) • PHI may be released for court cases, workers’ compensation cases, statutory reports, and research • Providers are responsible for protecting their patients’ PHI http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  19. HER, HIPAA and HITECH • Purpose of the HIPAA Security Rule • Protect the confidentiality, integrity, and availability of health information • Use of encryption, access control, passwords, log files, backups to replace items after damage, and by developing security policies to handle violations when they do occur. (pages 57 – 58)

  20. EHR, HIPAA, and HITECH • HITECH Breach Notification Rule • Requires covered entities to notify affected individuals following the discovery of a breach of unsecured health information • Covered entities have specific breach notification procedures (see page 59) • Breach occurs, individuals involved must receive a notification of the breach, which includes 5 key points of information, pg 59. (pages 58 – 60)

  21. EHR, HIPAA, and HITECH • Electronic Health Care Transactions and Code Sets (TCS) (pages 60- 62) • Establish standards for the exchange of financial and administrative data • Require covered entities to use common electronic transaction methods and code sets • Four National Identifiers are for employers, healthcare providers, health plans and patients

  22. EHR, HIPAA, and HITECH • Guard against potentially fraudulent situations • Regulations have been enacted to prevent fraud and abuse in healthcare billing • OIG has the task of detecting healthcare fraud and abuse and related law enforcement • FCA prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim • FERA strengthens the provisions of the FCA (pages 63 – 66)

  23. EHR, HIPAA, and HITECH • Enforcement of HIPAA (pages 66 – 68) • Reconcile differences in enforcement procedures • Office for Civil Rights enforces HIPAA privacy standards and CMS enforces all other standards • OIG combats fraud and abuse in health insurance and healthcare delivery

  24. EHR, HIPAA, and HITECH • Compliance plans include: • Consistent written policies and procedures • Appointment of a compliance officer and committee • Training plans • Communication guidelines • Disciplinary systems • Ongoing monitoring and auditing of claim preparation • Responding to and correcting errors • A sign that the practice has made a good-faith effort to achieve compliance (pages 68 – 70)

  25. Patient Encounters and Billing InformationChapter 3 • Classifying patients as new or established • Gather accurate information from patients to perform billing and medical care • New patients (NP)are those who have not received any services form the provider within the past three years • Established patients (EP) have seen the provider within the past three years • Established patients review and update the information that is on file about them (page 78)

  26. Patient Encounters and Billing Information • Five categories of information required of new patients (pages 78 – 87) • Basic personal preregistration and scheduling information • Patient’s detailed medical history • Insurance data for the patient or guarantor • A signed and dated assignment of benefits statement by the policyholder • Signed Acknowledgement of Receipt of Notice of Privacy Practices authorizing the practice to release the patient’s PHI for TPO purposes

  27. Patient Encounters and Billing Information • Information for established patients is updated: • Patient information forms are reviewed once a year by the patient • Patients are asked to double-check their information at their encounters • The PMP is updated to reflect any changes needed (pages 87 – 89)

  28. Patient Encounters and Billing Information • Eligibility for insurance benefits: • The provider checks the patient’s information form and medical insurance card • Contacts the payer to verify the patient’s general eligibility for benefits and the amount of copayment or coinsurance that is due at the encounter • Planned encounter a covered service considered medically necessary by the payer (pages 90 – 93)

  29. Patient Encounters and Billing Information • Referral or preauthorization approval • Preauthorization is requested before a patient is given certain types of medical care • Referrals; the provider often needs to issue a referral number and a referral document in order for the patient to see a specialist under the terms of the medical insurance • Providers must handle these situations correctly to ensure that the services are covered if possible (pages 93 – 95) http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  30. Patient Encounters and Billing Information • Primary insurance for patients who have more than one health plan: • Patient information forms, insurance cards • Provider determines which policy is the primary insurance • Information entered in PMP and communication with payers are performed (pages 95 – 97)

  31. Patient Encounters and Billing Information • Encounter forms: • Lists of medical practice’s most commonly performed services and procedures and often its frequent diagnosis • Provider checks off the services and procedures a patient received, and the encounter form is then used for billing (pages 98 – 100)

  32. Patient Encounters and Billing Information • Eight types of charges collected from patients at the time of encounter: • Previous balance • Copayments • Coinsurance • Non-covered or over-limit fees • Charges of nonparticipating providers • Charges for self-pay patients • Deductibles for patients with CDHPs • Charges for supplies and copies of medical records (pages 100 -102)

  33. Patient Encounters and Billing Information • Real-time claims adjudication tools in calculating time-of-service payments • Allow the practice to view, at the time of service, what the health plan will pay for the visit and what the patient will owe • Provide valuable information and checks so that the practice and patients are aware of the expected costs and coverage • Inform or remind patients of the financial policy and give estimates of the bills they will owe (pages 102 – 105)

  34. Patient Encounters and Billing Information • Purpose of ICD-10-CM (pages 113 – 114) • Diagnostic coding • Codes made of three to seven alphanumeric characters • Addenda to codes

  35. Diagnostic Coding: ICD-10-CMChapter 3 • Organization of ICD-10-CM (pages 114 -115) • Two major parts; Tabular List & Alphabet Index • Alphabet Index: • Neoplasm Table • Table of Drugs and Chemicals • Index to External Causes • Conventions followed

  36. Diagnostic Coding:ICD-10-CM • Alphabet Index (pages 115-118) • Structure • Content • Key conventions

  37. Diagnostic Coding:CID-10-CM • Tabular List (pages 118 – 122) • Structure • Content • Key Conventions

  38. Diagnostic Coding:ICD-10-CM • ICD-10-CM Official Guidelines for Coding and Reporting (pages 123-128) • Rules for outpatient coding • Primary diagnosis first followed by current coexisting codintions • Sequelae • Code to the highest level of certainty • Code to the highest level of specificity

  39. Diagnostic Coding:ICD-10-CM • Steps for assigning correct ICD-10-CM diagnosis codes (pages 133-135) • Step 1: Review complete medical documentation • Step 2: Abstract the medical conditions form the visit documentation • Step 3: Identify the main term for each condition • Step 4: Locate the main term in the Alphabetic Index • Step 5: Verify the code in the Tabular List • Step 6: Check compliance with any applicable Official Guidelines and list codes in appropriate order http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  40. Diagnostic Coding:ICD-10-CM • Difference between ICD-9-CM and ICD-10-CM codes (pages 135-137) • 10 offers major advantages because many more categories for disease and other health-related conditions are available thus more flexibility for adding new codes in the future • Federal government has prepared GEMS to help coders transition from 9 to 10.

  41. Procedural Coding: CPT and HCPCSChapter 5 • CPT Code Set (pages 144-146) • Category I codes: procedure codes found in the main body of CPT • Category II codes: optional CPT codes that track performance measures • Category III codes: temporary codes for emerging technology, services, and procedures

  42. Procedural Coding: CPT and HCPCS • Organization of CPT (pages 146-151) • CPT Index • Six sections of Category I codes • Evaluation and Management • Anesthesia • Surgery • Radiology • Pathology and Laboratory • Medicine

  43. Procedural Coding:CPT and HCPCS • CPT format and symbols (pages 151 – 153) •  (bullet or black circle) • ▲ (triangle) • ►◄ (facing triangles) • + (plus sign) • (lightening bolt) • # (number sign)

  44. Procedural CodingCPT and HCPCS • Assigning modifiers to CPT codes (pages 153 – 156) • CPT Modifiers: Description and Common Use in Main Text Sections- Table 5.2 pg. 156 • Modifiers are shown by adding a space and the two-digit code to the CPT code

  45. Procedural Coding:CPT and HCPCS • Six steps for selecting CPT procedure codes to patient scenarios. (pages 157- 159) • Step 1: review medical documentation • Step 2: medical procedures • Step 3: identify main term for procedures • Step 4: locate main terms in CPT Index • Step 5: verify the code in CPT main text • Step 6: determine the need for modifiers http://connect.mheducation.com/connect/hmEBook.do?setTab=sectionTabs

  46. Procedural Coding:CPT and HCPCS • Using key components in selecting CPT Evaluation and Management codes (pages 159-171) • Step 1: category and subcategory of service table 5.3 page 160 • Step 2: extent of history • Step 3: extent of the examination • Step 4: complexity of medical decision making • Step 5: requirements to report the service level • Step 6: service level • Step 7: complete documentation • Step 8: assign code

  47. Procedural Coding:CPT and HCPCS • Anesthesia section of CPT Category I codes (pages 172 – 173) • Physical status modifiers • Add-on codes • P1: healthy patient • P2: mild systemic disease • P3: severe systemic disease • P4: severe systemic disease –life threatening • P5: not expected to survive without surgery • P6: Brain-dead; organ donor

  48. Procedural Coding:CPT and HCPCS • Surgery section of CPT Category I Codes • Surgical packages include all the usual services in addition to the operation itself, • Separate procedures means that the procedure is usually done as an integral part of a surgical package, but no in all situations. (pages 173 – 177)

  49. Procedural Coding:CPT and HCPCS • Radiology section of CPT Category I codes (pages 177 – 179) • Two parts: • The technical component • The professional component

  50. Procedural Coding:CPT and HCPCS • Pathology and Laboratory section of CPT Category I codes (pages 179- 180) • Code for laboratory panels are bundled codes. Example of laboratory panel would be the electrolyte panel which requires: Carbon dioxide, chloride, potassium, and sodium

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