6) Coding, Billing, and Payment Flashcards
Assignment of Benefits
Payment of medical benefits directly to the provider instead of the member/subscriber
- Requires written release
- Provider needs to sign off on this if they’re going to bill insurance
Authorization
Gatekeeper/PCP approval for medical care or hospitalization
Balance Billing
Administrative practice of holding the pt financially responsible for the remained of medical service charges, beyond the insurer’s allowed amount
Does balance billing apply when a managed care contract contains a “hold harmless” clause
No
Cost Sharing
Methodology to decr utilization where the pt is responsible for a portion/percentage of the total charge
Denial
Refusal by insurer to reimburse for services that have already been done
- Insurance company has to provide a rationale for a denial
- Obviously bad for the provider bc then they don’t get paid
Explanation of Benefits (EOB)
Insurer-provided description of provided services with an explanation of those covered and those that were denied
Policyholder
Purchaser of an insurance policy
Pre-Authorization
Insurance company reviews the care that will be provided to establish appropriateness of payment/decide if they’re going to pay for it
- Seeing a pt prior to getting the pre-authorization is a risk for the provider
Pre-Existing Condition
Condition that occurs prior to the start of insurance coverage
Profiling
Insurance company collects data on provider’s utilization and billing
- Compares your trends to other providers
What are the basic things that providers need to get paid for services?
- Professional License
- Business Structure
- Services Available
- Business Policies
- Price List
- Charge System
- Billing Processes
- Reimbursement Contracts
- Accounting Procedures
- Collection Procedures
- Documentation System
When interacting with insurance companies, how should office staff act?
- Courteous
- Competent
- Reliable
What three authorizations/consents are needed to tx a pt?
- Informed consent
- HIPPA
- Assignment of Benefits
What is the one and only format informed consent can be in?
Written
If there’s no assignment of benefits, what is the alternative?
Pt pays for services and submits to their insurance for reimbursement
What does “clean claims” apply to and why is it important?
- Billing
- Important bc we need to make sure our documentation is clear→ If they’re not, it can hold up the process and you need $ to keep your practice runnning
Are providers allowed to look at other provider’s costs to help them decide what they want to charge and why?
No → It’s anti-trust
On a claim submission, what needs to be verified?
- Pt info
- Person responsible for bill
- Insurance info
- Coordination of Benefits
Coordination of Benefits
Generic term for situations where the pt may have coverages under >1 insurance plan
True or False: Providers are obligated from collecting copayments from pt’s. Explain.
True → If they don’t its fraudulent because then the pt isn’t contributing and then it says to the insurance company that the services can be provided for less
Medicare Advanced Beneficiary Notice (ABN)
Signed by Medicare pt’s when a service is not going to be covered or not medically necessary
National Provider Identifier (NPI)
10-digit ID code that can be used to track a provider t/o their career
- Purpose is to further streamline electronic claims processes already in place
- Must be put on claim forms when submitted to insurance
Describe how the out-of-network model works
- Provider has limited insurance contracts
- Provider collects payment directly from pt’s at the time of service and gives them an itemized bill which they can submit to their insurance
- Provider can also submit to their insurance on their behalf
Describe the cash practice model
- Provider has no insurance contracts
- PT’s are not allowed to opt out of Medicare!
- Pt’s pay in full at time of service OR insurance is billed directly and the pt has to pay the difference
- Typically comes w/higher pt cost-sharing
Diagnosis Billing Codes
When billing for services provided by a PT, the medical dx needs to be stated (ICD-10)
Intervention Billing Codes
CPT-4 Codes
What is the purpose of CPT codes?
Simplified communication
Who “owns”CPT codes?
AMA
Why did the APTA start billing based on pt-complexity?
So PT’s would be paid more for tx’ing complex pt’s
How long is each unit of billing?
15 minutes
What is the deal with billing for supervised modalities?
They don’t require direct one-on-one supervision so they can only be billed once per visit
What’s the deal with billing for “constant attendance modalities”?
Require that a provider have direct one-on-one contact w/the pt (can’t walk away from pt) for all minutes represented by billing
CMS 8-Minute Rule
Anything done for <8minutes isn’t billable
- The 1st unit is anywhere from 8-23minutes and incr in 15min increments
- 8/23/38/53/68/83
- If you’re doing 3 codes for 30min, bill for the code w/the highest time
Group Therapy Code
Used when care is provided to >1 pt at the same time
How many units will medicare pay for?
4 15-minute units in 1hr
Modifiers
Incr specificity of CPT codes
Corrective Coding Initiative
Corrects coding methodologies to eliminate improper unbundling of services for Medicare Part B claims
Code Pair Edit
Combo of 2 CPT codes that can’t be billed together
- Happens when:
- Code pair is for services that are mutually exclusive
- 1 code of the pair is considered a component of another more comprehensive code
- Reimbursement will occur for only 1 code and the prohibited code will be reported the provider
