Ch. 2 Reimbursement Processes and Tools Flashcards
What kind of department is the HIM Department
a service department
responsibility of Health Information Management
ensure claims for services are accurate and complete
Where are charges posted?
In accounts receivable (A/R)
what happens when charges are captured on the claims?
bills are dropped to A/R (moves to accounting department)
Accounts receivable
all the money that is owed to the business that they have not gotten yet.
charges posted = A/R goes up
payment recieved = A/R goes down
in A/R when is revenue is recorded?
when it is earned
after service is done but before they get money
in A/R when is cash recorded?
when they recieve the payment
discharged not final billed report (DNFB)
include all patients disharged from facility for whom billing process is not complete.
bill- hold period
3 days for bills to be finalized before it considered DNFB.
awaiting late charges, diagnosis or procedure codes, or other required info
why do coders work with physicians and CDI specialists
to avoid coding discrepancies
what depatment edits bills for missing or inaccurate links?
billing departments
Accounts Receivable Days
average # of days between discharge date & receipt of payment for service rendered
-measure success of revenue cycle
Medicare
65+ yrs or under 65 with disability
any age/person with instinct renal disease
Medicare A covers
hospital services
Medicare B covers
outpatient services
durable equipment like wheelchairs
monthly premium
Medicare C covers
advantage plans like eye, dental care
pt pays monthly premium
Medicare D covers
prescriptions
pay deductable, copay
Medicaid
low income adults, children, pregnant women, elderly, people with disabilities
Children Health Insurance Program (CHIP)
for uninsured children/family that make too much for medicaid but not enough for private insurance
Tricare
active or retired military members & families or from members that was killed
CHAMPVA
for veterns not eligible for Tricare or spouse/kids from one that was disabled from services
Indian health services
medical and public health service for federal recognized native american nations and alaska natives
Workers Compensation
medical benefit to people with work related injury or illness
Commercial Insurance
Humana
blue cross
aetna
Fee-for-Service
also known as indemnity health insurance
provider is paid after service provided/billed
issue: incentivizes quantity as doctor get paid per patient/service
-paid retrospectively
Managed Care Organizations (MCOs)
plans include provider networks, provider oversight, prescription drug tier, quality of care, resource monitoring
MCO was designed to ?
manage costs for provider and payer without sacraficing quality care
Preferred Provider Organization (PPO)
most common
large network of covered doctors/hospitals in network
patient pays less to see those “in network”
Health Maintenance Organization (HMO)
smaller selection of in network option to choose from
monthly premuims lower than PPO
patient required to have PCP
emphasis on prevantive care
Point of Service Plan (POS)
smaller network
low cost
required to have PCP
Prospective Payment System is
based on predetermined, fixed amount based on classification system for that service
used by CMS for medicare
Medicare Physician Fee Schedule
predetermined rate
reimburse provider for services covered by medicare B
RVUs
Relative Value Units (RVUs)
payment component that measure value of service compared to others
- physician work
- practice expense
- malpractice expense
uses Geographic Adjustment Factor (GAF)
Participating Providers (PAR)
doctors agreed to accept medicare,, reveive direct payment of all claims
medicare pay 80%, patient responsible for 20%
Non participating Provider (nonPAR)
have not agreed to accept assignment of claims
may accept on claim by claim basis
limiting charge, reduction of 5% allowable charge
Goal of Accountable Care Organization (ACOs)
improve quality of patient care, lower cost, enable all cities to have access to affordable care
anyone without health insurace qualifies for ACO
Characteristics of ACOs
-not a health insurance plan
-manage patient across continuum of care
-prospectively plan budget and resource needs
-big enough to support comprehensive,valid, reliable measurement of performance
Preadmission Review
prior authorization or pre certification required by some insurance plans before patient admitted for non emergency procedure/service
Utilization Review
preadmission, looking for medical necessity before patient admitted, entire time in hospital (concurrent), after discharge (retrospectively)
Case Management
group of people like social workers , to plan out and make sure resources being used properly
improve quality care while reducing cost
Encoder software
uses algorithim that mimic a tree
can not rely on its own as it can lead to wrong conclusion
Computer Assisted Coding (CAC)
incorporate AI into coding
cannot replace human coding as it is a lot less logical
CAC software - Natural language processing (NLP)
read electronic health record, pull out keyword and phrases in order to predict what code to use
logic based and knowledge based systems
based on rules - logic based software
uses keyword search tools- knowlege based
deep learning systems
act as a coding assistant to the medical coder
learn and adapt by looking at patterns
Benefits and features of CAC application
-coding professional learn ICD-10 more quickly with repetition
-accuracy can be studied retrospectively
-increased efficiency
-return on investment achieved
