Ch 3 Patient Access

Question 1

Describe the primary functions and responsibilities of Patient Access / Front Office related to:

Answer 1

1 - Scheduling
2 - Preadmission and preregistration
3 - Precertification and preauthorization
4 - Registration and admission
5 - Insurance verification
6 - Financial counseling
7 - Collection
8 - Compliance

Question 2

Which departments many responsibilities have a direct impact on patient satisfaction and the success of the Revenue Cycle

Answer 2

Patient Access / Front Office

Question 3

What are the responsibilities of the Patient Access / Front Office

Answer 3

1 - Creating a permanent patient medical record
2 - ensuring the accuracy of the patient account record
3 - collecting the necessary information to produce a clean claim

Question 4

What is the primary duty of the Front Office personnel, resistors?

Answer 4

To act as a liaison between physician and patient.

Question 5

Why is the front office staff critical?

Answer 5

We are vital in many areas of the Revenue cycle - from billing collections to quality patient care

Question 6

What are some of the improvements in the patient access process PAP from the continuous changes to expand a patient-centered focus ?

Answer 6

1 - Placing the focus on customer service to improve the initial patient impression
2 - Training staff to improve point of service collections and protect the patient’s financial health
3 - Ensuring that the admitting staff is well educated and can answer questions accurately
4 - Identifying ways to decrease wait times
Preregistering patients whenever possible
5 - Making the process a positive experience for the patient/ guarantor/family

Question 7

What are the three areas of the scheduling process that need to be balanced to create an idea experience?

Answer 7

1 - Patient satisfaction
2 - Collection of financial information, demographic information, and insurance information
3 - Clinical services

Question 8

What is the one area of the PAP - (patient access process) that will make the collections process a success?

Answer 8

A strong preadmission/preregistration system

Question 9

What is gathered during the preadmission/preregistration process?

Answer 9

1 -Patient demographics (name, address, date of birth, Social Security number, etc.)
2 - Financial information
3 - Socioeconomic information

Question 10

Patient Complaints should be reduced with the implementation of a preregistration process because….

Answer 10

1 - Financial planning and counseling can be done in advance of the service.
2 - Patients are familiarized with the admission process.
3 - Special needs can be identified and accommodated.
4 - Patients are more prepared and less anxious.
5 - Admission time is reduced.

Question 11

What other element may be address in this preadmission process?

Answer 11

This is where/when preadmission/service testing can be addressed.
Diagnostic Medical testing may be done in advance of surgical or invasive procedures to determine hospitalization / suitability

Question 12

What is obtained during the Precertification process

Answer 12

Authorization to treat and auth for an average length of stay/ number of services allowed for patients condition is obtained from insurance company review organization approving the medical necessity of the service

Question 13

One benefit of preauth/precert

Answer 13

It helps determin the financial risks and builds rapport

Question 14

What could be the result of not getting Preauthorization

Answer 14

1 - Billing delayed while getting retroactive auth and medical records
2 - Could result in total denial of claims
which would - increases i appeals,, time spent by billing staff .
and/or lost revenue

Question 15

What are some of the things that should be obtained at the time the appointment is made?

Answer 15

1 - Emergent or non-emergent status
2 New or established patient status (A new patient is one who has not received any professional services from that physician or any physician in a group practice within the past three years.)
3 Purpose of appointment
4 Physician preference (if multiple-physician facility)
5 Name and telephone number of patient for daytime contact
6 Patient demographics
7 Name of referring physician, if applicable
8 Name of family physician / primary care physician (PCP or the “gatekeeper”)
9 Patient insurance information (including subscriber date of birth, ID, etc.)
10 Third-party payer involvement
11 Guarantor demographics

Question 16

Other items that may be collected

Answer 16

1 Pulling charts and preparing fee tickets
2 Obtaining referrals for visits
3 Obtaining preauthorization to see if a patient’s insurance will cover a specific procedure

Question 17

Three responsibilities of the patient acess

Answer 17

1 - Timely, courteous and accurate registration
2 - Initiating the permanent patient medical record for the stay
3 Creating the patient account for the treatment/condition
4 Ensuring the accuracy of the patient account record
5 Collecting basic data (demographics, clinical information, financial information, socioeconomics, etc.)
6 Verifying insurance
7 Collecting valuables
8 Offering “guest services”

Question 18

Greeting and checking the patient in, including

Answer 18

1 Verifying patient information again
2 Making a copy of the current insurance card
3 Collecting patient copayments

Question 19

Obtaining information for the patient information form, including:

Answer 19

1 Name, address, and home telephone number
2 Gender
3 Date of birth and Social Security number
4 Primary and secondary insurance information
5 Subscriber information
6 Occupation and employer information
7 Guarantor information
8 Emergency contact’s name, address, and phone number
9 Name and telephone number of individual/group referring patient
11 Complaint/diagnosis
12 Indication of work-related illness or injury

Question 20

Material distribution at check -in inckude?

Answer 20

1 - HIPPA privacy notice
2 - PCP / Bill of rights

Question 21

Check out procedure includes

Answer 21

1 Scheduling the next appointment
2 Collecting financial obligations
3 Completing requisitions for ordered tests (such as laboratory and x-ray)
4 Scheduling tests (such as CT scan, etc.) that do not require preauthorizations
5 Obtaining patient signatures (such as medical records release, authorization for special medication or procedure, etc.)

Question 22

Maintaining patient charts include

Answer 22

1 Filing of medical records
2 Processing medical records requests
3 Making sure any outside records are scanned into the facility’s electronic medical records

Question 23

What are the tasks that must be done during or after the appointment?

Answer 23

1 - Greeting and checking the patient in
2 - Obtaining information for the patient information form,
3 - Distributing required materials, signing forms,
4 - Checking the patient out
5 - Maintaining patient charts
6 Verifying insurance eligibility
7 - Adhering to privacy requirements

Question 24

What is the reason for insurance verification

Answer 24

It will eliminate delays in reimbursement

Question 25

What questions should be asked

Answer 25

1. Is precertification required? Has it been obtained? 2. Is a second surgical opinion required? Is one on file? 3. Are benefits available for the diagnosis? 4. What is the deductible amount and has any portion of it been met? 5. What is the coinsurance amount and how much remains? 6. Is there an out-of-pocket limit and, if so, how much? 7. What is the address to submit claims? 8. Will the claim be adjudicated by a third-party administrator (TPA)? 9. Will the TPA release the check, or will that be handled by the insurance carrier office? 10. If liability case, what is the name of the insurance adjuster, if one is assigned?

Question 26

What questions should be asked 8 more

Answer 26

11. What is the telephone number of the claims office? 12. What is the approved maximum number of days for the diagnosis? 13. What is the daily room and board allowance? 14. Does the policy contain a provision for private accommodations? 15. Who is the policyholder? 16. What is the correct spelling of the name? What is the identification number? Who is the employer? 17. Does the carrier list additional third-party resources in its files? 18. Are there coverage limitations for diagnostic laboratory, radiology, ambulatory surgery, or rehabilitative services?

Question 27

What important tasks are typically included in the financial counseling process?

Answer 27

1 Obtain and verify the demographic detail of the patient. 2 Obtain basic financial information for the responsible party. 3 Establish the ability to pay and initiate applications for eligibility i financial assistance programs if the patient expresses the need. 4 Obtain all information regarding third-party resources. 5 Verify the benefits available through insurance sources. 6 Notify the responsible party of his or her financial obligation. 7 Request payment in full of the patient's estimated responsibility. 8 Establish payment arrangements, if necessary. 9 Complete all preadmission/service paperwork so that the patient’s experience is positive and not stressful.

Question 28

What Hospital tasks are added to the Financial Counseling

Answer 28

1 Explain the hospital collection policy to the patient or responsible party 2 Calculate the patient's estimated responsibility

Question 29

Calculating the patients estimate responsibility is based on?

Answer 29

1 The average length of stay (ALOS) for the diagnosis 2 The average cost per day by type of service (medical vs. surgical) 3 The admitting physician's estimated length of stay 4 The average cost of the outpatient procedure being performed 5 The hospital's flat rate procedures / diagnosis-related group (DRG) / Contractual Payer Allowance 6 The daily room charge by type (ICU, CCU, semi-private) 7 Patient third-party insurance plan benefit levels

Question 30

What is included in a good preadmission/service and Preregistration process?

Answer 30

1 - determining the estimated patient portion for services 2 - informing patients so they can bring their payment at time of service

Question 31

T or F Patients are more likely to pay their estimated portion before or at the time of service than after insurance adjudicates the claim and pays the provider

Answer 31

T

Question 32

T or F The informing patient of his portion to be paid at TOS is the best type of POS (point of service) collection is the only cost-effective way to collect small-dollar copayments

Answer 32

T

Question 33

T or F It is not permissible to ask if patients know whether they have met their deductible nor is it permissible to ask for total due for services provided that day,

Answer 33

F you may ask or call insurance co for verification AND you MAY request total due at TOS

Question 34

Five collection control points for facility (hospital) are

Answer 34

1. Preadmission 2. Admission 3. In-house 4. At discharge 5. After discharge

Question 35

Five collection control points for provider practice (clinic) are

Answer 35

1. Preservice 2. Time of service 3. In-house 4. At checkout 5. Post service

Question 36

What is a deposit

Answer 36

the estimated portion of the patient’s bill not covered by insurance

Question 37

When may payments be made, and how?

Answer 37

Payments can be collected prior to admission, at admission, or at discharge - Payment can be made in one installment or financed over time

Question 38

what is an advantage of a deposit collection program, when combined with a good preregistration and insurance verification program?

Answer 38

1 Increased hospital cash collections 2 Reduced amount due at discharge 3 Reduced overall accounts receivable 4 Reduced financial risk and bad debt

Question 39

What are the disadvantages of the deposit collection program ?

Answer 39

possibility of creating a public relations issue between the hospital and the doctor, the patient and the hospital, or the patient and the doctor.

Question 40

What is the compliance plan what does it do?

Answer 40

25. The compliance plan serves to prevent, identify, and remedy instances of fraud or abuse or other unacceptable conduct

Question 41

T or F Patient Patient Access does not have a key role in a compliant billing process.

Answer 41

F Patient Access has a key role in a compliant billing process.

Question 42

Why does the Patient Access have a key role in the compliant billing?

Answer 42

The information entered during registration affects many other areas, and much of the data appears on the claim. Incorrect demographics can lead to fraudulent or abusive bills.

Question 43

What are some important document that are example of compliance documents

Answer 43

1 Important Message from Medicare (Hospital) 2 Medicare Outpatient Observation Notice (MOON) 3 Guarantor forms 4 Advance Beneficiary Notice of Noncoverage (ABN) 5 Hospital Issued Notice of Noncoverage (HINN) (Hospital)

Question 44

T or F Patient Access is responsible for handling the Important Message from Medicare that hospitals are required to give to all Medicare and Medicare Advantage beneficiaries who are hospital inpatients

Answer 44

T

Question 45

When is the Message from Medicare required to be issued? (hospital)

Answer 45

This notice is required to be issued within two days of admission and again within two days of discharge.

Question 46

NOTICE Acronym

Answer 46

Notice of Observation Treatment and Implication for Care Eligibility

Question 47

What does the NOTICE Act require

Answer 47

Act requires that hospitals must inform patients who are hospitalized for more than 24 hours if they are in observation status. No later than 36 hours after a patient begins to receive observation services, the patient must be informed,

Question 48

MOON

Answer 48

Medicare Outpatient Observation Notice (MOON)

Question 49

How is the MOON notice to be given?

Answer 49

Both orally and in writing, of his or her observation status.

Question 50

What is MOON when is it needed

Answer 50

is a standardized notice developed to inform beneficiaries (including Medicare health plan enrollees) when they are an outpatient receiving observation services and when they are not an inpatient of the hospital or critical access hospital (CAH).

Question 51

Is MOON used for inpatient?

Answer 51

NO - outpatient

Question 52

What status must the patient be in to use the MOON

Answer 52

Observation services

Question 53

What plan of Medicare is the MOON used for Patients with Medicare A or B or both

Answer 53

Patients who do not have Plan B

Question 54

What is covered in Medicare Plan B

Answer 54

Medicare Part B is the medical insurance portion of Original Medicare, covering doctors' services, outpatient care, and some preventive services.

Question 55

T or F You must have Medicare Plan A to be eligible to get plan B

Answer 55

T

Question 56

Which Medicare plan covers the Observation stays

Answer 56

Plan B that's why the MOON is used when patients do not have plan B coverage

Question 57

Per Medicare Claims Processing Manual, The MOON also applies to:

Answer 57

1 Beneficiaries who do not have Part B coverage 2 Beneficiaries who are subsequently admitted as an inpatient prior to the required delivery of the MOON 3 Beneficiaries for whom Medicare is either the primary or secondary payer

Question 58

When does the MOON apply

Answer 58

The MOON applies to Medicare Part A and Medicare Advantage plans, as well as patients in Psychiatric and Critical Access Hospitals.

Question 59

What happens when a beneficiary refuses to sign a MOON and there is no representative to sign on behalf of beneficiary?

Answer 59

1 notice must be signed by the staff member of the hospital or CAH who presented the written notification 2 The signature of the staff member must include the name and title of the staff member 3 a certification that the notification was presented. 4 the date and time the notification was presented 5 The staff member then must annotate the Additional Information section of the MOON to include the staff member’s signature and certification of delivery. 6 The date and time of refusal is considered to be the date of notice receipt

Question 60

What is the ABN and when is it used?

Answer 60

Advanced Beneficiary Notice of Noncoverage. It can be use to avoid having to write off claims that Medicare deems not "reasonable and necessary"

Question 61

What should the ABN contain:

Answer 61

1 The description of the service 2 estimated cost 3 the reason the service is not expected to be covered

Question 62

T or F The ABN signed by patient serves as proof that the beneficiary was aware prior to receiving the service that Medicare may not pay

Answer 62

T

Question 63

What happens if the ABN is not signed prior to the services being rendered?

Answer 63

Patient can not be billed for what Medicare refuses to pay and the provider/facility is financially liable.

Question 64

What decoration does this ABN support

Answer 64

This supports Medicare’s rule that a beneficiary is not protected from financial liability of a noncovered service if that person had knowledge or should have had knowledge of the noncoverage

Question 65

T or F An ABN is also known as a notice of noncoverage. Entities that issue ABNs are known by CMS as “notifiers.”

Answer 65

T

Question 66

How are provider notified if a procedure is not going to be covered?

Answer 66

Many providers use software to enter procedure and diagnosis codes to determine if a service might not be medically necessary; the software then prints an ABN ready for signature when applicable,

Question 67

Is it appropriate to use an ABN in the ED? Why

Answer 67

No, Care in the ED is deemed medically necessary

Question 68

Why would it be inappropriate to not use an ABN in th eED

Answer 68

it is also inappropriate to just write off all noncovered services in the ER or other departments, as this could be construed as an inducement and would be against CMS rules.

Question 69

What is a triggered Event?

Answer 69

Providers are required to issue an ABN when an item or service is expected to be denied based on any provision in the mandatory use section of the ABN.

Question 70

When may a triggered event occur

Answer 70

A triggered event can occur during initiation, reduction, or termination during the course of treatment.

Question 71

When does Initiation occur?

Answer 71

can occur during initiation, reduction, or termination during the course of treatment

Question 72

When does Reduction of a triggered event occur?

Answer 72

Reduction occurs when the frequency or duration of care is decreased. This doesn’t mean that an ABN is issued every time that a service is reduced, but if reduction occurs and the beneficiary wants to continue to receive care that is no longer considered medically necessary, the ABN must be signed prior to receiving the continued care.

Question 73

When does Termination of a triggered event occur?

Answer 73

Termination of a triggering event occurs when there is a discontinuation in the services being provided. The ABN is only issued to the beneficiary at the termination of the care if the beneficiary elects to continue treatment that Medicare deems is no longer reasonable or necessary.

Question 74

T or F A beneficiary should NOT be given an ABN unless there is genuine doubt of Medicare payment. (For example, an ABN is required for lab tests associated with routine physical.

Answer 74

T

Question 75

T or F ABN should be given to a beneficiary in an ER room prior to being stabilized.

Answer 75

F

Question 76

Per CMS, how long must ah ABN be retained from discharge or the completion of the care, provided that there are no other applicable requirements which fall under state-specific law.

Answer 76

for 5 years regardless if the beneficiary refused the care, refused to select an ABN option, or refused to sign the notice. Electronic versions of the document are acceptable