Encounter, Billing, and Revenue Cycle Flashcards
Capitation
Payment method of an HMO in which a contractually fixed payment paid by the payer covers the provider’s services to a plan member for a specified period
What are the two types of insurance plans?
Indemnity Plan and Managed Care Plans
Indemnity Plan
Type of medical insurance that provides the freedom to choose the providers and hospitals you want to attend and reimburses a policyholder for medical services under the terms of its schedule of benefits; may require you to pay upfront and then submit a claim for reimbursement
Managed Care Plan
a plan that has contracts with various healthcare providers and medical facilities and members must see one of these in-network providers to avoid higher fees; premiums and deductibles are lower
Types of Managed Care Plans
Health maintenance organizations (HMOs)
Point-of-service plans
Preferred Provider organizations (PPOs)
Consumer-driven health plans
Health Maintenance Organizations (HMO plans)
an MCO that agrees to offer healthcare to members for fixed periodic payments from the plan to the provider; members must have a PCP and receive referrals for specialists; regulated by the state to provide certain services to members and dependants, such as preventative care
Point-of-Service (POS) plan, or Open HMO
Payment method of an HMO which reduces restrictions and allows members to choose providers who are out of network; Typically, the patient must pay 20 to 30% of the charge for out-of-network service, and the deductible can be very high. The HMO pays out-of-network providers on a fee-for-service basis.
Preferred Provider Organizations (PPO)
an MCO that is structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge
Consumer-driven Health Plan (CDHP)
an MCO that combines a high deductible with low premiums and a medical savings plan that covers some out-of-pocket expenses; the idea that patients who themselves pay for healthcare services become more careful consumers and believe that asking patients to pay a larger portion of medical expenses reduces costs
Private Payers
A small number of large insurance companies dominate the national market and offer all types of health plans. There are also several nonprofit organizations
Emergency Medical Treatment and Active Labor Act (EMTALA)
hospital emergency departments must provide care for all patients in need of medical services, regardless of their ability to pay
Self-funded Health Plans
Rather than paying premiums to an insurance carrier, the organization “insures self”. It assumes the risk of paying directly for medical services and sets up a fund from which it pays for claims. Most are set up as PPOs; fewer than 10% are set up as HMOs.
Government-Sponsored Healthcare Plans
Medicare - covers people who are 65 and over and those who, regardless of age, are disabled or have permanent kidney failure
Medicaid - jointly funded by federal and state governments and covers low-income people who cannot afford medical care
TRICARE - covers active duty members of the Uniformed Services and their spouses children and other dependents, retired military personnel and their dependents, and family members of deceased active duty personnel.
CHAMPVA - covers the spouses and dependents of veterans with permanent service-related disabilities, and spouses and dependent children of veterans who died from service-related disabilities
10 Steps of the Revenue Cycle
Before the Encounter
1. Preregister patients
During the Encounter
2. Establish financial responsibility
3. Check in patients
4. Review coding compliance
5. Review billing compliance
6. Check out patients
After the Encounter
7. Prepare and transmit claims
8. Monitor payer adjudication
9. Generate patient statements
10. Follow-up payments and collections
HIPAA 270
transaction to determine if a patient or service is covered by their health insurance plan; can also be used to inquire about Medicare eligibility
Advanced Beneficiary Notice (ABN)
forms the patient must sign to prove that patients have been told about their obligation to pay the bill before uncovered services are given
Preauthorization
process to determine coverage for medical services; focuses on the medical necessity of a service or treatment
Precertification
process to confirm coverage for certain healthcare services or procedures before they are performed
X12 278
HIPAA Referral Certification and Authorization; a referral document that describes the services the patient is certified to receive (referral)
Referral Waiver
Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending (eg, patient for got to bring in the referral)
Coordination of benefits (COB)
A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim
Birthday Rule
The guideline that determines which of two parents with medical coverage has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary
Gender Rule
Coordination of benefits rule for a child insured under both parents’ plans under which the father’s insurance is primary (less common, but some states have regulations that require a plan that uses this rule)
COB Guidelines for a child of divorced parents
Joint custody - Birthday Rule applies
Sole custody (unless otherwise directed by a court order) 1) The plan of the custodial parent; 2) The plan of the spouse of the custodial parent, if the parent is remarried; 3) The plan of the parent without custody
Encounter Form
Lists the medical practices most frequently performed procedures with their procedure codes which must be updated as new codes are released; superbill, charge slip, routing slip
Acceptance of assignment
A participating physician’s agreement to accept the insurance plan’s allowed charge as payment in full
Claims form even non-PAR providers must still submit as a courtesy
Even these providers file Medicare forms as a courtesy
Collections made at the time of service
Previous balances
Co-payments
Coinsurance
Non-covered or over-limit fees
Charges of non-participating providers
Charges for self-pay patients
Deductibles for patients with CDHPs
Real-Time Adjudication
An insurance claim processed at patient check-out; allows the practice to know what the patient will owe for the visit
1) Informs the practice if there are any errors in the claim so they can be fixed and the claim immediately resent for adjudication
2) States whether the patient has met the plan’s deductible
3) Provides the patient’s financial responsibility
4) Supplies an explanation of benefits
CCOF
Credit Card on File
Upcoding
The code does not reflect the actual procedure provided
Intentional - fraud
Unintentional - abuse
Downcoding
Payer reduces level of procedure
Unbundling Codes
Incorrect billing practice
Instead of one CPT code for a package of codes, two or three codes are used
MUEs
Medically Unlikely Edits
CMS unit of service edits that check for clerical or software-based coding or billing errors, such as anatomically-related mistakes
Code Linkage
Connection between service and condition/illness; indicates why the service was provided
Allowed charge
Maximum amount that a health plan will pay
Maximum Allowable Fee, Maximum charge, Allowed amount, Allowed Fee
Balance Billing
Difference between fee and allowed amount; NonPAR may be allowed to charge the patient
Write Off
Difference between amount charged and amount allowed; the difference is deducted from the patient’s account; due to payer agreement to accept allowed amount as payment in full
Adjustment
Change in a patient’s account whether it is pos or neg
Compliant Billing
Correct claims report the connection between a billed service and a diagnosis
OIG’s LEIE
Office of the Inspector General’s List of Excluded Individuals/Entities
Individuals or companies that, because of reasons bearing on professional competence, professional performance, or financial integrity, are not permitted by OIG to participate in any federal healthcare programs
CCI
Correct Coding Initiative
Medicare’s national and local coverage and payment policies; private payers develop code that is similar to those of the CCI
Compliance Errors
Healthcare payers often base their decisions to pay or deny claims only on the diagnosis and procedure codes; Errors relating to code linkage and medical necessity
Truncated Coding
Using diagnosis codes that are not as specific as possible
Assumption Coding
Reporting items or services that are not actually documented but that the coder assumes were performed
Global Period
a period of time starting with a surgical procedure and ending some period of time after the procedure
Unrelated work during the global period
visits during a post-operative period that are not related to the patient’s surgical procedures are billable, use modifier 79 to indicate the situation
Global period for minor procedures
their preoperative is just the day of the procedure; post-operative period is 0 or 10 days
Global period for major procedures
a one-day preoperative with a 90-day postoperative
