Lec 6: Language Of Payment/Coding/Billing Flashcards
Assignment of Benefits:
Payment of medical benefits DIRECTLY to the provider rather than the member/subscriber, requires written release
Authorization:
Gatekeeper/primary care provider approval for hospitalization or care
Balance Billing:
The administrative practice of holding the pt financially responsible for the remainder of medical service charges, beyond the insurer’s allowed amount.
Does not apply when a managed care contract contains a “hold harmless” clause
Cost sharing:
Patient responsible for portion or % of total charge
Methodology to reduce utilization
Denial:
Refusal by insurer to reimburse services that have been rendered
Can be for various reasons
Explanation of Benefits (EOB)
Insurer-provided description of provider services and explanation of those covered and denied
Policyholder:
Purchaser of an insurance policy
In group health insurance, this is usually the employer who purchases policy coverage for its employees
Pre-authorization:
Insurance company review of care before delivery to establish appropriateness of payment
Pre-existing condition:
Physical or mental condition of patient occurring before start of insurance coverage
Profiling:
Data collection by insurers on billing and utilization by providers
What is needed to get paid for professional services?
Professional license Business structure Services available Price list Business policies (registration and verification of info) Reimbursement contracts, arrangement Charge system Billing processes Accounting procedures Collection procedures Documentation system
PT relationship with payers: Cultivate a reputation for _________, appropriate documentation (payers track this information)
QUALITY care
Office staff relationship with payers:
Phone courtesy
Competence
Reliability
What does the client admissions process include?
Medical record
Business account
Authorizations/consents
Client Admissions Process: What is included in medical record ?
Demographics
Patient record
Client Admissions Process: What is included in business account?
Payment info
Client Admissions Process: What is included in authorizations/consents
Informed consent
Confidentiality/HIPAA
Assignment of benefits
AOB: A patient’s voluntary signed agreement to a provision such as “I hereby request assignment of payment of all insurance benefits to the ___________”
Provider of service
AOB: The provider then directly submits the claim to the ______
Payer
AOB: Provider must typically be __________
participating
AOB: Alternative- patient pays for service and submits for reimbursement from _______
Insurer
Billing for services: Bills submitted to patient or third party payer, or provided to __________ to prepare bills
Claims clearinghouse
Billing for services: most billing is now ______
Electronic
Billing for services: there is an importance of _______
CLEAN CLAIMS
Fee Determination: A provider must know their ______ in order to determine _____
Costs
Fees
Fee determination: Basing charges on ______ plus reasonable profit avoid ________________
COST
Anticompetitive pricing issues
Fee determination: A single fee schedule with fee discounts based on policy and arrangements with payers is more _________ than multiple fee schedules
Defensible
Claim submission: Must verify 4 things
Patient info
Person responsible for bill
Insurance info, including primary and secondary
Coordination of benefits
Coordination of benefits: Generic term for situations where the patient have have coverages under _________
More than one insurance plan
Coordination of benefits: Health Vs. Liability insurer:
Primary pay or may be decided by liability (workers comp or auto)
Coordination of benefits: Medicare patients with supplemental coverage – A medicare patient may have supplemental coverage, either ______ or _______
Medical insurance
Medicaid
Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE:
In adults, each spouse’s employee health insurance is the primary payer for his/her care; spouse’s family coverage is _______
Secondary
Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE: With children, if one parent has family coverage and the other only individual coverage, then the _________ is the only payer
Family coverage
Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE: If both have family coverage, most states use the ______
Birthday rule
The insurance of the parent with the bday earlier in the calendar year pays first
