Module 15: Administrative Assisting Flashcards
Schedule Matrix
Flat, two-dimensional table that shows relationships between dates, activities, and human resources which are planned ahead by an associate schedule
Wave scheduling
Allows three patients to be scheduled at the same time, to be seen in the order in which they arrive. Allows one patient arriving late to not disrupt the provider’s schedule
Modified wave scheduling
Allocates two patients to arrive at a specified time and the third to arrive approximately 30 minutes later. Sequence is continuous throughout the day
Double-booking
Two patients are scheduled at the same time to see the same provider. Used to work in a patient with an acute illness when no other time is available. Creates delays in the provider’s schedule that continues through the rest of the day
Information necessary to schedule an internal appointment with an established patient
Name, DOB, reason for visit, time the patient and provider will need for the visit, preference for day of the week or time
Notice of privacy practice
HIPPA mandated, describes how your medical information may be used and disclosed
Purpose of documenting cancellations and no-shows
To protect the provider from legal action and demonstrate noncompliance
Filing systems: conditioning
grouping related papers together, removing all paper clips and staples, attaching smaller papers to regular sheets, and fixing damaged recrods
Filing systems: releasing
marking the form to be filed with a mark of designated preference (ready to be filed, provider’s initials, using a stamp)
Filing systems: indexing and coding
determining where to place the original record in the file and whether it needs to be cross referenced in another section
Filing systems: sorting
ordering papers in a filing structure and placing the documents in specific groups
Filing systems: storing and filing
Securing documents permanently in the file to ensure medical record documents do not become misplaced
Filing systems: alphabetic filing
Files are arranged by last name, first name, and middle initial
Filing systems: numeric filing
Typically combined with color coding, used for larger health centers or hospitals. Allows for unlimited expansion without the need to shift files to create room. Saves time for retrieving and filing charts and provides additional patient confidentiality
Filing systems: subject filing
Used for general correspondence using the alphabetic or alphanumeric filing method. All correspondence dealing with a particular subject is placed under a specific tab with subject headings
Legal requirements maintenance, storage, destruction of medical records
Charts should never leave the office.
Transcription should be processed in a timely manner, documents that have yet to be filed should be locked away at closing.
Prescription pads should be kept in a locked, tamper-proof safe.
Any patient covered by medicare or medicaid must have their records retained for a minimum of 10 years.
HIPPA does not require a specific method for disposal, but it should be professional and confidential document destruction service
CPOE
Computerized physician order entry. Created to improve the safety of medication orders, but now allows providers to digitally order laboratory and radiology testing, treatments, referrals, and prescriptions
How to handle requests for medical records
All requests need to be provided in writing and release filed into patient’s chart.
The patients attorney, mediator, etc. must obtain approval from the patient, unless a legal power of attorney document authorizes otherwise
Copay
Specified sum of money based on the patient’s insurance policy benefits at the time of service
Coinsurance
An amount a policyholder is financially responsible for according to their insurance. Ex: Must meet a specified deductible amount before the medical insurance company will contribute their portion. Typically 80/20 ratio
Deductibles
Specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying for services
Explanation of benefits
Provided to the patient by the insurance company as a statement detailing what services were paid, denied, or reduced in payment. Also explains amounts applied to deductible, coinsurance, or allowed amounts.
Sent to the patient after the claim has been processed
Remittance advice
Explanation of benefits sent to the provider from the insurance carrier, includes electronic fund transfer information. Used to post payments to patient accounts
Advance beneficiary notice
Form a medicare patient will sign when the provider thinks Medicare might not pay for a specific service or item. An official payment decision is made and a Medicare Summary Notice sent to the patient with an explanation for noncoverage; expectation that the patient will have to pay for services
Federal policy insurance plans
Tricare (military and dependents).
Medicaid is funded by those who meet specific criteria
Medicare is for those 65 and older or the disabled
Workers comp is a state law that protects employees against the cost of work-related injury
Private policy insurance plan
Include group policies offered through employer, individual policies are those that an individual funds themselves. Patients might pay entire premium themselves if self-employed
Information needed to verify insurance
Patient’s full name, DOB, Policy number, SS number (depending)
Indigent program
charity care programs that offer free or low-cost treatment for those who can’t pay
ICD-10-CM vs ICD-10-PCS
ICD-10-PCS is for procedural codes in hospital settings, while ICD-10-CM is for procedure codes in clinical and outpatient settings.
ICD-10 codes represent patient diagnoses
CPT codes and modifiers
Current Procedural Terminology codes and modifiers are used to document procedures and technical services based on services by providers in outpatient settings.
All information in medical record must be accurate.
CPT codes identify services rendered rather than patient diagnoses
HCPCS codes
Healthcare Common Procedure Coding System is a group of codes and descriptions that represent procedures, supplies, products, and services not covered or included to the CPT coding system.
Updated every year like CPT codes.
Designed to enhance uniform reporting and collection of statistical date on medical supplies, products, services, and procedures. Typically used for Medicare and Medicaid insurance plans
Forms used to obtain information necessary to send out claim
Patient encounter form, treatment or progress notes, history and physical exam notes, discharge summaries; operative report or pathology report if surgery or lab services
CMS-1500 form requirements, responsibilities of a medical assistant (billing)
1) All new patients need to fill out a registration form with demographic and insurance information.
Insurance information needs to be verified for eligibility and specific requirements.
2) Determine whether patient requires an authorization or referral from the insurance carrier.
3) Review patient medical records for accurate documentation for the visit.
4) Encounter form / superbill from provider will determine the correct procedural code and diagnoses. Review the medical documentation to substantiate the correct charges and confirm accurate diagnoses are used for each procedure.
5) Send the claim to the insurance company for reimbursement and services rendered
Proper formatting for insurance claims
If paper, needs to be manually filled out and mailed to insurance company.
Clear and concise, formatted correctly, all uppercase, no punctuation included, nothing photocopied, nothing handwritten, no staples.
Usually sent electronically through direct billing system or clearinghouse vendor
Definition of chart reviews; purpose for billing
Collection and clinical review of medical records to ensure that payment is made only for services that meet all plan coverage and medical necessity requirements. Insurance companies will review charts to reduce payment or billing errors or documentation issues
E/M services acronym
Evaluation and management; E/M coding involves translating the encounters into CPT codes to facilitate billing
Three factors in determining level of service with E/M coding
History, Examination, and Medical decision making
Provider will document whether the patient has a problem-focused, detailed, or comprehensive history.
Provider will document their examination of the patient regarding specific body areas and organs systems, as well as level of examination provided.
Provider will document place of service and patient status.
The level of E/M service code must be documented with full detail in patient’s medical record and noted on the encounter form for billing procedures
When should a referral be submitted?
After approval of the provider and authorization from the insurance company has been obtained
Types of referral
Regular (3-10 business days)
Urgent (24 hours)
Stat (as quickly as possible) - sometimes additional information is required
Information to include in a patient referral
Demographic and insurance information, provider’s identification information (including National Provider Identification (NPI)), diagnosis, planned procedure or treatment
Preauthorization
A process required by some insurance carriers in which the provider obtains permission to perform specific procedures or services or refers a patient to a specialist.
Most managed care and HMO insurances require preauthorization.
Financial obligations are typically higher, and the patient should be aware of covered and noncovered benefits.
Services typically for nonemergent surgeries, expensive tests, medication therapies
What to include when obtaining or verifying prior authorization?
Authorization code, date it is effective and it expires
Authorized diagnosis and procedural codes
Contact information for the specialist office
How many visits are authorized
What the authorization has been issued for
Precertification
Process required by some insurance carries in which the provider must prove medical necessity before performing a procedure. Also sometimes required for specific types of lab tests, diagnostic tests, and unusual or expensive procedures.
Most insurance companies require precertification within 24 hours of admission
Participating providers
Agree to adjust the difference between the amount charged and the approved contracted amount the insurance company will reimburse you
Account balance
Total balance on an account; can be a debit (negative) or a credit (positive)
Accounts receivable
The amount owed to the provider for the services rendered
Accounts payable
Debt incurred but not yet paid; can be for supplies or utilites
Assets
Property of an individual or organization that is subject to payments for debts owed
Liabilities
Items that are outstanding (debts)
Requirements for credit arrangements
Medical assistant must provide a detailed explanation of fees, services, and charges, as well as convey a tactful and courteous explanation of the payment plan.
Discussion of payment info must be documented and signed by an authorized member of the office and the patient, this documentation must be attached to the patient’s financial record with a copy given to the patient.
The medical office has the right to charge additional fees if a check is returned to the medical office for nonsufficient funds
Process of charge reconciliation
1: adding deposits; deducting outstanding checks, bank service charges, NSF checks and fees, and check-printing charges
2: adding the interest earned along with any notes receivables collected by the bank
3: Make sure the bank statement and office accounts match
4: Compare the adjusted balances and record all adjustments to reconcile the balance, this confirms the accounts are accurate
Running an aging report (collections)
Necessary before submitting any account to collection. Aging reports are grouped by day of last payment. Generally the assistant makes a reminder call, letters, etc.
When the final notice is sent the account must be sent to collections and all further patient contact regarding the account must be discontinued.
Always treat the patient with respect
Steps to appeal a denial
1) determine why the claim is denied
2) obtain and complete the insurance company’s appeal document as quickly as possible
3) Include a letter from the provider to provide support for medical necessity, progress notes from the treating provider, and relevant results from any testing performed
EMR vs EHR
EMR are electronic medical records; digital charts. They can be created and maintained by those within a single health care organization.
EHR are electronic health records, include the EHR and other information to be used between facilities
