Module 5: Administrative Assisting Flashcards
Referrals
An order from a provider for a patient to see a specialist or to obtain specific medical services.
*May be required when a patient is seeking services outside the realm of the primary care provider.
Can be completed by a phone call, creation/sending via the EHR, or visiting the payer website or provider portal, or it could have a formal written process depending upon the policies of the third-party payer
Electronic Referrals
The health care organization can submit an electronic request to refer a patient to a specialty medical provider.
This can be done using the electronic health record or practice management software.
The electronic referral must be completed on a secure site and can only be emailed or sent using a secure service where encryption is used to ensure that it cannot be downloaded or viewed by an unauthorized user.
*Many third-party payers have a specific electronic form that must be used by the medical provider to provide a referral to a patient. Some third-party payers have the form accessible on their website. Once again, documentation would be attached to support the medical necessity of the referral. A copy of the request and follow-up of the referral would be included in the patient health records.
Third-party payer for referrals
Referrals could have a formal written process depending upon the policies of the third-party payer
The third-party payer can help to determine the route to take with a referral for a patient because proper reimbursement is contingent on their policies.
Many third-party payers require the patient to schedule an appointment with their primary care provider to discuss the need for a referral.
Referrals and HIPPA
For compliance purposes, referrals are considered part of the HIPAA exclusions for Treatment, Payments, and Operations (TPO), so a separate, signed release of medical information form is not required unless the organization has a policy stating otherwise.
Practice management system (PMS)
The administrative side of the EHR:
Software used to electronically manage administrative functions, such as scheduling appointments, integrating patient documentation from electronic health records, coding, billing, and revenue cycle tasks such as running aging reports and managing the accounts receivable.
EMR vs EHR
Electronic medical record (EMR): a digital version of a patient’s medical and health care information within a specific health care organization.
Electronic health record (EHR): a record of patient medical and health care information accessible to providers and other staff members with log-in credentials regardless of location, which contributes to more efficient patient workflow.
*EHR results in more accuracy and efficiency and a greater continuity of care for the patient. This integration allows for lab and diagnostic test orders to be entered and viewed by the patient and their providers in real time
Real-time adjudication (RTA)
A tool that allows for a submission of the coded visit to the insurance company by participating providers for reimbursement decisions by third-party payers while the patient is present.
Centers for Medicare & Medicaid Services (CMS)
A federal agency that oversees the Medicare program and assists states with Medicaid programs.
The CMS publishes documentation guidelines to ensure timely, accurate, and efficient documentation occurs:
- The publications are provider-type specific to give detailed information on documentation requirements.
- The publications include guidance with documentation errors that commonly occur and possible resolutions.
- Ex: incomplete progress notes, orders, or procedures and how to address updating the documentation.
*The lack of proper documentation can have a detrimental effect on the overall patient care and also can result in denied or inaccurate reimbursements from the third-party payers.
Paper Medical Records
There are various storing and filing methods, but alphabetic filing (by the patient’s last name) is the most common. Inside the chart, paper records are assembled in reverse chronological order, with the most recent medical services on the top.
Disadvantages:
- can be cumbersome
- only allows access of one user at a time
- no real-time adjudication (RTA) interoperability among health care providers.
- searching for and locating charts can be time consuming.
Storage of Medical Records: Electronic
Typically stored using cloud storage; most back up in real time and are easily accessed and retrieved.
Electronic records and backup data must be stored at a location offsite in case the original data source is lost or damaged
Storage of Medical Records: Paper
Current records are stored on site, and archived records would be stored at a convenient offsite location to allow for retrieval as necessary.
Archived records may need to be retrieved for the purpose of medical history, general patient care, or in the event of a legal matter, such as a subpoena.
Benefits of a good schedule
Effectively and accurately maintaining the schedule will positively contribute to the workflow and success of the organization, resulting in staff, patient, and provider satisfaction.
Matrix
The designed time frame for appointments based on the method of appointment durations.
Scheduling Methods
- Specific time
- Wave scheduling
- Double-booking
- Clustering
Specific time
Type of scheduling method
A specific time gives each patient an individual time for their appointment.
Wave scheduling
This system schedules two or three patients during a designated hourly time period, perhaps the top of the hour or within the first 30 minutes, and then patients are seen based upon who arrives first. This gives more flexibility within each hour.
Double-booking
A type of scheduling in which two or more patients are scheduled within the same time slot and then provides medical services concurrently.
It is beneficial if one has labs or tests that need to be done and the provider can alternate between their care.
Clustering
Patients are scheduled in groups with common medical needs
Ex: schedule all new patients on Tuesdays or all wellness exams on Fridays
New Patient Appointment
The initial patient appointment or the first encounter after a 3-year absence from the organization. Includes known complaint/condition
Approximate Time Required: 60 min
Types of Office Visits/Appointment
- New patient
- Established patient (could include follow-up, sick, or consultation)
- Comprehensive
- Preventive care (complete physical exam, annual wellness exam, chronic care management)
- Urgent
- Other entities
Established Patient Appointment
Received services from the same provider or same group (and same specialty) within 3 years—includes known complaint/condition
- could include follow-up, sick, or consultation
Approximate Time Required: 15 min
Comprehensive Appointment
New or established patient for a specified complaint at highest coding level, multiple complaints, injuries, or worsening chronic conditions
Approximate Time Required: 45 to 60 min
Preventive Care Appointment
Thorough review of body systems including preventive care and screenings
Complete physical exam, annual wellness exam, chronic care management
Approximate Time Required: 45 to 60 min
Urgent Appointment
Medically necessary within 24 hr
Approximate Time Required: 20 min
Other Entities (Appointment)
Non-patient related (depositions, sales, representatives, staff meetings, training)
Approximate Time Required: 30 min
Determine the Type of Appointment Needed
Determining the type of appointment needed will help ensure the appropriate amount of time has been scheduled for the patient visit.
- When a patient calls for an appointment, always ask the reason for the visit to determine the type and amount of time needed for the appointment.
- Review the patient record to gather more information about the appointment. Is the patient coming in for chronic care management, a wellness exam, or a follow-up of a current condition?
- Once the reason for the visit is determined, ask the patient their preference of time and day for the appointment and then give them a few options of availability.
- Another consideration of scheduling is to ask if they prefer a virtual (telehealth) or an in-person visit.
Screening Questions to Identify Type of Appointment Needed
Questions can include:
1. patient name and contact information
2. reason for the visit
3. nature of the current condition
4. other health care–related questions that relate to the nature of the current condition
Screening
Refers to asking questions to determine the patient’s signs and symptoms as well as the history of the current condition to prioritize the medical services.
- Important process to help determine the type of appointment that is needed.
- Used to determine if there is a need to route the call, such as forwarding to the clinical staff or another department such as the billing department.
The health care organization will have established written policies and protocols for questions to ask when screening calls.
Eligibility
Meeting the stipulated requirements to participate in the health care plan.
Copayment
A set amount determined by the plan/payer that the patient pays for specified services, usually office visits and emergency department visits.
Steps to Screening
- Ask questions to determine what type of appointment is needed
- Once the screening questions have been asked, verify the third-party payer (insurance) information and eligibility.
- Inform the patient of policies regarding patient financial responsibility requirements, such as copayment due at the time of services.
How early should you ask a patient to arrive prior to their appointment?
It is best practice to also ask patients to come in at least 15 minutes earlier than the appointment to allow for time to fill out or update required paperwork.
Prioritize Appointment Needs Based on Urgency
A patient who calls in with a request for an urgent visit for minor injuries or acute conditions not requiring emergency care would be prioritized.
This is not an appointment that would be scheduled for the next available time slot; instead, fit them in as soon as possible.
The screening process (as established by the organization) will determine if the situation is an emergency (life-threatening) and should be referred to an emergency department or if it is urgent and could be accommodated by the office schedule.
Patient check-in
Starts when the patient arrives for their appointment.
- Verify the patient’s identity, eligibility, and insurance information.
- Ask to see a photo identification, such as a valid state identification card or driver’s license, to ensure that the name and birth date matches the information on the insurance card and patient medical record. - Verify their patient demographics and ask if anything has changed so information can be updated if needed.
- Patient registration forms will be checked to confirm they have been signed and uploaded to the patient account. The insurance card and valid state photo identification will be scanned into the system.
- Some health care facilities will take a picture of the patient to upload into the medical record. This helps to verify patient identity and decrease the possibility of identity fraud. Patients have the option to agree to or decline having a picture taken or photo ID scanned.
- When verifying the patient insurance eligibility, the MA will also determine any copayments or patient financial responsibilities to be collected before medical services are rendered.
- It is far more efficient to collect the amounts due up front than after the appointment or once the patient has left.
- The patient should have been informed of amounts due at the time of service when the appointment was made. - Provide any assistance needed for patients when they are being escorted to the exam room. The patient should be asked if they need any accommodations or assistance; it should never be assumed.
Claim denials often result from what?
Missing, incomplete, or inaccurate demographic information, and the check-in process is the time to ensure accuracy.
Patient check-out
Process occurs after the medical encounter has been completed.
- Review the after-visit summary (AVS) and ask if the patient has any questions or concerns.
- Any follow-up needed should be noted and highlighted for the patient, including scheduling follow-up appointments or assisting with scheduling diagnostic tests or lab work.
- In the event of additional patient financial responsibility, such as deductible or coinsurance owed, it would be collected during check-out.
*The patient check-out should be just as cordial and professional as the greeting prior to the appointment.
After-visit summary (AVS)
Information that includes follow-up appointments, provider orders, instructions, educational resources, and financial account information.
Deductible
The amount that must be paid before benefits are paid by the insurance company.
Coinsurance
The percentage of the allowed amount the patient will pay once the deductible is met.
Notice of Privacy Practices (NPP)
Document that identifies how the provider will distribute and disclose a patient’s protected health information.
Administrative Sections of the Medical Record
- Patient’s demographic information (name, address, phone number, birthdate, sex (assigned at birth), insurance information, place of employment)
- Notice of Privacy Practices (NPP)
- Advance directive
- Consent forms
- Medical release forms
- Correspondence and messages
- Appointments and billing information
Clinical Sections of the Medical Record
- Health history
- Physical examinations
- Allergies
- Medication record
- Problem list
- Progress notes
- Laboratory data
- Diagnostic procedures (electrocardiograms, radiology reports, spirometry reports)
- Continuity of care (consultation reports, home health reports, hospital documents)
Editing/Correcting a paper record
Done by adding a correcting entry or addendum or by drawing a line through data and adding new data—it should never be permanently deleted.
Paper records must have the physical writing of the person with their name, date, and time.
*The patient medical record is a legal document. All information included in the medical record should be kept confidential and private and accessed only by those authorized. Compliance must always be maintained.
Patient flow sheet
Records and tracks patient health data, such as vitals or lab results
