Patient Access / Front Office Flashcards
1
Q
Patient Access / Front Office is often referred to as what?
A
Admitting, Patient Intake, or Registration
2
Q
What are the responsibilities of Patient Access / Front Office (3)?
A
- creating a permanent patient medical record
- ensuring the accuracy of the patient account record
- collecting the necessary information to produce a clean claim
3
Q
What is the primary duty of the Front Office personnel
A
act as a liaison between the physician and the patient
4
Q
What are the primary functions of the Patient Access department (8)
A
- Scheduling
- Preadmission and preregistration
- Precertification and preauthorization
- Registration and admission
- Insurance verification
- Financial counseling
- Collection
- Compliance
5
Q
Challenges in scheduling result from the need to balance what three elements
A
- Patient satisfaction
- Collection of financial information, demographic information, and insurance information
- Clinical services
6
Q
What information is gathered during preadmission and preregistration process (3)
A
- Patient demographics (name, address, date of birth, Social Security number, etc.)
- Financial information
- Socioeconomic information
7
Q
Complaints should decrease with the implementation of a preregistration program because (5)
A
- Financial planning and counseling can be done in advance of the service.
- Patients are familiarized with the admission process.
- Special needs can be identified and accommodated.
- Patients are more prepared and less anxious.
- Admission time is reduced.
8
Q
What information must be distributed to the patient during an appointment?
A
- HIPAA privacy notice
- Patient Care Partnership brochure / Bill of Rights
9
Q
Describe POS (point of service) collection
A
A good preadmission/service and preregistration process will include determining the estimated patient portion for services beforehand and informing patients so they can bring their payment at time of service. This type of POS (point of service) collection is the only cost-effective way to collect small-dollar copayments. Front-end collection is important overall because 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
10
Q
What are the five collection control points (by setting)
A
Facility/Provider Setting:
1. Preadmission/Preservice
2. Admission/Time of Service
3. In-house/In-house
4. At discharge/At checkout
5. After discharge/Post Service
11
Q
What is a deposit?
A
Essentially co-pay - it’s the estimated portion of the patient’s bill not covered by insurance
12
Q
Decsribe a deposit collection program
A
Payment can be made in one installment or financed over time, and can be collected:
* prior to admission
* at admission
* or at discharge.
13
Q
Describe the advantages of a deposit collection program
A
When combined with a good preregistration and insurance verification program, include:
* Increased hospital cash collections
* Reduced amount due at discharge
* Reduced overall accounts receivable
* Reduced financial risk and bad debt
14
Q
Describe the disadvantages of a deposit collection program
A
Possibility of creating a public relations issue between:
* hospital and the doctor
* patient and the hospital
* patient and the doctor
15
Q
What does the acronym “MOON” stand for
A
Medicare Outpatient Observation Notice (MOON)
16
Q
What does the acronym “ABN” stand for?
A
Advance Beneficiary Notice of Noncoverage (also known as a notice of noncoverage)
17
Q
What does the acronym “HINN” stand for
A
Hospital Issued Notice of Noncoverage
18
Q
Describe the Important Message from Medicare (and when it must be issued)
A
- In many facilities, Patient Access is responsible for handling the Important Message from Medicare
- Hospitals are required to give this to all Medicare and Medicare Advantage beneficiaries who are hospital inpatients.
- This notice is required to be issued within two days of admission and again within two days of discharge.
19
Q
What does the acronym “NOTICE” (as in NOTICE Act) stand for?
A
Notice of Observation Treatment and Implication for Care Eligibility
20
Q
Describe the NOTICE Act
A
- 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, both orally and in writing, of his or her observation status.
- The MOON is a standardized notice developed to inform beneficiaries (including Medicare health plan enrollees) when they are an outpatient receiving observation services and are not an inpatient of the hospital
21
Q
Describe the MOON
A
The MOON is a standardized notice developed to inform beneficiaries under the NOTICE Act (including Medicare health plan enrollees) when they are an outpatient receiving observation services and are not an inpatient of the hospital
22
Q
What does the acronym “MOON” stand for?
A
Medicare Outpatient Observation Notice
23
Q
To whom does the MOON apply?
A
- Medicare Part A and Medicare Advantage plans
- Patients in Psychiatric and Critical Access Hospitals
- Beneficiaries who do not have Part B coverage (As noted on the MOON, observation stays are covered under Medicare Part B.)
- Beneficiaries who are subsequently admitted as an inpatient prior to the required delivery of the MOON
- Beneficiaries for whom Medicare is either the primary or secondary payer
24
Q
What happens if the patient refuses to sign the MOON
A
If the beneficiary refuses to sign the MOON and there is no representative to sign on behalf of the beneficiary:
* The notice must be signed by the staff member who presented the written notification.
* The signature of the staff member must include the name and title of the staff member, a certification that the notification was presented, and the date and time the notification was presented.
* The staff member then must annotate the Additional Information section of the MOON to include the staff member’s signature and certification of delivery.
* The date and time of refusal is considered to be the date of receipt.
25
Describe the ABN
The Advance Beneficiary Notice of Noncoverage (ABN) - also known as a notice of noncoverage:
* To avoid having to write off **claims that Medicare deems not “reasonable and necessary,”** providers can use the ABN.
* When a service does not meet or is not expected to meet medical necessity, the **beneficiary is given an ABN before services are furnished** that states that the provider believes that Medicare will not or probably will not cover the specified item.
* The ABN contains a brief description of the service, the estimated cost, and the reason the service is not expected to be covered.
* **Patients sign and date the ABN after indicating their decision to proceed with the service (knowing they will have to pay personally if Medicare denies payment) or to forego the service.**
* If a valid and signed ABN is not obtained prior to the services being rendered, the provider cannot bill the beneficiary for those services and will be held financially liable if payment is not received by Medicare.
26
Describe ABN Triggering Events
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 which can occur during initiation of treatment/new encounter/new plan of care or during reduction/termination (if the beneficiary wants to continue treatement instead)
27
How long must and ABN be retained?
* **Five years from discharge or the completion of the care**, provided that there are no other applicable requirements which fall under state-specific law.
* Retention is still required **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.
28
Describe the HINN
Hospital Issued Notice of Noncoverage:
* The HINN is similar to an ABN in that it is a liability notice, but affects providers submitting claims to Medicare Administrative Contractors (MACs) for **hospital inpatient services**.
* Hospitals give HINNs to fee-for-service inpatient hospital beneficiaries who are due to receive specific **diagnostic or therapeutic procedures that are separate from treatment covered / paid / bundled into the inpatient stay**.
29
What are some examples of services that do not require issuance of an ABN (or HINN, when applicable)?
Statutorily excluded items, such as:
* Screening mammogram
* Prostate Screening Antigen (PSA)
* Routine physical
* Routine foot care
* Cosmetic surgery
* Dental care and dentures (in most cases)
Non-emergent services in the Emergency Department
Chiropractic care
Ambulance service that is considered a technical denial (meaning it did not meet the definition of the ambulance benefit)
Services listed in the beneficiary Medicare manual (because the patient is presumed to know such items are not covered), such as:
* Routine eye care, eyeglasses, etc.
* Personal comfort items
Services for which the patient previously signed an ABN
Self-administered drugs
30
Describe implied consent – in fact
consent by silence; the patient implies consent to the treatment by not objecting
31
Describe implied consent – by law
occurs in a situation where the patient is unconscious and is taken to the emergency room; the law allows treating the patient
32
Describe assignment of benefits
A written authorization, signed by the policyholder (or the patient, in the absence of the policyholder) to an insurance company, to pay benefits directly to the provider.
An assignment of benefits is the act of signing documentation authorizing a health insurance company to pay a physician directly. In other words, the insurance company can pay claims without the direct involvement of the patient in the process.
When assignment is not accepted, the payment will be sent to the patient, and the provider will have to collect it.
33
Describe emancipation
Although parental consent is generally required for treatment of a minor, emancipation is a process by which a minor is freed from parental control.
The emancipated minor is defined as any minor where a court of law has declared the child emancipated based on the following criteria:
* No longer requires parental guidance or financial support
* Has fathered or given birth to a child
* Has reached the age of majority (The age of majority varies from state to state, but usually ranges from 18 to 21.)
34
What conditions prevent a person from consenting to services (3)?
If they are:
* Intoxicated
* Unconscious
* Declared mentally incompetent by the courts
35
What does the abbreviation "NCD" stand for?
National Coverage Determination
36
What does the abbreviation "LCD" stand for?
Local Coverage Determination
37
Describe a National Coverage Determination
Medical review policies issued by CMS which identify specific medical items, services, treatment procedures, or technologies that can be covered and paid for by the Medicare program.
38
Describe a Local Coverage Determination
Policies developed by MACs that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary, and appropriate.
39
What does the abbreviation "MAC" stand for?
Medicare Administrative Contractor
40
Describe Definitive Diagnosis
one in which the LCD or NCD discusses and lists specific diagnosis codes, ICD (International Classification of Diseases) procedure codes, and possibly signs and symptoms to support the need for the item or service being given.
41
Describe non-definitive LCD or NCD
one that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms, or ICD-10 codes that will be covered or noncovered. Non-definitive LCDs/NCDs can include language such as: "This policy is not exclusive. Claims not supported by these diagnoses may be reimbursable with supporting documentation."
Another example of a non-definitive LCD/NCD is when the Medicare contractor considers or utilizes factors and information other than that in the LCD/NCD when making a coverage determination. With non-definitive coverage determinations, a review of the medical record documentation is required for a determination of medical necessity to be made.
42
What does the acronym "MSP" stand for?
Medicare Secondary Payer
43
Describe the history of the Medicare Secondary Payer program
Until 1980, Medicare was the primary payer for nearly all Medicare-covered services. Since 1980, Medicare Secondary Payer (MSP) laws have shifted costs from the Medicare program to other sources of payment. MSP information is gathered from each beneficiary to determine the proper coordination of benefits.
44
Presently Medicare is the secondary payer for whom?
The working aged:
* **65 or older, currently working, and have coverage through a Group Health Plan (GHP).**
* beneficiary has **coverage through an employed spouse** of any age (including same-sex marriages.)
* In order to meet the working aged provision, the **employer must have at least 20 employees** working for the company.
Individuals who are **under age 65**, **disabled**, and **covered by a group health plan** (with an employer who has **100 or more employees**) due to their own or other family member’s current employment status
Individuals with end stage renal disease (ESRD):
* Medicare is the secondary payer during the **30-month coordination of benefits (COB) period for ESRD patients** who have coverage under their own, a spouse’s, or other family member’s employer-sponsored or employee organization group health plan.
* Medicare remains the secondary payer throughout the entire 30-month period even if the beneficiary becomes entitled to Medicare based on disability or age before the COB period ends.
* Medicare coverage for ESRD will **end 12 months after the month the individual no longer requires maintenance dialysis**, **36 months after a successful kidney transplant**, or if the **patient becomes deceased**.
Individuals who receive services covered under:
* **Workers’ compensation benefits** when services rendered are related to an injury, illness, or disease sustained on a job
* The **Black Lung Benefits Act** (The Federal Black Lung Program is designed for individuals who have been diagnosed with pneumoconiosis, or black lung disease. The program is administered by the Department of Labor and pays for all covered medical services that are directly related to the treatment of black lung disease.)
Automobile, no-fault, or liability plans:
* **No-fault insurance** pays for medical expenses related to an injury resulting from an accident regardless of who may be at fault. There are various types of no-fault insurance including homeowners insurance, commercial insurance, and automobile insurance (medical or med-pay).
* **Liability insurance** is any source which provides payment on a claim based on a legal liability for illnesses, damages to property, or injuries. Examples of liability plans include malpractice, wrongful death, product liability, and uninsured motorist.
45
What does the acronym "IEQ" stand for?
Medicare's Initial Enrollment Questionnaire
46
Describe the Initial Enrollment Questionnaire
**About three months before** patients become entitled to Medicare, an Initial Enrollment Questionnaire (IEQ) is mailed to them.
The questionnaire **asks about any other healthcare coverage that may be primary to Medicare**.
The IEQ **responses are processed and the information is entered in the Common Working File (CWF)**.
47
What does the acronym "CWF" stand for
Medicare's Common Working File
48
Describe the MSP Questionnaire (MSPQ)
On an ongoing basis, beneficiaries complete an MSP Questionnaire (MSPQ) to **help determine if Medicare is primary or secondary**.
It asks about employment, accidents, and several other relevant subjects.
49
For recurring outpatient accounts how often should the MSPQ be completed?
An MSPQ can be completed once every 90 days if the beneficiary is receiving identical services and treatments as the month before.
50
How long much MSP information be stored?
All MSP information obtained on patients must be retained by the provider for 10 years. MSP data is also stored in the CWF.
51
Describe the Common Working File (CWF)
The CWF is a CMS file that contains Medicare patient eligibility and utilization data. It stores information, such as:
* Entitlement to Medicare Part A and Part B
* Date of birth
* Date of death
* Part A and Part B deductible information
* Benefit periods and days remaining in the current benefit period
* MSP information like MSP type, effective date, and termination date, Patient relationship, Subscriber name and policy number, Insurer type, name, group number, address, city, state, and zip code, Remarks code, Employer name, address, city, state, and zip code, Employee ID number and information
52
What does the acronym "ALOS" stand for
Average Length of Stay
53
How is Average length of stay (ALOS) calcuated
Average length of stay (ALOS) is calculated by dividing the total number of patient days by the number of discharges.
Add up the number of patients on the midnight census for each day in the period of interest, then divide by the number of discharges in that period.
54
Describe the Midnight Census
The census refers to the number of patients in the hospital at a particular point in time. The most common form is the midnight census.
Midnight census is determined from the census count for the previous midnight, minus any discharges, plus any admissions, plus/minus any status changes (for example, add any patients whose status changed from observation to inpatient).
55
What does the acronym "ADC" stand for?
Average Daily Census
56
Describe the Average Daily Census
Average daily census (ADC) is the average number of inpatients maintained in the hospital each day for a specific period of time. Each daily census during that period of time is added to determine the total number of patient days. This is then divided by the number of days
57
Describe Percentage of Occupancy
Percentage of occupancy is the ratio of actual patient days to the maximum patient days as determined by bed capacity. This calculation can be performed for any given period of time. A low percentage of occupancy indicates inefficiency. A percentage that is too high will mean difficulty finding available beds, long hold times in ER, etc.
58
Describe Number of Patients Seen per Day
Number of patients seen per day is the total number of patient encounters for all physicians/specialties in the time period divided by the number of days in the time period.
59
To qualify for SNF coverage, Medicare requires a person to have been a hospital inpatient for how many days?
At least three consecutive days (not including the day of discharge).
