Week 2 Flashcards
If a new patient calls to schedule, what should you do?
take the time to outline policies (payment, scheduling and cancellations)
if possible, verify the insurance benefits before the aptient arrives for their first appointment
request for treatment
usually patient initiates by phone
ask them to arrive 15-20 minutes before the appointment
when the patient requests treatment, what are some things you should go over with them?
payment scheduling cancellations have patient come early online forms welcome packet
welcome packet guidelines
welcome letter patient financial respsonsibility letter patient information form medical and health history forms informed consent form HIPPA privacy policy and acknoledgements financial hardship policy and application
written and printed policies available for patient guidelines
medical and health history forms (necessary)
informed consent
HIPPA privacy policy form and acknowledgements
what do you need to do to establish patient financial responsibility?
insurance information obtained (copy card front and back)
insurance verification (phone or internet)
financial policy explained
if insurance hasn’t been verified, what needs to happen?
DC may have to give patient an estimate of medical fees
medicare has the ABN form
ABN form
advanced benefitiary notice or waiver of liability
what should you require from patients during the inital visit?
copy of insurance card (front and back)
verification
referrals or pre-authorization (if necessary)
have patient sign forms (request for records/release, assignment of benefits)
you already verified the person’s insurance, do you still need a copy of their insurance card?
yes
what else do you need to do when you get their insurance card?
ask for a valid form of ID
what questions should you ask of patients who are established?
has any info changed since our last visit?
has insurance changed since last visit?
have you had any changes in your health history?
why do you need to ask all the questions to the established patients?
to verify if information has changed
see if their condition has changed
treatment plan requirements
diagnosis named what the treatment plan will be how many visits how long the plan is expected outcome and how you will measure it
date of onset is when for medicare?
the first date you saw the patient
documentation needed after appointment
document what happened
complete a fee slip (superbill)
collect any money owed from the patient
remin patient of next appointment (write down on card or have them write it down)
EOB/remittance
a form sent to the patient (proider) stating what has been paid by insurance and what patient owes
how do you get a reimbursement?
service must be
covered under payer’s health benefit plan
medically necessary according to apyer
appropriately documented in patient’s medical record
define medically necessary services
have been established as safe and effective
are consistent with symptoms or diagnosis
are necessary and consistent with generally accepted medical practices
are furnished at the most appropriate, safe and effective level
paradigm shift
cost sharing
patient needs to understand that most insurances will not pay 100% of the bill
patient needs to understand they need to accept responsibility for their portion of the bill
5 most common features of cost sharing
deductible co-pay co-insurance elimination/waiting periods out of pocket max
flow chart for payment
submit a claim is claim paid (follow up in 30 days if not, if yes, match EOB) is payment correct? (have policy in place if no) follow up send to collections rejected or denied? file and appeal appeal again (if you can) write off disallowed amount
if there is overpayment, what do you do? underpayment?
overpay- pay back ASAP
underpay- appeal
how often do you follow up on payments?
at least every 30 days
run reports in 30, 60. 90 day intervals
try to work out regular payments with patient before you send to collections
send to collections
should be outlined in payment policy and not an emotional decision
pay for a company to collect money for you (50% of what is collected)
disallowed amount
insurance adjusted amount or network savings
then balance bill to patient
essential benefits list
ambulatory patient services
emergency services
hospitalizations
maternity and newborn care
mental health and addiction treatment
prescription drugs
rehabilitative and habilitative services and devices
lab services
preventative and wellness services and chronic disease management
pediatric services, including oral and vision care
premium
buying insurance
deductible
amount that patient has to pay in a time period before benefits will be paid (typically per calendar year)
after deductible, who pays?
patient
managed care
created to contain costs and maintain quality
MCO
AKA HMO, PPO
(health maintenance organization or preferred provider organization)
actively manages medical aspect of patient care, financial aspect of patient care
MCO characteristics
selected providers furnish package of services to enrollees
explicit criteria for selection of providers
quality assurance, utilization review, outcome measures
incentives
penalties
risk-sharing
appropriate care, cost-effective mix
billing MCO
contact them
billing manuals and instructions
be sure to understand extra costs involved with MCO
1500 claim form
AMA, CMS and payer organizations created it
most insurances use this
where can you look for claim form?
chirocode deskbook
www.nucc.org
HSA acronym meaning
health savings account
HRA
health reimbursement arrangement
MSA
medicare medical savings acount
VEBA
voluntary empolyee benefit association
MEWA
multiple employer welfare arranement
HSA job
permits eligible individuals to save and pay for health care expenses on a tax free basis
empowers patients to spend their own money
money is held in a tax exempt trust or custodial account
to qualify, patient must have a high deducible health plan
MSA job
for medicatre patients
enrollment annual
eliminates need for medigap
patient can pay for services not covered by medicare
patient can “save up” for future expenses
HRA job
employer sponsored
patient can determine how, when and where the money is spent
may promote better doctor patient relationships
VEBA job
empolyees ina geographic area band together
create member owned healthcare plans
growth and impact has been small but is growing
MEWA job
two or more unrelated employers may establish a healthcare plan
can use insurance or another type of funding
designed to give small employers access to low cost health coverage
positives for cash practice
hassle free eliminayion of administrative waste less paperwork and overhead cost no insurance forms/bills no referral approval/authorization lower fees to patients
risks for cash practice
fewer patients initially
having false illusions that quality is not important
may become a target of unfair fee allegations by 3rd party payers
personal injury examples
MVA
accidents in a home where patient doesn’t reside
accidents occuring on a business site not work related
sources of payment for bodily injury
fault-based no-fault attorney health insurance/HMO/PPO patient payment
faulty based
liability
under/uninsured motorist
no fault
medpay
personal injury protection
attorney
will disburse payments from case
health insurance/HMO/PPO is used if..
fault-based, no-fault or attorney is exhausted
patient payment
cash
HSA
flex spending
cafeteria accounts
liability
coers damages caused by negligence or fault of insured
uninsured/underinsured motorist
covers patient when person liable is uninsured or underinsured
medpay
limited to medical expenses
covers insured regardless of vehicle
available for other policies
using medpay will usually not result in premium increase for insured
PIP
personal injury prtection
similar to medpay but also covers lost wages
may be mandatory in “no fault” state
medical leins/healthcare lien
attorney represents patient
filing a lien is usually a simple procedure
may prevent bill being discounted by lawyer
insurance company may put patient and DC name on check
what is a HIPAA exemption example?
work related illness or injury
what information do you need for worker’s comp cases?
employer
payer
date and time of injury/illness and how it occured
what do you need to verify for workers comp?
employer
empolyer knows of incident and report has been filed with insurance company
name of industrial insurance carrier
empolyer’s WC policy #
what should the first report of injury contain?
patient information employer information payer information accident or illness description physician's assessment of patient verification of other previous related illness/injury estimated return to work status treatment summary permanent impairment or disability as a result of accident/injury
FECA
DCs are treated as physicians and a patient with FECA might choose a DC as provider (doesn’t cover preventative care)
tricare
might now cover DC care
CHAMPUS
CHAMPVA
civialian health and medical program of uniformed services
government programs
FECA tricare CHAMPUS/CHAMPVA VA medicaid
