1 Patient Encounters and Billing Information Chapter 3 © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

1

Patient Encounters and Billing

Information

Chapter 3

© 2010 The McGraw-Hill Companies, Inc. All rights reserved.

Chapter 3 2

Learning OutcomesAfter studying this chapter, you should be able to:3.1 Explain the method used to classify patients as new and or established.

3.2 Describe the information that new and returning patients provide before their encounters.

3.3 Discuss the purpose of the Assignment of Benefits.

Chapter 3 3

Learning Outcomes (Continued)

3.4 Explain the purpose of the HIPAA Acknowledgment of Receipt of Notice of Privacy Practices.

3.5 Describe the procedures for verifying patients’ eligibility for insurance

benefits and for requesting referral or preauthorization approval.

3.6 Explain how to determine the primary insurance for patients who have more than one health plan.

Chapter 3 4

Learning Outcomes (Continued)

3.7 Discuss the use and typical formats of encounter forms.

3.8 List the four types of charges that are collected from patients at the time of service.

3.9 Describe the billing procedures and transactions that follow patients’ encounters.

3.10 Explain the importance of communication skills in working with patients, payers,

and providers.

Chapter 3 5

Key Terms

• Accept assignment• Acknowledgment of

Receipt of Notice of Privacy Practices

• Adjustment• Assignment of

benefits• Birthday rule• Certification

number

• Charge capture• Chart number• Coordination of

benefits (COB)• Direct provider• Encounter form• Established patient

(EP)• Financial policy

Chapter 3 6

Key Terms (Continued)

• Gender rule• Guarantor• HIPAA

Coordination of Benefits

• HIPAA Eligibility for a Health Plan

• HIPAA Referral Certification and Authorization

• Indirect provider• Insured• New patient (NP)• Nonparticipating

provider (nonPAR)• Partial payment • Participating

provider (PAR)• Patient information

form

Chapter 3 7

Key Terms (Continued)

• Primary insurance• Prior authorization

number• Real –time claims

adjudication (RTCA)

• Referral number• Referral waiver• Referring physician

• Secondary insurance

• Self-pay patient• Subscriber• Supplemental

insurance• Tertiary insurance• Trace number• Walkout receipt

Chapter 3 8

Gathering Patient Information

• Information to collect from new patients:– Preregistration and scheduling information– Medical history– Patient/guarantor information and

insurance information– Assignment of benefits– Acknowledgment of Receipt of Notice of

Privacy Practices

Chapter 3 9

Gathering Patient Information (Continued)

• Information to collect from established patients:– Updated personal demographics– Updated insurance information– Signed Acknowledgment of Receipt of Notice

of Privacy Practices on file?

Chapter 3 10

Patient Information

Patient• Full name • Social Security Number

• Gender • Employer information

• Marital status • Spouse’s name and employer

• Birth date • Contact person

• Address

Health Plans• Policyholder name and personal information,

identification number

• Other health plan

Chapter 3 11

Patient Information

Processing patient information• Scan or photocopy insurance card• Double-check the information on the patient

information form– Group identification number– Effective date– Member name – exact match– Member identification number– Health plan information

• Process assignment of benefits form

Chapter 3 12

Acknowledgment of Receipt of Notice of Privacy Practices

• A patient must be given a direct provider’s Notice of Privacy Practices once

• The patient is asked to sign an acknowledgment of receipt of this notice

• Provider must document in the medical record whether patient has signed

• Shows good-faith effort of office to inform patients of privacy practices

Chapter 3 13

Communication Skills

Communication skills are critical!• Medical insurance specialists handle patient

interactions effectively.• They also frequently communicate with

payers’ representatives.• Communicating appropriately with providers

and other team members contributes to a successful practice.

Chapter 3 14

Establishing Financial Responsibility

The financial policy should be posted.

Three steps to establish financial responsibility:

1) Verify patients’ insurance coverage prior to non-emergency services.

2) Determine preauthorization and referral requirements

3) Determine primary payer if applicable

Verification of Patient Eligibility for Insurance Benefits

• Current enrollment and benefit eligibility

• Copayment information

• Plan provisions: Is the planned service medically necessary?

Determining Preauthorization and Referral Requirements

• Preauthorization: if required, secure preauthorization number

• Referral: if required, secure referral number/document

• HIPAA Referral Certification and Authorization transaction – X12 278.

Chapter 3 17

Determining the Primary Insurance

Coordination of Benefits:• If the patient has one policy, it is primary

• If the patient has coverage under two plans, the patient’s longest running plan is primary and the other plan is secondary. A third, or tertiary, plan or a supplemental plan may also be in effect.

• A patient’s plan is also primary if the patient is:

– Listed as a dependent on another person’s plan

– Covered under a government-sponsored plan, that is in addition to an employer’s plan

– Retired, but covered under a working spouse’s plan

Chapter 3 18

• If the patient is a dependent child covered by both parents’ plans, the “birthday rule” usually determines primary coverage

• If the patient is a dependent child of divorced or separated parents, primary insurance is determined in the following order:– plan of custodial parent

– plan of spouse of custodial parent if remarried

– plan of parent without custody

Determining the Primary Insurance(continued)

Chapter 3 19

HIPAA Transactions

Electronic verification under HIPAA:

• HIPAA Eligibility for a Health Plan transaction

• HIPAA Referral Certification and Authorization transaction

• HIPAA Coordination of Benefits transaction

• Electronic format used to verify benefits

• A referral document that describes the services a patient is certified to receive

• When a patient has more than 1 policy, the primary carrier must be determined

Chapter 3 20

Updating Patient Diagnoses, Procedures, and Charges

Medical services provided by physician• Diagnosis(es) determined• Treatment documented

Encounter form completed• Compiles data for each office visit• Details dx and procedure codes and charges

Chapter 3 21

Updating Patient Diagnoses, Procedures, and Charges

Coding• The completed encounter form and the patient

medical records are used to code or verify the assigned codes.

Charges Calculated• The charges for the services are calculated,

based on the current fee schedule.

Chapter 3 22

Collecting Time-of-Service Payments

Potential patient responsibility: review

• Copayments

• Coinsurance

• Deductibles

• Excluded services

• Overlimit usage

Set dollar amount payable for encounter

Percentage of charges set as patient responsibility

Amount insured pays before insurance benefits begin

Services not covered by insured’s benefit plan

Dollar/number of services exceed plan benefits

Chapter 3 23

Collecting Time-of-Service Payments

Practices collect:

• Copayments

• Noncovered or overlimit fees

• Charges of nonparticipating providers

• Charges for services to self-pay patients

Practices may also collect:

• Partial payments

• Full payment when real-time claim adjudication tool is available from the payer

Chapter 3 24

Checking Out Patients

Estimating Patients’ Bills1. Verify the amount and status of the

deductible.

2. Check required coinsurance or other payments.

3. Calculate charges based on the fee schedule.

4. Determine payer’s allowed amounts.

Charges – (patient deductible/TOS payments) – (payer’s payment) = Estimated Bill

Chapter 3 25

Checking Out Patients

Processing Payments – Payment Methods:• Cash: A receipt is issued.• Check: The payment amount and check

number are entered on the encounter form, and a receipt is offered.

• Credit or Debit Card: The card slip is filled out, and the card is passed through the card reader. The approved card slip is signed by the payer, and a receipt may be offered.