WK3 DISCUSSION1 HP-214
COMPLETE IN DETAIL 250 WORDS
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WK3DISCUSSION1HP-214.docx
WK3DISCUSSION1INFOHP-214PPT.pptx
WK3DISCUSSION1HP-214.docx
WK3 DISCUSSION1 HP-214
Before the widespread use of computers, and in some small practices today, office finances were monitored with a system called the “pegboard”. The pegboard, or write-it-once, bookkeeping system uses a board with pegs running down the left side. The pegs hold a daysheet, or daily journal, in place on the board. All transactions for the day are recorded on this daysheet. Each patient has a ledger card (record of the patient's financial activities). When a patient transaction occurs, the bookkeeper places the ledger card over the daysheet and the charge slip (preprinted patient bill) over the ledger card on the next available entry line and makes the appropriate entry on the ledger card. At the end of the day, all the transactions have been added to the daysheet, allowing for easy tracking of charges, payments, and adjustments.
Your text describes the importance of the daysheet but does not elaborate on the value that the financial information can provide to the office staff. An example can be found when the daysheet includes a column for the CPT code for the service provided. The office manager, or billing specialist, can observe what codes are used most often by each provider. If one provider charges more often for a higher-level code (E&M office visit) than their peers (other providers) this may be a flag that indicates the need to verify chart documentation to ensure that it supports the higher services or may indicate the benefit of providing a “coding in-service” to providers. In other words, the daysheet can be instrumental for process evaluation purposes.
Refer to the daysheet example on slide # 35 of this week’s PowerPoint.
1. Compare the different patient information on the sheet and explain the information following the name Timothy Taylor.
2. Review if the daysheet did include the CPT codes and there was an indication that one provider was either upcoding or downcoding (not intentionally of course)
3. New information to keep in mind is that this practice has 4 providers and 3 exam rooms. Mentally, add a column for the CPT codes and a column for the provider’s initials. (You will not be turning in a revised daysheet, only discussing possibilities.) Be sure to explain your reasoning…. Any answer can be correct if it is well supported.
Model the process for tracking finances in a medical office.
Include the following aspects in the discussion:
· What do we know about Timothy Taylor?
· Discuss how you would suggest to providers the benefit of a meeting to review E&M coding.
· Discuss one suggestion for how to present a coding in-service to the providers.
· Name one other way that we can use the daysheet as an evaluation tool.
· Make an educated guess for one way that we could use the daysheet as a process evaluation tool
WK3DISCUSSION1INFOHP-214PPT.pptx
REIMBURSEMENT METHODOLOGIES
Revenue Cycle Management
Also known as
Accounts Receivable Management
Week 3
Development resource obtained from www.cengage.com
Revenue Management Cycle
Strong performing businesses will often use a CQI model (Continuous Quality Improvement). For a medical office this would mean tracking every step that a patient takes from the moment they have contact with the office and walk in the door to the moment they leave including all follow-up contacts and billing.
The revenue cycle, or accounts receivable, management not only improves the financial outcome but can help to provide quality services to patients.
The completion of each step, using caution to ensure accuracy, is very important.
Important Forms
First, let’s look at the forms that you will be using both in the office setting and in this course
Sample Portion of Patient Registration Form
Provides unique information for patient identification and billing.
Forms you will use
Insurance verification form – Note, you can think of this form as a sandwich where the meat is in the middle.
The plan type (HMO vs PPO, etc.) is important if the office is helping to setup diagnostic testing or an appointment with a specialist. Knowing the plan type may indicate the need for a preauthorization.
The patient’s deductible, and if that deductible has been met, directly impacts the patient’s charge for today’s visit.
Whether the patient has a flat rate copayment or has coinsurance that is a percentage of the total bill also directly impacts the charge to the patient for today’s service.
Forms you will use
The Encounter Form (superbill)
Generated for each appointment
Provider marks procedures performed and diagnosis for each service
Used by biller to fill out the CMS 1500 form which will be submitted to the insurance company for payment in the outpatient setting.
Forms you will use
CMS 1500 claim form used for billing insurance
The UB-04 is a similar form used to bill insurance in the hospital setting.
Revenue Cycle – Step 1
Physician’s order in the hospital setting or
Patient calls to schedule appointment in the office setting
** Because there are more coding and billing positions in the outpatient setting, and because these positions typically require the employee to take on several roles, we will focus from the perspective of the outpatient setting.
Revenue Cycle – Step 2
Patient Registration
Established Patient – 3 steps
Verify patient registration information.
Collect copayment from patient.
Generate encounter form for current visit.
New patient – 8 steps (continued)
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Preregister new patient and ensure PAR status (participating provider)
On day of appointment patient completes registration form, which is inspected for completeness and accuracy. (form on slide 3)
Photocopy front and back of patient’s insurance identification card(s). (example on slide 10)
File copy in patient’s financial record.
Typical Information on Insurance Card
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Confirm patient’s insurance information by contacting payer via telephone, Internet, or fax. (form on slide 5)
Collect copayment from the patient.
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Verify information with patient.
Make appropriate changes.
Perform coordination of benefits (COB) when patient has more than one policy.
** The COB is VERY important and there are consistent rules for you to know and follow:
COB Rules for knowing which insurance to bill first:
For Adults Primary is the insurance where the patient is the policyholder versus secondary insurance the patient is listed as a dependent. (example: married heterosexual couple when patient is the wife then bill her insurance. The husband’s insurance will be secondary.)
For Children
Children of divorced parents – custodial parent’s plan is primary
If parents are remarried – custodial parent is primary, custodial step-parent is secondary and the non-custodial parent is tertiary.
Children living with both parents
Each parent has different insurance then follow the birthdate rule = parent whose DOB month and day (not year) comes first in the calendar year is primary. (if parents both born on same month and year then oldest policy is primary)
Gender rule for parents – some self-funded insurance plans use the father as primary
So, you may need to verify with the insurance plan which rule they follow.
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Create new patient medical record.
Generate patient encounter form. (slide 5)
Collect copayment
Revenue Cycle – Step 3
Charge Capture – may be done via a “chargemaster”, “encounter form” or computer program.
Chargemaster
Also called charge description master (CDM)
List of procedures with charges for each procedure.
Revenue Cycle – Step 4
Diagnosis and procedure coding by completing the “Encounter Form” which is then given to the coder/biller.
Revenue Cycle – Step 5
Patient Discharge Processing
Discharge instructions (hospital)
Schedule follow-up visit
Begin preauthorization process if needed for appointment with specialist or diagnostic testing.
Revenue Cycle – Step 6
Billing and Claims Processing
Complete CMS 1500 form (slide 7) for outpatient visit or UB-04 for hospital visit
** When this step is performed accurately and completely the Revenue Cycle is shortened saving frustration, time, labor and costs. No errors when filling out the claim (producing a “clean claim”) means that claims will not need to be “resubmitted” or “appealed” for non-medical reasons.
Revenue Cycle – Step 6
Billing and Claims Processing
Complete CMS 1500 form (slide 6) for outpatient visit or UB-04 for hospital visit
Signature of patient and provider required
SIGNATURE ON FILE can be substituted for patient’s signature (if patient’s signature is on file in the office).
Completed claim is proofread for accuracy.
Supporting documentation is attached to claim (if needed).
Revenue Cycle – Step 6
Billing and Claims Processing
Often providers will use a “clearinghouse” where errors can be caught, claim information is encrypted to ensure PHI is intact and submitted to the insurance provider.
**A clearinghouse can be compared to the post office where letters are checked for completed addresses and a stamp.
Claim Processing
The typical route for a claim from the office to the insurance company.
Important for HIPAA/HITECH compliance
Revenue Cycle – Step 7
Resubmitting Claims – needed due to initial errors or missing information, which leads to a claim rejection.
A rejected claim will be accompanied by a “RA” from the insurance company that will explain the missing information.
RA = Remittance Advice
Correct and resubmit
Claim Processing
Insurance Adjudication Process
{
Why Claims are Denied
Procedure/service not medically necessary
Incorrect codes or incorrectly linked codes were reported.
Preexisting condition not covered or failure to obtain preauthorization
Noncovered benefit or termination of coverage
Out-of-network provider used
Lower level of care could have been provided
Bundled service or global period service is not eligible for separate payment.
Claim contained incomplete information or another insurance plan is primary.
A Clean Claim
The revenue cycle for a “Clean Claim” (without errors or omissions) will look like this:
Revenue Cycle – Step 8
Third-Party Payer Reimbursement Posting
First party = patient
Second party = provider of care
Third party = insurance, workman’s comp, auto policy following accident, etc.
** Post the insurance payment to patient’s account
RA and EOB
The Insurance company will send the provider a RA (remittance advice) explaining the payment or denial and will send the patient an EOB (explanation of benefits).
The RA may look very similar to the EOB except the EOB will always say, “This is not a bill.”
Example EOB on next slide
Example EOB
Revenue Cycle – Step 9
Appeals process for denied claims
Rejected claim = missing information
Denied claim = coding error, lack of medical necessity, data error, patient not covered
Revenue Cycle – Step 10
Patient Billing only needed if:
Did not collect copay at time of visit
Patient has “coinsurance” that is a percentage of the bill not a flat copay
Patient has no insurance and did not pay at time of appointment
Revenue Cycle – Step 11
Patient payment is posted to their account.
Steps 12 & 13
Collections and collections reimbursement posting Have a standardized “collections
procedure”. Example on pg 108 of text.
Sample Patient Ledger
The patient ledger will contain all charges, payments and write-offs (adjustment for charge that is not “allowed” by the contract agreement between the provider and the insurance company)
This software tracks each “visit” as a transaction number. Some software will group by date of service.
In both visits logged above, it took over one month to receive payment from the insurance company.
Sample Day Sheet
What does this day sheet tell us:
There is only 1 NPI so we know that this is for one provider only.
The charge is for one procedure (adding a column for the CPT code would be helpful).
The “adjustment” is the difference between what the office charges and what the insurance contract allows.
The “credit” is what the insurance allows and the amount that should be pending from insurance.
The “Net Change” is the amount paid by the patient.
The Day Sheet is filled out each day and represents all patient visits for that day.
The day sheet can be used to provide a monthly report “at a glance” by carrying the totals from the previous day to top the list on the next day.
Sample Insurance Claims Registry
The Insurance Claims Registry is important for tracking all pending insurance payments. When an insurance claim is submitted it is logged in the registry. When the payment is received that too is logged in the registry.
The registry can be used to track payments that have not yet been received and indicates a claim that requires further investigation.
A claim that is more than 30 days old
A claim that is more than 60 days old, etc.
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WK3DISCUSSION1HP-214.docx
WK3 DISCUSSION1 HP-214
Before the widespread use of computers, and in some small practices today, office finances were monitored with a system called the “pegboard”. The pegboard, or write-it-once, bookkeeping system uses a board with pegs running down the left side. The pegs hold a daysheet, or daily journal, in place on the board. All transactions for the day are recorded on this daysheet. Each patient has a ledger card (record of the patient's financial activities). When a patient transaction occurs, the bookkeeper places the ledger card over the daysheet and the charge slip (preprinted patient bill) over the ledger card on the next available entry line and makes the appropriate entry on the ledger card. At the end of the day, all the transactions have been added to the daysheet, allowing for easy tracking of charges, payments, and adjustments.
Your text describes the importance of the daysheet but does not elaborate on the value that the financial information can provide to the office staff. An example can be found when the daysheet includes a column for the CPT code for the service provided. The office manager, or billing specialist, can observe what codes are used most often by each provider. If one provider charges more often for a higher-level code (E&M office visit) than their peers (other providers) this may be a flag that indicates the need to verify chart documentation to ensure that it supports the higher services or may indicate the benefit of providing a “coding in-service” to providers. In other words, the daysheet can be instrumental for process evaluation purposes.
Refer to the daysheet example on slide # 35 of this week’s PowerPoint.
1. Compare the different patient information on the sheet and explain the information following the name Timothy Taylor.
2. Review if the daysheet did include the CPT codes and there was an indication that one provider was either upcoding or downcoding (not intentionally of course)
3. New information to keep in mind is that this practice has 4 providers and 3 exam rooms. Mentally, add a column for the CPT codes and a column for the provider’s initials. (You will not be turning in a revised daysheet, only discussing possibilities.) Be sure to explain your reasoning…. Any answer can be correct if it is well supported.
Model the process for tracking finances in a medical office.
Include the following aspects in the discussion:
· What do we know about Timothy Taylor?
· Discuss how you would suggest to providers the benefit of a meeting to review E&M coding.
· Discuss one suggestion for how to present a coding in-service to the providers.
· Name one other way that we can use the daysheet as an evaluation tool.
· Make an educated guess for one way that we could use the daysheet as a process evaluation tool
WK3DISCUSSION1INFOHP-214PPT.pptx
REIMBURSEMENT METHODOLOGIES
Revenue Cycle Management
Also known as
Accounts Receivable Management
Week 3
Development resource obtained from www.cengage.com
Revenue Management Cycle
Strong performing businesses will often use a CQI model (Continuous Quality Improvement). For a medical office this would mean tracking every step that a patient takes from the moment they have contact with the office and walk in the door to the moment they leave including all follow-up contacts and billing.
The revenue cycle, or accounts receivable, management not only improves the financial outcome but can help to provide quality services to patients.
The completion of each step, using caution to ensure accuracy, is very important.
Important Forms
First, let’s look at the forms that you will be using both in the office setting and in this course
Sample Portion of Patient Registration Form
Provides unique information for patient identification and billing.
Forms you will use
Insurance verification form – Note, you can think of this form as a sandwich where the meat is in the middle.
The plan type (HMO vs PPO, etc.) is important if the office is helping to setup diagnostic testing or an appointment with a specialist. Knowing the plan type may indicate the need for a preauthorization.
The patient’s deductible, and if that deductible has been met, directly impacts the patient’s charge for today’s visit.
Whether the patient has a flat rate copayment or has coinsurance that is a percentage of the total bill also directly impacts the charge to the patient for today’s service.
Forms you will use
The Encounter Form (superbill)
Generated for each appointment
Provider marks procedures performed and diagnosis for each service
Used by biller to fill out the CMS 1500 form which will be submitted to the insurance company for payment in the outpatient setting.
Forms you will use
CMS 1500 claim form used for billing insurance
The UB-04 is a similar form used to bill insurance in the hospital setting.
Revenue Cycle – Step 1
Physician’s order in the hospital setting or
Patient calls to schedule appointment in the office setting
** Because there are more coding and billing positions in the outpatient setting, and because these positions typically require the employee to take on several roles, we will focus from the perspective of the outpatient setting.
Revenue Cycle – Step 2
Patient Registration
Established Patient – 3 steps
Verify patient registration information.
Collect copayment from patient.
Generate encounter form for current visit.
New patient – 8 steps (continued)
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Preregister new patient and ensure PAR status (participating provider)
On day of appointment patient completes registration form, which is inspected for completeness and accuracy. (form on slide 3)
Photocopy front and back of patient’s insurance identification card(s). (example on slide 10)
File copy in patient’s financial record.
Typical Information on Insurance Card
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Confirm patient’s insurance information by contacting payer via telephone, Internet, or fax. (form on slide 5)
Collect copayment from the patient.
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Verify information with patient.
Make appropriate changes.
Perform coordination of benefits (COB) when patient has more than one policy.
** The COB is VERY important and there are consistent rules for you to know and follow:
COB Rules for knowing which insurance to bill first:
For Adults Primary is the insurance where the patient is the policyholder versus secondary insurance the patient is listed as a dependent. (example: married heterosexual couple when patient is the wife then bill her insurance. The husband’s insurance will be secondary.)
For Children
Children of divorced parents – custodial parent’s plan is primary
If parents are remarried – custodial parent is primary, custodial step-parent is secondary and the non-custodial parent is tertiary.
Children living with both parents
Each parent has different insurance then follow the birthdate rule = parent whose DOB month and day (not year) comes first in the calendar year is primary. (if parents both born on same month and year then oldest policy is primary)
Gender rule for parents – some self-funded insurance plans use the father as primary
So, you may need to verify with the insurance plan which rule they follow.
Revenue Cycle – Step 2
Patient Registration
New patient – 8 steps
Create new patient medical record.
Generate patient encounter form. (slide 5)
Collect copayment
Revenue Cycle – Step 3
Charge Capture – may be done via a “chargemaster”, “encounter form” or computer program.
Chargemaster
Also called charge description master (CDM)
List of procedures with charges for each procedure.
Revenue Cycle – Step 4
Diagnosis and procedure coding by completing the “Encounter Form” which is then given to the coder/biller.
Revenue Cycle – Step 5
Patient Discharge Processing
Discharge instructions (hospital)
Schedule follow-up visit
Begin preauthorization process if needed for appointment with specialist or diagnostic testing.
Revenue Cycle – Step 6
Billing and Claims Processing
Complete CMS 1500 form (slide 7) for outpatient visit or UB-04 for hospital visit
** When this step is performed accurately and completely the Revenue Cycle is shortened saving frustration, time, labor and costs. No errors when filling out the claim (producing a “clean claim”) means that claims will not need to be “resubmitted” or “appealed” for non-medical reasons.
Revenue Cycle – Step 6
Billing and Claims Processing
Complete CMS 1500 form (slide 6) for outpatient visit or UB-04 for hospital visit
Signature of patient and provider required
SIGNATURE ON FILE can be substituted for patient’s signature (if patient’s signature is on file in the office).
Completed claim is proofread for accuracy.
Supporting documentation is attached to claim (if needed).
Revenue Cycle – Step 6
Billing and Claims Processing
Often providers will use a “clearinghouse” where errors can be caught, claim information is encrypted to ensure PHI is intact and submitted to the insurance provider.
**A clearinghouse can be compared to the post office where letters are checked for completed addresses and a stamp.
Claim Processing
The typical route for a claim from the office to the insurance company.
Important for HIPAA/HITECH compliance
Revenue Cycle – Step 7
Resubmitting Claims – needed due to initial errors or missing information, which leads to a claim rejection.
A rejected claim will be accompanied by a “RA” from the insurance company that will explain the missing information.
RA = Remittance Advice
Correct and resubmit
Claim Processing
Insurance Adjudication Process
{
Why Claims are Denied
Procedure/service not medically necessary
Incorrect codes or incorrectly linked codes were reported.
Preexisting condition not covered or failure to obtain preauthorization
Noncovered benefit or termination of coverage
Out-of-network provider used
Lower level of care could have been provided
Bundled service or global period service is not eligible for separate payment.
Claim contained incomplete information or another insurance plan is primary.
A Clean Claim
The revenue cycle for a “Clean Claim” (without errors or omissions) will look like this:
Revenue Cycle – Step 8
Third-Party Payer Reimbursement Posting
First party = patient
Second party = provider of care
Third party = insurance, workman’s comp, auto policy following accident, etc.
** Post the insurance payment to patient’s account
RA and EOB
The Insurance company will send the provider a RA (remittance advice) explaining the payment or denial and will send the patient an EOB (explanation of benefits).
The RA may look very similar to the EOB except the EOB will always say, “This is not a bill.”
Example EOB on next slide
Example EOB
Revenue Cycle – Step 9
Appeals process for denied claims
Rejected claim = missing information
Denied claim = coding error, lack of medical necessity, data error, patient not covered
Revenue Cycle – Step 10
Patient Billing only needed if:
Did not collect copay at time of visit
Patient has “coinsurance” that is a percentage of the bill not a flat copay
Patient has no insurance and did not pay at time of appointment
Revenue Cycle – Step 11
Patient payment is posted to their account.
Steps 12 & 13
Collections and collections reimbursement posting Have a standardized “collections
procedure”. Example on pg 108 of text.
Sample Patient Ledger
The patient ledger will contain all charges, payments and write-offs (adjustment for charge that is not “allowed” by the contract agreement between the provider and the insurance company)
This software tracks each “visit” as a transaction number. Some software will group by date of service.
In both visits logged above, it took over one month to receive payment from the insurance company.
Sample Day Sheet
What does this day sheet tell us:
There is only 1 NPI so we know that this is for one provider only.
The charge is for one procedure (adding a column for the CPT code would be helpful).
The “adjustment” is the difference between what the office charges and what the insurance contract allows.
The “credit” is what the insurance allows and the amount that should be pending from insurance.
The “Net Change” is the amount paid by the patient.
The Day Sheet is filled out each day and represents all patient visits for that day.
The day sheet can be used to provide a monthly report “at a glance” by carrying the totals from the previous day to top the list on the next day.
Sample Insurance Claims Registry
The Insurance Claims Registry is important for tracking all pending insurance payments. When an insurance claim is submitted it is logged in the registry. When the payment is received that too is logged in the registry.
The registry can be used to track payments that have not yet been received and indicates a claim that requires further investigation.
A claim that is more than 30 days old
A claim that is more than 60 days old, etc.
n67
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