HSPT billing + coding

PMS

administrative side of EHR - scheduling, entering/tracking demographics, billing procedures

RTA

• sends insurance info while patient is still at office so they know what insurance covers/what they have to pay right away

• Stored using cloud storage and easily retrieved

New pts:

not receive service within past 3 years

Established pts:

received services within past 3 years

Comprehensive:

long detailed visit for serious issues - highest coding level

Preventive Care:

check up when youŕe not sick - wellness/annual exams

Copayment:

set amount pt pays for specific service -- determined by insurance + visit

Deductible:

amount pt must pay before insurance company starts paying

Coinsurance:

percentage of allowed amount patient will pay once deductible is met

Superbill/Encounter Form:

record of diagnostic code/procedures from current visit - reason of visit, not apart of chart

Flow sheets:

record/track health data

ICD-10 CM Diagnostic Codes:

reason for visit, describes condition/cause/location/type

CPT Codes:

what was done (exam, lab) - must match

HCPCS Codes:

codes for supplies/procedures not covered by CPT

Utilization:

what insurance will cover/pay for

Precertification:

checks if service is covered/how much will be paid

Preauthorization

approval before treatment to make sure its medically necessary

CMS:

oversees Medicare/medicaid - ensure accurate efficient records

ABN:

medicare form for services that might not be covered - pt informed ahead of time, if denied → pt pays

Reconciliation:

checking accounts to make sure pt/payments are accurate

Revenue Cycle:

everything related to money for pt care (records, documentation, coding/billing, claims, payments)

Incentive Models:

shift from Fee-for-Service to Pay for Performance/Quality Care - providers earn rewards/penalties based on: care, improving pt health, etc

Accounts Receivable:

money owed to organization

A/R Aging Report:

showing outstanding balances/prioritizes older debts

Billing/Deposits:

deposits slips - for cash//checks received

Claims

must follow insurance guidelines

Clearninghouse:

edits claims/submits them to insurance

Reimbursement Claims:

must be filed on time

Denied Claims:

fix codes/support medical necessity, resubmit/appeal

Private/Commercial Insurance:

provided by employers/purchased individually - copays, deductibles, coinsurance 

In-Network:

provider contracted w/ insurance = lower costs

Out-of-Network:

provider not contracted = higher costs, insurance may pay less

HMO:

needs PCP/referrals for specialists = lower costs, must say in-network

PPO:

flexible, no referral needed = higher cots if out-of-network

Premium:

monthly payment to keep plan

Max Out-of-Pocket:

most patients will pay in a year

Pre-existing conditions:

most be covered under ACA - cannot be denied

Birthday Rule:

for kids w/ divorced patients w/ both insurance plans → primary plan = parent whose birthday comes first in the year

• 837P/CMS-1500:

used for outpatient/professional clams 

- P = professional 

- 8371 = inpatient/hospital claims

Endorsing:

signing a check

Posting Payments:

recording payments received

• Cycle billing:

• sending bills on a schedule