Comprehensive Guide to Patient Accounts, Practice Management, and Banking

Professional Certification and Career Paths in Billing and Coding

• The MIBC Certification: The MIBC is recognized as the only billing and coding certification available in the United States. While organizations like the AAPC offer specialized certifications (e.g., hospital coding), the MIBC is the foundational standard for combined billing and coding proficiency.
• Roles in Medical Administration:     * Coder: Focuses exclusively on translating clinical documentation into standardized codes.     * Biller: Managing patient accounts, following up on claims, and handling practice management.     * Combined Role: Many professionals handle both coding and patient accounts. This entails following a surgeon's activities from morning to night to ensure all financial aspects of their cases are managed accurately.

Financial Management and Operating Expenses

• Operating Expense Management: The primary goal of financial management in a billing office is to ensure the facility generates sufficient revenue to cover operating expenses, including rent, salaries, and potential bonuses.
• Accountability: Billers and coders are directly responsible for the accuracy of billing. They must monitor if claims are paid correctly and handle any denials or partial payments.
• Outside Accountants: Billing facilities typically work with outside accountants who balance the books, close out the month, and facilitate physician payments.

Definitions of Accounts Receivable (AR) and Accounts Payable (AP)

• Accounts Receivable (AR): Money that is expected from insurance claims or patients but has not yet been received. For example, if a facility bills out $10,000$, they might expect to receive $6,000$ based on contracts; the billed amount sits on the AR report until paid.
• Accounts Payable (AP): Management of debt incurred by the facility that has not yet been paid, such as payroll and rent.

Bookkeeping Foundations: Debits, Credits, and Records

• Debit: A bookkeeping entry that increases the accounts payable or what is owed by the provider.
• Credit: A bookkeeping entry that increases the AR or what is owed to the provider.
• Patient Account Record Requirements: Must include the name and address of the guarantor, insurance ID numbers, telephone numbers, special billing instructions, and emergency or alternative contact information.
• History of Bookkeeping: Older systems utilized a "pegboard" or masonite board with physical pegs to manually track entries before the advent of practice management software.

Transaction Posting and Analytics

• Line Item Posting: The process of posting payments against specific services (e.g., an office visit, an EKG, and a casting) rather than as a bulk sum.     * Benefits: Reduces patient inquiries because patients receive an Explanation of Benefits (EOB) that matches the line items.     * Data Analytics: Allows the practice to track what specific insurance companies pay for specific codes (e.g., $99214$) to determine if fees need to be adjusted.
• Adjustments and Write-offs: The difference between the amount billed and the amount allowed by a contract. If a provider bills $80$ and the contract allows $40$, the difference must be written off if the provider is contracted. If there is no contract, the patient may be responsible for the full balance.

Credit Balances and Refunds

• Definition: A credit balance occurs when an overpayment or duplicate payment is made, or a patient pays in advance.
• Refund Policy: Refunds should only be issued if the patient overpaid. If an insurance company overpays, the money must be returned to them. Insurance companies perform audits and may cease all future payments to a practice to recoup overpayments even years later.
• Audit Response: When a patient requests a refund due to a perceived credit, the biller should state: "I will audit your account and get back to you. If there is a credit balance that you have paid, I will certainly send you a refund."

Payment at Time of Service and Insurance Counseling

• Patient Misconception: Many patients view their insurance card as a credit card and believe they shouldn't have to pay anything. Billers must counsel them on their specific responsibilities.
• PPO vs. HMO Responsibilities:     * HMO: Patients typically only owe a co-payment unless a service is not covered.     * PPO: Co-payments usually only apply to the office visit. Patients are often responsible for $20$ of the allowed amount for additional services like EKGs or x-rays.
• Professional Sensitivity: Billers must be sensitive when asking for money, as healthcare is rarely a voluntary expense. Conversations about money should be held privately, never in front of other patients.

Refusal of Service and the Post-Op Period

• General Rule: A practice can refuse service for non-payment, with a critical exception for the post-operative period.
• Post-Op Global Period: Typically a $60$-day window following a surgery. During this time, related follow-up visits are included in the surgical fee. Practices cannot charge co-payments or refuse to see a patient for a balance related to the surgery during this time, as it could lead to legal liability if complications arise.
• Administrative Coding: Post-op visits are recorded using a specific code (e.g., $99024$) with a charge of $0 for data tracking purposes.

Legislation and Patient Statements

• Truth in Lending Act (TILA): Enforced by the Federal Trade Commission. If an agreement is made to pay a provider in more than $4$ installments, a finance charge should be assessed, and a signed disclosure statement must be kept in the patient's chart. If no finance charge is assessed, the account is not subject to TILA.
• Monthly Statements: Sent to all accounts with a balance. Billers should review statements for accuracy (e.g., checking for unearned credit balances) before mailing.
• Guarantors for Minors: Minors cannot be held financially responsible unless they are emancipated. Bills for minors must be sent to the parents/guarantors.

Financial Assistance and Indigent Care

• Medically Indigent Programs: Hospitals often have social services departments to assist patients who cannot pay.
• AB 75 (California): A program where fines from DUIs were directed into funds to help hospitals cover bills for the medically indigent.
• Victims of Crime: A program that can cover hospital bills for patients who were victims of violence and do not qualify for other insurance like Medi-Cal.
• Professional Courtesy/Hardship: Physicians may choose to waive co-payments or fees for patients facing extreme hardship (e.g., a patient with a broken car window), though this should be verified to prevent fraud (e.g., wealthy patients appearing poor).

Payment Methods: Cash, Checks, and Cards

• Cash Payments: While beneficial, large bills (over $50$) should be verified. Making change for large bills is a known method for money laundering.
• Checks:     * Verification: The written amount on the check (e.g., "Twenty dollars") takes legal precedence over the numeric amount (e.g., "$20.00$") if they differ.     * Restricted Checks: Practices should generally not accept third-party, payroll, or out-of-town checks.
• Contactless and Portal Payments: Modern practices use online portals linked to credit/debit cards, which reduces the need for awkward face-to-face money discussions.

Collections and Account Aging

• Aging Categories:     1. Current: $0$ to $30$ days.     2. Overdue: $31$ to $60$ days.     3. Hot Point: $61$ to $90$ days.     4. Difficult to Collect: $91$ to $120$ days.     5. Uncollectible ("Old Money"): Over $120$ days.
• Collection Etiquette: Calls must be made between $8:00\,AM$ and $9:00\,PM$. Billers must stay respectful and never call a patient's place of work or make repeated calls on the same day.
• Skips: An account where the patient has moved with no forwarding address. The biller must trace these through return mail and other records.

Bankruptcy and Estate Claims

• Chapter 7 Bankruptcy: "No asset" bankruptcy. The balance must be written off completely within $3$ to $4$ months.
• Chapter 13 Bankruptcy: "Wage earner" bankruptcy. The debtor pays off debt over $3$ to $5$ years. These balances do not necessarily need to be written off immediately if payments are being made.
• Patient Expiration: Once a patient dies, bills should be addressed to "The Estate of [Patient Name]" to avoid causing distress to the family.

Legal Action and Small Claims Court

• Small Claims Court: An inexpensive way to recover debt, typically limited to amounts between $2,500$ and $3,000$.
• Key Rule: No attorney is required in small claims court; often, a biller will represent the practice.
• Collection Agencies: Once an account is sent to an agency, the practice should stop sending statements. If the patient pays the practice directly after being sent to collections, the practice must notify the agency and pay them their commission (the "Net Back").

Banking and Payroll

• Federal Reserve Bank: The "banker's bank" for the US Treasury and commercial banks. There are $12$ regional banks in the US system.
• Deposit Procedures: Daily deposits must match the day's payment posting reports. Accurate records/copies of deposits should be kept for $7$ years.
• Endorsements:     * Restrictive Endorsement: Limits the check to being deposited only (e.g., "For Deposit Only").     * Signature Endorsement: A simple signature on the back.
• Payroll:     * W-4 Form: Completed by employees to set exemptions and deductions.     * Gross vs. Net: Gross is the total earned; Net is the actual take-home pay after deductions.     * Frequency: Weekly or bi-weekly is common; monthly is less desirable for employees.