coding notes

Pre-Registration and Patient Check-In Process

  • Pre-registration Overview
    • Pre-registration involves collecting patient information over the phone to schedule an appointment and verify insurance.
    • Scheduling is technically separate from pre-registration, but both processes are linked and encompass similar activities.
  • Workflow
    • Upon calling to pre-register, the office collects necessary information from the patient (e.g., personal data, insurance information).
    • Registration continues upon the patient’s arrival, including presenting insurance cards.

Revenue Cycle Steps

  1. Pre-registration

    • Patients provide necessary information about themselves and their insurance before their appointment.

  2. Financial Responsibility

    • Confirming patients have insurance coverage and understanding their financial responsibilities.

  3. Check-in Process

    • Patients check in upon arrival; their information is verified again.

  4. Review Coding

    • Ensure that the coding for procedures aligns with what is provided by the doctor.

  5. Review Billing Compliance

    • Compliance with billing regulations must be reviewed for proper billing practices.

  6. Payment Posting

    • Patients can make payments, and these must be accurately posted in the system.

  7. Checkout Process

    • Ensuring the patient is checked out properly with all discharge documentation and appointment scheduling for any follow-ups.

  8. Prepare and Transmit Claims

    • Claims for services rendered must be prepared and sent to insurance carriers.

  9. Monitoring Payer Adjudication

    • Adjudication is the process of determining whether the insurance claim will be paid or not.
    • Important to verify that payments are processed correctly and sent to the right place.

  10. Generating Patient Statements

    • After the insurance processes claims, statements must be generated for patients to inform them of any remaining balances.

  11. Follow-Up and Collect Payments

    • This involves contacting patients for any outstanding balances and making arrangements for payment.

TRICARE Overview

  • Definition

    • TRICARE is a healthcare program governed by the Department of Defense that serves active and retired military personnel and their families.

  • History

    • TRICARE replaced the Civilian Health and Medical Program of Uniformed Services (CHAMPUS) and serves approximately 9.6 million beneficiaries.

  • Program Structure

    • Managed care options that incorporate military hospitals and civilian networks to provide healthcare access.
    • All military treatment facilities (MTFs) are part of the TRICARE program.

  • Authorized Providers

    • Providers must be certified as authorized by TRICARE to serve patients.

  • Military ID Verification

    • Upon patient arrival, their military IDs are photocopied or scanned to check coverage validity.

TRICARE Non-Participating Providers

  • Charging Limits
    • Non-participating providers can charge up to 115% of the allowable charge; excess amounts may not be collected from the patient.
    • Example: For allowed charges at $50, non-participating providers may charge a maximum of $57.50 (115%).

TRICARE Plans

  • TRICARE Prime

    • A managed care plan similar to Health Maintenance Organizations (HMOs), requiring referrals for specialty services.
    • Covers essential health services meeting Affordable Care Act requirements.

  • TRICARE Select

    • A fee-for-service option allowing patients to choose any TRICARE-authorized provider, whether in-network or out-of-network, without needing referrals.
    • Not available for active-duty service members.

  • TRICARE For Life

    • Covers military retirees and family members eligible for Medicare, allowing usage of both military and civilian services.

  • CHAMPVA

    • CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) covers healthcare expenses for family members of veterans with service-related disabilities.

Compliance Guidelines for Covered Services

  • Services must be medically necessary and delivered at an appropriate level of care.

Workers' Compensation

  • Overview
    • Workers' compensation pays for medical expenses and lost wages due to work-related injuries.
  • Eligibility
    • Most states require employers to provide workers' compensation insurance to all employees.
    • Exclusions include self-employed individuals, railroad employees, and certain contractors.

Definitions and Terminology

  • Injury Coverage Types
    • Medical expenses for work-related injuries, temporary and permanent disabilities.
  • Independent Medical Examination (IME)
    • Conducts thorough assessments to confirm disability status as required for workers' compensation claims.

Test Preparation Advice

  • Key concepts related to TRICARE, CHAMPVA, and Medicaid should be reviewed as they'll be included in the upcoming test.
  • Focus on understanding the differences among TRICARE plans, including Prime, Select, and For Life, and the various coverage guidelines.
  • Study the revenue cycle steps and ensure clarity on terminology such as adjudication, pre-registration, claims processing, and coding compliance.