Untitled Flashcards Set

Utilization review (UR)- an analysis to make sure services and procedures being billed to a third-party payer are medically necessary

Third-party administrator (TPA)- an administrator who processes claims Claims administrator- manages the third-party reimbursement policies

Guarantor- the person responsible for paying the patient's medical bill Dependent- spouse, children, or other individuals covered under a health care plan.

Group insurance is most commonly purchased through an employer.

Often, the employer will pay a part of the premium.

Individual insurance is when a person purchases a policy and agrees to pay the entire premium for health coverage.

• The Affordable Care Act (ACA) opened up more options for individuals to purchase individual insurance through a healthcare marketplace at a more affordable price

Health care savings account (HSA) - allows employees to save money through payroll deduction

INSURANCE

Private programs

• Funded solely by their enrollees

• Cost and coverage benefits will vary widely

Types of private programs

• Fee-for-service- providers are paid based on the services they provide

• Value-based plans- insurance coverage that changes the amount of reimbursement based on health outcomes of patients and the quality of the service they receive

• Managed care- controls costs by requiring physicians to adhere to specific rules as a condition of payment

INSURANCE - MANAGED CARE ORGANIZATIONS (MCO)

Health maintenance organization (HMO)

• Providers receive reimbursement based on capitation, not by service

• Focused on preventive care

• Patients must see in-network providers to be covered

• Patients must choose a primary care physician (PCP)

• Requires referrals for specialists

Independent practice association (IPA): several independently practicing physicians contracted with an HMO to provide services to

HMO members

INSURANCE- MANAGED CARE ORGANIZATIONS CMCO)

Preferred Provider Organization (PPO)

• Contract with health care agencies to provide care at reduced rates

• Referrals are not required for in-network specialists

• Patients may see out-of-network providers and pay more

Exclusive Provider Organization (EPO) - combines an HMO and a

• It will not reimburse patients for visiting out-of-network physicians

• Physicians are reimbursed based on fee-for-service

INSURANCE- MANAGED CARE ORGANIZATIONS CMCO)

Point of service (POS)

• The patient selects a primary care physician (PCP) who must pre-approve visits to specialists, who do not have to be in-network

• The patient may visit out-of-network physicians if they are willing to pay a higher copayment and deductible

• For in network services, there is no deductible and copayments are lowered

INSURANCE

Accountable Care Organizations (ACOs)- group of providers who join together to provide coordinated care to their patients

• Reduces unnecessary healthcare costs

Patient-Centered Medical Homes- a model of health care delivery in which the PCP coordinates the care for patients and refers patients to other providers for medical care as needed

Workers Compensation- covers the cost of healthcare related to workplace illness or injury

• The employer can request a copy of these records so a separate medical record is created

Public programs

• Directed and funded by the federal or state government

Medicaid- For people with low income and few resources

• Federally and state-funded

• Eligibility varies by state and should be verified at each patient visit

• Covers dependents as well

INSURANCE- PUBLIC PROGRAMS

Children's Health Insurance Program (CHIP) - a low-cost insurance program for children

• Federally and state-funded

• Covers children of families who earn too little to pay for private coverage but earn too much to be eligible for Medicaid benefits

• Some states choose to cover certain adults as well, such as the parents of children who are eligible for CHIP and pregnant women

Special Needs Plan (SNP) - Plans for patients who have no income or have special medical needs

INSURANCE- MEDICARE

Medicare- For people age 65 and older and people with disabilities, as well as end-stage renal failure

• Federally funded through tax dollars

• Also funded by premiums, deductibles, and coinsurance payments that many Medicare patients pay

• Four parts: A, B, C, and D

Part A- Covers inpatient service including hospital stays, extended care, home-health, and hospice

INSURANCE- MEDICARE

Part B- Covers outpatient services including office visits, radiology, laboratory, therapy, ambulance fees, and durable medical equipment

Part C (Medicare Advantage) - covers both inpatient and outpatient services including preventive care, dental coverage, eyeglasses, and hearing aids

Part D- prescription drug coverage

INSURANCE AND BILLING

Coordination of benefits (COB) - coordinating policies for patients with multiple policies

• One must be selected as primary and the other as secondary; and tertiary if the patient has a third policy

The Birthday Rule- if a child is a beneficiary of both parents' insurance policies, the primary policy is that of the parent whose birthday comes first in the year

• If the parents are divorced, the custodial parent's insurance is primary unless stated otherwise in a court document

INSURANCE AND BILLING

Explanation of benefits (EOB)- statement from insurance that outlines the services that are being paid

Remittance advice- explanation of benefits that go to the provider which outlines how the claim was processed by the insurance company Charge entry- the process of entering the services provided into the

PMS/EHR system

Contractual adjustment- a difference between the amount billed and the maximum allowable charge

Balance billing- Physician charges the patient the difference between the physician's usual charge and the plan's allowable charge

INSURANCE AND BILLING

How fees are determined

Resource-Based Relative Value Scale (RBRVS)- the system Medicare uses to set their fees

• They take the provider's work and expenses into account as well as the malpractice risk

Diagnosis-related groups (DRGs- categories used to determine hospital and physician reimbursement for Medicare patients' inpatient services

INSURANCE AND BILLING

Advance Beneficiary Notice of Noncoverage (ABN)- a notice a provider should give a patient before service if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service

• Also known as a waiver of liability

Allowed amount-the maximum amount that a health insurance company will pay for covered health care services

Tickler file- a file reminder system

REFERRALS AND PRE-AUTHORIZATION

Referral- authorization from a medical practice for a patient to have specialized services provided by another medical facility

• Routine referrals can take 3-10 working days for approval

• An urgent referral can take up to 24 hours

• A STAT referral can be approved immediately by phone

Pre-authorization- required before certain types of treatments, procedures, or medications

• Must communicate medical necessity

• If approved, you will receive an authorization number which must be documented in the patients chart

BILLING- CLAIMS

UBO4- used for inpatient admissions, emergency services, home-health, hospice, and long-term care

CMS 1500- universal claim form used for outpatient services

• Use the encounter form to ensure accuracy

• Up to 6 CPT codes and 12 ICD-10 codes can fit on a claim form

• National Provider Identifier (NPI) - 10-digit identification number assigned to all healthcare providers

• Must be on the claim form

Charge capture and coding- the process of entering the appropriate CPT and ICD-10 codes to prepare a claim

BILLING- CLAIMS SUBMISSION

Electronic claims clearinghouse- a company that receives claims from various providers and sends them in batches to insurance carriers

Direct Data Entry DDE) - sending claims directly to the carrier

A clean claim includes all correct information that is necessary for processing

• Incomplete or inaccurate forms will be returned

CODING- ICD- 10

International Classification of Diseases (ICD-10)- the patient's diagnosis or reason for the visit

• 3-7 characters long, starts with a letter

• The more characters, the more specific the code

• Primary diagnosis- required the most resources or was primarily responsible for the services performed

• Up to ll secondary diagnoses can be entered on the claim

• The ICD-10 PCS coding system is used only for reporting inpatient hospital procedures

• The ICD-10 CM is used for outpatient services

Current Procedural Terminology (CPT) codes- represents the procedure performed in response to the physician's diagnosis

• Describes services, procedures, and supplies

• 5 digits long

• Two-digit modifiers make it 7 digits long

• Modifiers give more information about the procedure

• May indicate complexity or unusual circumstances

CODING-CPT AND HCPCS

The Healthcare Common Procedure Coding System

(HCPCS) - supplementary to codes in the CPT-4

• Durable medical equipment, medical supplies, and drugs not found in the CPT4

• Required method of reporting for all Medicare Part B claims

Downcoding- If the procedural code is too vague or too ambiguous, it will be reduced to its most basic form by the insurance carrier

MEDICAL RECORDS

Electronic Medical Record (EMR) - limited to one practice

Electronic Health Record (EHR)- can be used to exchange info among multiple organizations, offices, etc.

Chief complaint- main symptom or cause that brings the patient in to see the doctor

History of present illness (HPI)- how long it lasted or other characteristics

Patient history (PH) - medical history and social history (whether your pt smokes, drinks, exercises)

Family history (FH) - history of diseases in the immediate family

Safety Data Sheet (SDS)- describes the appropriate manner in which hazardous chemicals such as alcohol and cleaning supplies should be handled, stored, and contained in the event of an emergency