HAP 410 Final Exam Study Guide

Fee for Service/Indemnity

Health insurance of the 1960's, now rare because it is so expensive. First dollar coverage, usually 80% covered, 20% out of pocket co-insurance. Flexibility to choose any doctor or hospital.

Workers Compensation

Mandatory by law for any business. Covers workers who are injured which is work- related. A portion or their compensation for an extended period of time is covered, depending on severity of the injury.

Business Interruption policy

A policy which will guarantee continued revenue/cash flow to the business in the event of a catastrophic event( as a fire) or a natural disaster (hurricane/tornado)

(HDHP) High Deductible Health Plans/Consumer Directed Plans:

Due to high healthcare costs, many companies are shifting costs to their employees through higher deductibles. To go with the "stick" of higher deductibles, the 'carrot" is allowing individuals and companies to put "pre-tax" dollars in accounts to help pay for the high front end deductibles. Laws have been passed by Congress, where Health Savings Accounts (HAS), Health Reimbursement Accounts (HRA) and Flexible Spending Accounts (FSA) have been created. In 2011, pre-tax medical savings accounts under high deductible account allowances are now $1,200 per individual, and $2,400 for a family. Insurance benefits start after the deductible is met.

Deductible

First dollar out of pocket payment required by some plans before the insurance company pays. The patient, not insurance company at risk for payment of services at the beginning of the plan year.

Difference between negligence and tort as it relates to malpractice.

Negligence is the commission or omission of an act that a reasonably prudent person would or would not do under a given circumstance. A bad medical outcome is not necessary proof of negligence. The patient's attorney must show that the damages were due to an error that would not have been committed by a physician exercising reasonable care and skill. A physician is responsible for the personal care of the patient, and also for the care provided by the employees. A tort is an act where the physician sets out to, and does intentional harm to the patient. Much less common than negligence.

Premium

Paid monthly in return for coverage under the policy. Price based on contracted benefits in the health policy. Most employers pay a portion of the premium, with the employee paying a portion based on a designated payroll deduction.

Define the purpose /components of OSHA (Occupational Safety and Health Administration)

This Act of 1970. Employers must reduce/eliminate hazards in the work environment.The Acts Hazard Communication Standard is composed of five key elements. These five key elements are: 1. Materials Inventory - A list of the hazardous materials present in your work area. 2. Material Safety Data Sheets - A detailed description of each hazardous material listed in the Materials Inventory. 3. Labeling - Containers of hazardous materials must have labels which identify the material and warn of its potential hazard to employees. 4. Training - All employees must be trained to identify and work safely with hazardous materials. 5. Written Program - A written program must be developed which ties all of the above together. -TB testing...skin testing and records keeping -Bloodborn Pathogens...Exposure to blood or other bodily fluids. Universal precautions when coming into contact.

Pre Authorization

Process of reviewing certain medical, surgical, behavioral health services to ensure necessity and appropriateness of care. Many times requited for non-emergency inpatient and certain outpatient services.

Co-Insurance

Service balance that remains after the deductible and co-pay has been paid, which is the responsibility of the insured.

Referral

a form required by some insurance companies.... From a primary care practice to a specialty practice. This states the medical reason as to why the patient. It is meant to prevent "inappropriate" self referrals

What is/who qualifies for Family and Medical Leave (size or organization, minimum hours worked)

employers with 50+ employees must provide eligible (must be employed 12 months, have worked minimum of 1,250 hours) up to 12 weeks of unpaid leave for illness, birth or adoption of a child, care for a sick family member

Directors and Officers policy

in the event of a malpractice claim, the plaintiffs' attorney will also name the corporation and its offices as party to the claim. This policy protects the directors (owners) as well.

Property and Casualty Insurance

insures the assets and contents of the building.

Define Fraud

intentional deception or misrepresentation made by an individual who knows that the false information could result in benefit to him or herself, or another person. It must be proven that the acts were committed knowingly and were intentional. Examples: *Billing health plan for a drug that was never provided * Billing for services not provided * Unbundling (billing for procedures under separate codes when only a single code was necessary) * Falsifying a diagnosis in order to receive better payment * Billing for non-covered services * Submitting duplicate claims

Pre-Certification

refers to discovering whether a treatment (surgery, hospitalization, tests) is covered under a patient's contract.

Exclusions

services not covered in the policy (common are laser eye surgery, cosmetic surgery, fertility treatments.)

Electronic Health Record Defined

"An electronic record of health related information that conforms to nationally recognized interoperability (exchange of electronic health information with other covered entities under HIPAA....provider healthcare organizations, health plans, clearinghouses ) that can be created , managed, and consulted by authorized clinicians and staff across more than one health care organization." This is a hardware and software system that allows a practice to create, store, edit, and retrieve patient charts on a computer...replacing paper charts. It offers tremendous productivity and efficiency benefits to a practice, as eventually racks of paper charts will be eliminated. Most importantly, it will provide better integration of care for a patient across the health care system.

Self Insured

(A company, usually large) that creates a fund for collection of premiums/payments of claims for its employees. The Third Party Administrator is the outside company that administers the plan, processes the claims, etc. for their employees. The company assumes the risk of providing health care to their employees.

Preferred Provider Organizations (PPO)

(Has some model features of Fee for Service) Insurance companies contract with networks of providers and hospitals, from which the patient can select. Doctor accepts/insurance and patient pays a lower rate, in exchange for joining the network. Going "out of network" is much more costly for the patient. Primary care gatekeeper is usually not required.

Define Waste

* Overutilization of services or other practices that result in unnecessary costs * Generally not caused by criminally negligent actions but rather misuse of resources Example: *Ordering excessive tests on a patient *Prescribing excessive medications per standard of care.

Define Abuse

* Provider practices that are inconsistent with sound fiscal, business, or medical practices & result in: * Unnecessary cost to Medicaid/Medicare program * Reimbursement for unnecessary services or services that fail to meet professionally recognized standards for healthcare Example: ** Ordering generic medication for the patient and billing the health plan for a brand name medication

List steps in the hiring process

- Post position - Collect Resumes - Telephone Interview - On site interview/complete application - Background check/references - Selection and offer position - Orientation and on board

-Know the differences between the collaboration models we reviewed, starting with employment, and ending with PPMC, and examples of each

-Employment Model...Doctors becomes employees of the hospital or health system, vs. Owning or being employed by a physician practice corporation. (one Tax ID number) Attachment # 5, Hospitals buy Doctor Practices -Management Model- A Management Services Organization (MSO) employs office and billing service staff and contracts with physicians. Physician pays a fee to the MSO to manage the practice. Doctor maintains autonomy/ retains own separate Tax ID # -Contractual Agreements....Doctors have a contractual arrangement to provide services to the hospital. Doctors usually maintain their separate corporate structure, and bill the hospital under their tax ID number, and not as hospital employees. Examples: - Pathology - Radiology - Emergency Room - Hospitalists/Intensivists -Joint Ventures....Hospital and a group of physicians' form a separate corporate entity for joint ownership of a service. Requires agreement on shared governance, agreements in equity investments, and the sharing of profits and losses. Examples: - Surgery centers - Outpatient Rehabilitation/PT - Outpatient Radiology/Imaging - Urgent Care -Physicians and Physician Practice Management Companies (PPMC) (usually independent of hospitals, but mentioned here)........ A PPMC is usually and independent, for profit corporation, specializing in the management of a medical specialty. Physician practices can be owned/physicians employed by the PPMC, or the independent physician practice can have a management contract and pay a monthly management fee (% of collections, like Burger King Franchise owner) to the PPMC. Examples: - US Oncology - Vein Centers of America

Key players of Medicare and how its works

-Federal Government: Congress mandates and Medicare rules and regulations -Medicare Administrative Agencies: Operational responsibility. Under the Dept. of Health and Human Services is CMS (Center for Medicare Services) -Non-Governmental Medicare Agencies...Private companies called intermediaries, who contract with CMS to process claims. Also called MACs (Medicare Administrative Contractor). Very often a private insurance company as Blue Cross or Aetna may serve as intermediaries for Medicare in different sections of the country, since they have the infrastructure in place. -Hospitals provide services under Medicare Part A. -Physicians provide services under Medicare Part B...Note that a physician can be a participating or non-participating provider. To be participating, a physician must submit an application form to Medicare to provide services to beneficiaries. An NPI (National Provider Identifier) number is assigned for billing. -Participating provider sees Medicare beneficiaries and "accepts assignment" which means that they accept Medicare's fee schedule. Medicare pays 80% of allowable reimbursement, with remaining 20% collected from the patient. -Non-participating...doctor does not accept assignment. Fee schedule is 95% of fee schedule for participating provider. Payment of the claim sent to patient, not to doctor. Beneficial for doctor to be participating.

Which govt. agencies monitor fraud and abuse?

-OIG....Office of Inspector General -FBI...can investigate federal and private payer cases -DOJ....Department of Justice

Define three legged stool of hospital governance.

-The Hospital Board of Directors....community leaders, health system representative (if applicable), medical staff representatives, sometimes hospital CEO. Ultimate oversight of the hospital and the medical staff. The board has their own set of bylaws -Medical Staff....MDs, DOs , Podiatrists, Dentists , Nurse Practitioners, Physician Assistants.....who are credentialed to perform designated services and procedures by the Board of Directors, based on their education, specialty, training. The medical staff has their own set of bylaws and rules and regulations, which must be approved by the Board of Directors. In addition, the doctor must be credentialed by the insurance company in order to be considered part of the insurance company's network in order to be reimbursed, and must provide this to the hospital as well. -The Hospital Administration is responsible for the operations of the hospital including finances and employees *Note that both for privileges in a hospital, as well as to be reimbursed by insurance companies, the physician must be credentialed

Define Tricare, who it covers, basic elements

-Worldwide health services with military facilities that provides services for the military and their families. Which includes.....active duty.....retired service members,.......active/non active/retired National Guard. -Tricare provides network (military medical personnel and facilities) and non-network .benefits. Only specialized/medically necessary services usually provided out of network -The VA (Veterans Administration) provides acute care, ambulatory, and rehabilitation services to veterans. -There are also military hospitals (Walter Reed. Bethesda Naval) for active military

A good compliance plan will include:

1. Auditing and monitoring of claims 1. Practice standards for proper coding and billing. Medically necessary services, documentation supported for services in the medical record 2. Guarding against kickbacks, self referrals 3. Designation of a compliance officer, who will coordinate education and training for staff 4. Procedures for responses to inquiring from outside organizations 5. Creation of communications procedures to allow staff to report fraud and abuse internally (anonymous hotlines)

Issues for EHR implementation

1. Cost of set up and maintenance-Not only must the provider pay for the physical hardware and/or software, the organization must also put forth a considerable dollar amount for setup, maintenance, training, IT support and system updates. For many smaller practices with lower cash flow, cost alone prohibits the ability to properly implement and maintain the system. 2. Lack of physician supports, resistance to change and reduced patient interaction 3. Drop in productivity-drop in physician productivity in the initial implementation phases of the EMR. While ultimately the goal is to increase productivity in the office or hospital, expect to see a significant drop in productivity, and ultimately revenue, in the first several months. 4. Usability- Some EHR systems present usability challenges. Multiple screens, unclear navigation and too many options leave physicians and nurses frustrated or unable to process patient notes. Many practices and hospitals may not have the extra time required to learn how to work with a new system. Not understanding how to use an EHR program can have a negative impact on productivity, so overcoming usability issues is important. 5. Privacy Concerns-Paper records may be tedious and inefficient, but they don't face threats from cyber-attacks. Such security breaches could cause substantial harm to patients, as well as result in legal issues to providers.

Federal Laws Governing Wages, Hours Benefits ...know differences/definition of exempt (salary) vs. non exempt (hourly) employee classifications

1. Fair Labor Standards Law....Defines an exempt employee (executive, administrative, professional, special education, judgment and discretion independence) vs. a non-exempt, or hourly employee. Laws relating to non-exempt.....minimum wage, pay for hours clocked in, payment of overtime, (over 8 hours worked in a day). In health care, compensation for "on-call" time....on standby duty, ready to come in. Non exempt employees are entitled to overtime pay who work more than 40 hours in a given workweek, unless they meet certain exceptions. Exempt employees are employees who are not entitled to overtime pay for a various of reasons. 2. Equal Pay Act......salary disparities based on gender are prohibited. Usually males are paid at a greater rate vs. females 3. Family and Medical Leave Act .....employers with 50+ employees must provide eligible (must be employed 12 months, have worked minimum of 1,250 hours) up to 12 weeks of unpaid leave for illness, birth or adoption of a child, care for a sick family member

Four examples of major legislation for fraud and abuse

1. False Claims Act...submitting false or fraudulent claims for approval and payment 2. Civil Monetary Penalties Act....Submission of claims that the doctor knew or should have known were not medically necessary, but were furnished 3. Stark Self Referral Law.... Doctors cannot refer Medicare and Medicaid patetins for services in which they, or an immediate family member have a financial relationship 4. Anti -Kickback Act of 1986...Referral to another physician or service, where a financial kickback is made to the referring physicians. In the recent past, hospitals would recruit physicians and set them up in practice as independent practitioners. Would often include subsidized rent of a year, and a salary guarantee. In return the expectation was that the physician would send all referrals to that hospital. This is now illegal, considered a "kickback." The way around this...it is legal for a physician employed by the hospital to provide these referrals to said hospital.

Disability Discrimination

1. Federal Law prohibits employment discrimination against qualified individuals with disabilities. Handicap= A person with physical or mental impairment that limits life's activities....has a record of impairment...and is regarded as being impaired Current alcohol and drug abusers are not covered, but those in rehab are American Disability Act (ADA)...covers a qualified individual who has the required skills, experience, education to meet the requirements of a position, and who with or without reasonable accommodation can perform essential functions of the position. This requires that the employer must accommodate the physical or mental impairment of a handicapped individual, unless the job would require undue hardship on the operations of the employers business. Reasonable accommodation can include making existing facilities accessible, job restructuring, modified work schedules, providing readers of sign language...but does not require "best " or desired accommodations.

Federal Laws Governing Hiring and Termination....interview questions which

1. Interview Questions.....Only questions may be asked relating to meeting the qualifications of the position, vs. asking questions of which are non-job related/discriminatory in nature. Examples of questions you cannot ask: (1) Race, religion, national origin, age (2) marital and family status (3) height or weight (4) pregnancy (5) Arrest records 2. Screening...employer can be held liable for failing to exercise due care in hiring employees, (a day care center who hires a child abuser). Allowed are criminal background checks, references, drug screening, medical exam for essential job functions (lifting) 3. Immigration Laws....Prohibits employment of aliens or illegal immigrants...an individual not lawfully admitted for permanent residence, or is authorized to work in the US. Checking of proper ID, authorization, and completion of Immigration and Naturalization Form (I-9) 4. Wrongful Discharge...The "Employee at Will Doctrine" states that there is a legal presumption that the employment relationship can be severed either by the employee or employer for any reason at any time....Except, when there is a written or implied contract of employment. Employee handbooks usually have a disclaimer which states....."This hiring is not an explicit or implied contract."

Know the basic functions of a Human Resources Dept (12 listed in notes)

1. Keeper of Job Descriptions/Position Master 2. Keeper of wage scales 3. Compensation and Benefits Administration -Oversight of payroll system, including raises - Oversight of benefits package...vacation, holiday, sick (CLB) - Health, Dental, Vision Life. Disability Insurance...401K retirement - Sample employee benefits, 4. Employee Handbook, which includes all personnel related policies in the organization. 5. Keeping centralized employee files... Job applications, W-2 and state withholding forms, benefits (health and dental insurance applications) forms, evaluations, discipline...all except health related forms. 6. Conducts orientation/annual training 7. Keeping of health records...usually in a separate file from employee records, pre-employment physical, annual TB test, random drug testing, and release to return to work. - Oversight of Hiring Process - Post position - Collect Resumes - Telephone Interview - On site interview/complete application - Background check/references - Selection and job offer - Orientation and on board 9. Keeper of Performance -Giving an employee feedback on job performance (based on job description) -Feedback from supervisor, based usually on the job description and prior year goals from last evaluation...what the employee is doing well, what they can improve upon -Develop goals and objectives for next year, related to their job performance, their dept. objectives, and personal development (education) goals -Compensation adjustment/bonus/incentive pay based upon performance appraisal 10. Oversight of Disciplinary Action Program 11. Dealing with Employee Resignations, Terminations, and Other Departures 12. Development of Strategies with Diverse Demographics of the 21st Century workplace - Strategies for accommodating cultural and religious diversity in your workplace and patient population, - Strategies for accommodating generational differences in your workforce and patient population,

Race and National Origin Discrimination

1. Prohibits discrimination based on race or national origin. - Most common complaint is when a white individual is selected for a position vs. an equal Non- qualified white, although whites have sued on the basis of "reverse discrimination" - More subtle practices include racial discrimination due to a candidates or employee's arrest record, credit rating, or termination due to excessive wage garnishment, theory being minorities have higher probability of these - Employers may defend charges due to a business reason...hospital moving to suburbs attracts less minority candidate.

Details of the ACA

1.Employers may continue to provide employer based coverage. Beginning in Oct.2015 (delayed from 2014) employers of >50 employees, AND whose employees work more than 29 hours per week will be required to provide health insurance for their employees. If they do not, then the IRS (Internal Revenue Service is responsible for monitoring the program and issuing penalties) will impose a $2,000 penalty per year per employee 2. Medicaid coverage for the indigent will be expanded, so that more at or close to the poverty line will be covered. Close to $1 Trillion over 10 years will be allocated to these patients, which will mean Medicaid reimbursement will equal Medicare....(currently Medicaid reimbursement is approx. 80% of Medicare.) 3. Medicare coverage will continue. However, to fund the increase in Medicaid, and to keep the ACA "budget neutral" the $1 trillion listed above will be cut from Medicare over ten years. (Will this result in decreased Medicare reimbursement, where doctors and hospital will elect to see less Medicare patients? Rationing of care for Medicare patients?) 4.30 million patients will be receiving, or will be required to purchase health insurance. With this influx of patients in the system, many argue that there will not be a corresponding increase in physicians, resulting in longer waits/less access. a. (Yes, you can have coverage, but is there corresponding access into the healthcare system?) 5.The "working poor" and all people (young and healthy including college students)/middle class, etc) without current health insurance will be required to purchase a policy by 2014. If they do not, they will be taxed or fined at a maximum of 2.5% of their adjusted gross income. This must be indicated on the yearly tax return, enforced by the IRS. These fines will be place into a pool to cover the healthcare costs of those who do not elect to purchase health insurance. 6.For those without health insurance and who elect to purchase a policy there will be Health Insurance Exchanges created. This will be created either by the state government, or if they elect not to, the federal government. This is a forum where buyers (prospective subscribers) and sellers (private insurance companies who elect to sell) come together in a completive forum to buy and sell insurance. In theory, the private insurance companies either improve their price, or get run out of the Exchange. There are certain mandated govt. benefits under a plan purchased. For example, ALL will have OB/GYN services, pediatric dentistry, and birth control included. Relevant for a 50 year old couple?!

Pre-authorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.

What does a clearinghouse do?

An agency that is an interface between the practice and the payer, both private and governmental. They validate the claim as complete and accurate before it is sent to the payer. A claim is "scrubbed" by them. If it is not "clean" (inaccurate patient or practice information) it will be rejected, resulting in re-work and delays. The right combination of the billing group number (tax ID), place of service, physician, correct codes and modifiers must all be present and correct.

CPT code? Most common CPT code/how it is numbered?

CPT (Current Procedural Terminology) ) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer. Since everyone uses the same codes to mean the same thing, they ensure uniformity. It should be noted, however, that uniformity in understanding what the service is, and the amount different practitioners get reimbursed will not necessarily be the same. For example, Doctor A may perform a physical check up (99396) and be reimbursed $100 by your insurance company. If you went to Doctor B, his reimbursement by your insurance company for that same checkup, Code 99396, might only be $90. (This is not true for Medicare patients. Medicare uses HCPCS codes instead.) The most common CPT code is New Patient: 99205

Define CLIA (Clinical Laboratory Improvement Amendments )/purpose of CLIA regulations...which department in the practice does it apply to?

Congress passed this Act in 1988 to establish quality standards for all non-research laboratory testing: • Performed on specimens derived from humans; and • For providing information for the diagnosis, prevention, and treatment of disease or impairment, or assessment of health. CLIA mandates that virtually all laboratories, including physician office laboratories, meet applicable Federal requirements and have a CLIA certificate to operate. CLIA regulations establish quality standards for laboratory testing performed on specimens from humans, such as blood, body fluid and tissue, for the purpose of diagnosis, prevention, or treatment of disease, or assessment of health. CLIA requires the U.S. Department of Health & Human Services (HHS) to certify laboratories performing non-research testing. The Centers for Medicare & Medicaid Services (CMS) administers the CLIA certification program for HHS along with the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC).

Types of plans

Fee for Service/Indemnity, PPO, HMO (capitation), HDHP

Penalties of violating HIPAA

HIPAA Violation: Individual did not know (and by exercising reasonable diligence would not have known) that he/she violated HIPAA HIPAA violation due to reasonable cause and not due to willful neglect. Minimum Penalty: $100 per violation, with an annual maximum of $25,000 for repeat violations (Note: maximum that can be imposed by State Attorneys General regardless of the type of violation) Maximum Penalty: $50,000 per violation, with an annual maximum of $1.5 million HIPAA violation due to reasonable cause and not due to willful neglect Minimum: $1,000 per violation, with an annual maximum of $100,000 for repeat violations Maximum: $50,000 per violation, with an annual maximum of $1.5 million HIPAA violation due to willful neglect but violation is corrected within the required time period Minimum: $10,000 per violation, with an annual maximum of $250,000 for repeat violations Maximum: $50,000 per violation, with an annual maximum of $1.5 million HIPAA violation is due to willful neglect and is not corrected Minimum: $50,000 per violation, with an annual maximum of $1.5 million Maximum: $50,000 per violation, with an annual maximum of $1.5 million

Direct Contracting

Health insurance coverage may also be obtained through this. Under this, the employer arranges for health services directly with a provider, outside of the framework of a commercial health care plan. This may work best when a third-party administrator (TPA) is hired to handle the administrative issues. However, employers may be reluctant to engage with a TPA if they consider a large part of the high cost of managed care plans to be administrative cost.

Define differences between ICD-9 vs. ICD-10.

ICD 9: 3-4 numbers in length About 14,000 codes First digit may be alpha (E or V) or numeric; digits 205 are numeric Limited space for new codes Lacks detail Lacks laterality (Right, left) 17 chapters ICD 10: 3-7 alpha numeric characters in length About 69,000 codes Digit 1 is alpha; digits 2 and 3 are numeric; digits 4-7 are alpha or numeric Flexibility for adding new codes Very specific Has laterality 21 chapters

Examples of revenue producing services, and the types of specialties which may implement specific types of services ( example: orthopedic group most likely to implement Physical Therapy services)

In addition to seeing patients in the clinic setting, physician offices very often offer services both for the convenience of the patient, and to produce additional revenue for the medical practice. - Physician office lab (POL). Lab test specimens are collected and analyzed in the practice. It should be noted that many practices do not offer lab services because of the cost as related to labor equipment and supplies, and also many insurance companies will not contract with a physician lab because the per unit cost of running a test is so much higher than a reference lab which produces hundreds of tests every day, at a much lower per unit cost. The POL must conform to the Clinical Laboratory Improvement Act of 1988. These labs must obtain a certificate of registration, or certification from the government to meet certain clinical and quality standards. This is obtained following a government inspection. -On Site Radiology (x-ray) testing......very often in orthopedic practices and urgent care. Certified radiology tech on site is needed. Must conform to clinical and quality inspections to become certified. -Echocardiography...ultrasound scans of the body. Very often on cardiology and OB/GYN to check on the fetus. -EKG....Measure activity of the heart. A basic test most adult medicine practices offer. -Treadmill/Stress Test.....measures performance of the heart under strenuous activity

what is a behavioral interview?

Is a structured strategy that is based on past behavior being the best predictor of future performance. Future job success is predicted by examining behavior in past-job related situations. The interview questions are based upon actual experience, give examples of competencies sought, open-ended, seek extreme examples, and avoid hypothetical

Examples of why claims are rejected.

It could be a result if a pre-existing condition, a cosmetic rather than a medically necessary procedure, or the purchased coverage did not cover the type of procedure performed

Importance of mapping work flows before and after EHR implementation

It is important to do a process and needs assessment. This is an analysis of current work flow.... how the individuals' work is sequenced, and how the work is transferred within the organization Eliminate redundancy and streamlines work flow. Usually headed by outside consultant. The desired work flow is then developed. This is called the operational analysis, which looks at the whys and what for of the workflow analysis. What can be modified for the greatest efficiency?

How/Why Medicare rates are used as a benchmark in rate negotiations for managed care contracting.

Managed care contracts are an essential part of a sound financial strategy. Successful managed care contracts can preserve revenue and yield additional dollars through new insurance products and models. They can also enhance patient satisfaction, because they facilitate patient access to comprehensive treatment and services. Using medicare rates as a benchmark will ensure that your CPT codes are above your payer contracted rates.

Four Parts of Medicare

Medicare, Part A...hospital services, including inpatient hospitalization, Skilled nursing, Home care, hospice care. Patients have a 90 day hospital stay benefit in a given benefit period (usually one year), plus a 60 day lifetime reserve. Patient must enroll at the time just before or after 65th birthday. Premiums covered under Social Security. Medicare Part B....Physician/nurse practitioner services services, outpatient hospital services, hospital and ambulatory surgery, physical and speech therapy, chemotherapy. Patient must be enrolled in Part A, and then pays monthly premium out of pocket. Medicare Part C...... Started in 1997, also called Medicare Advantage or Medicare Managed Care. Broader in-network coverage (more restrictive), lower out of pocket costs vs. Medicare Part B. Plans to phase this down/maybe out. Medicare Part D......started in 2006. Voluntary drug benefit program. Patient must enroll in a private insurance plan approved by Medicare for Part D. Coverage. A restricted formulary is provided based on the diagnosis and treatment of a medical condition.

Achieving Meaningful Use

Once the system is up and running, Medicare and Medicaid have programs providing financial incentives for achieving levels of quality care, identified by this concept. This concept is using certified electronic health record (EHR) technology to: * Improve quality, safety, efficiency, and reduce health disparities * Engage patients and family * Improve care coordination, and population and public health * Maintain privacy and security of patient health information Ultimately, it is hoped that the meaningful use compliance will result in: * Better clinical outcomes * Improved population health outcomes * Increased transparency and efficiency * Empowered individuals * More robust research data on health systems This concept sets specific objectives that eligible professionals (EPs) and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services (CMS) Incentive Programs.

Optimal time for reminder call for upcoming appointment

Optimal time is 48 hours prior to apt.

Understand the concept of Population Health (PMH)

Population health is the delivery of high-value, cost effective care designed to improve the quality of care in the area. PMH utilize strategies to successfully manage the health needs and risk factors of an increasingly diverse population. For example, effective PMH strategies include assembling and identifying the right mix of staff and skills for a given population, offering the right intervention to the right patient at the right time, or building in high-quality clinical evidence.

Insurance payment

Portion of health services paid by the insurance carrier. Amount paid is in the insurance policy.

Pregnancy Discrimination

Pregnancy discrimination Act (PDA) of Title VII...prohibits against employment decisions made on the basis of pregnancy, childbirth, Related medical conditions...as long as they can meet the job requirements.

Referral

Process of sending a patient to another provider for services or consultation that the referring source believes is outside their scope of practice. This must be approved by the insurance company. Meant to cut down on unnecessary services.

Pros and cons of an automated phone answering system, vs. a "live person"

Pros: •Automated maintenance •Automated system upgrade •No more physical equipment/devices/hardware •Portability •Mobility •Great costs saver Cons: •Subscribers are locked-in with the provider •Limited SIP trunks •Call quality •Downtime •Limited purchase options •Security issues •Patients feel less comfortable and taken care of.

Age Discrimination

Protection to employees 40 - 65 years old. Age Discrimination Employment Act (ADEA) Discrimination against hiring, termination, compensation, promotions etc. due the age of the employee. Courts have generally ruled that an employee must demonstrate age discrimination, without which the adverse employment discrimination would not have been made

Know /Define terms in "Who's Who" in Health Insurance

Provider: is the medical professional who provides the healthcare services to the patient. In the medical office, this is usually the doctor, nurse practitioner, and physician assistant. Policy Holder: whose name is covered by the insurance company. Ultimately responsible for payment of the bills. Makes it possible for Dependents (spouse, children, significant other) of the insured to be covered.

What is an RVU? Who/why were they developed? Three components of RVU.

Relative Value Unit (RVU)... a standardized, collective value assigned to a procedure or service for reimbursement purposes. Also a cost base for the skill, time and resources involved in every physician service provided to patients. Three components of the RVU are: (1) Physician work component, (2) practice expense (3) malpractice expense. The original work RVU.s came from a Harvard University study. Each CPT code has a RVU assigned to it, which, when multiplied by the conversion factor (CF) and a geographical adjustment (GPCI), creates the compensation level for a particular service.

Co-Payment

Required payment to the provider or institution at the time of service, per the policy. Very common for patient to pay a $10-$25 in a doctor's office for this.

Risk management

Risk is a potential variation in outcomes. When risk is present, outcomes cannot be forecasted with certainty. As a result, risk gives rise to uncertainty. To guard against rick, and to protect potential liability (monetary, negligence, criminal) the medical practice must purchase various types of insurance policies, like workers comp, malpractice, general liability,

Key elements in employee handbook/personnel policies.

Some key components are the disciplinary polcies, compliance plan/code of conduct, and HIPAA. Some examples are; Personnel Adminstration, employment policies, standards of conduct, wage and salary policies, pay period and hours, performance and compensation reviews, work schedule, combined leave benefit, Workers Compensation, Retirement plan,

Basic of Obama Care

The ACA was passed in 2010. Driven by President Barak Obama, with passage by Democratic votes exclusively in the House of Representatives and Senate, and deemed constitutional by the Supreme Court in 2012. Driving Forces: 1.Aging and increasing population 2.30 million uninsured in the US 3.Escalating healthcare premiums for insurance, and costs, as healthcare consumes 17% of our GNP 4.Desire to provide affordable/accessible/high quality healthcare

Physicians can participate through MIPS or APM, define and understand

The MACRA QPP (Quality Payment Program) will help us to move more quickly toward our goal of paying for value and better care. The Quality Payment Program has two paths: 1. Merit-Based Incentive Payment System (MIPS) 2. Alternative Payment Models (APMs)

Health Savings Accounts (HSA):

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provided for this plan. This is a medical savings account that participants fund with before-tax dollars. The money in this plan can be used for both current and future qualified medical expenses. Savings not spent within the year in which the contribution is made can be carried over for use in future years. They are coupled with high deductibles health plans in which deductibles and out of pocket expenses are defined and adjusted annually. They do not allow participants to be covered by secondary insurance. This plan both individuals and employers to make contributions to the account. They differ from HRA's, in which no separate savings account established.

Which govt. agency enforces HIPAA?

The Office of Civil Rights is responsible for implementing HIPAA, and depending on the degree of violation, penalties can be criminal and civil, including fines and imprisonment. Depending of the size of the breach (number of patients impacted), there may be required public disclosure, including informing local news outlets.

Define covered entities/ business associates who they are, what they mean under HIPAA, as related to exchange of PHI

The Privacy Rule protects protected health information (PHI) disclosure except to those with a "need to know" based on the medical treatment of a patient for "Covered Entities." A covered entity is a: 1. Healthcare provider and/or organization as a hospital, medical practice, and long term care facility. 2. A Health Plan 3. A billing Clearinghouse A business associate is a person or organization other than a covered entity that performs certain services on behalf of a covered entity that has access to personal health information. The business associate needs to have business associate agreement with the covered entity.

Best time/location for collecting co-pays

The best time and location is at the front desk during check out. .

Concept of an infrastructure for a self -insured company

The concept of this is allowed from COBRA (Consolidated Omnibus Budget and Reconciliation act of 1978): Employees can pay out of pocket to continue employer sponsored health plan 18 months after leaving the organization. The COBRA act dictates that employers with 20 or more employees must offer continued health insurance coverage to qualified employees or their families. COBRA allows employers to charge the insured up to 10% of the monthly premium to maintain coverage. Self Insured companies can have multiple plan designs, such as Flexible Savings Account (FSA), Health Reimbursement Account (HRA), and Health Savings Account (HSA).

Understand each step in the revenue cycle process: 1. Collection of Information from the Patient (Front Desk Function):

The first step of the revenue cycle process involves: •When the patient calls to schedule a visit with the practice, the appointment scheduler should obtain accurate basic demographic and insurance information before the actual visit. This is also called the pre-registration process. It is assumed that insurance verification has taken place before the patient arrives. Prior authorization for procedures from the insurance company should also be completed prior to arrival of the patient. •In addition, key financial policies should be communicated to the patient regarding no-shows, expected time of payment, and payment plans. •When the patient arrives, the front desk/registration staff must gather /verify demographic information as name, DOB, address, employer, insurance company (group number, member number), authorization for release of information, assignment of benefits. This is called the intake or registration form, completed by the patient. •Scanning/copy of driver's license •Scanning copy of insurance card at every visit (credit card analogy),

Know and define high end, desired, floor/bottom targets in negotiations

The high-end target is the negotiators optimal goal The floor/bottom target (the resistance point) is the negotiators bottom line ZOPA (Zone of possible agreement) which is the spread between resistance points Settlement point: where both parties believe this is the best they can get.

Understand each step in the revenue cycle process: (6) Working Claims/Insurance Company (Biller function)

The sixth step of the revenue cycle is when once the insurance company pays the claim either electronically (electronic funds transfer) or by paper check, (or rejects the claim for nonpayment) and Explanation of Benefits (EOB) form is sent either electronically (electronic remittance advice) or by paper to both the medical practice and the patient.

Advantages/disadvantages in using a collection agency. Impact of write offs on accounts receivable

They use a variety of methods to collect these funds from the patient. They will usually retain 30-50% of the amount collected, with the other portion going to the medical practice. Advantages: (1) Free up your time and resources (2) They have tools that you do not (3) They are professionals who can normally collect when you cant. Disadvantages: (1) A collection agency is pricy (2) It may affect client relations (but your patient may or may not be dropped from the practice for being sent to collections). If a patients accounts receivable is identified as uncollectable, it is written off by removing the amount from Accounts Receivable. The entry to write off a bad account affects the balance sheet. Accounts: a debit to Allowance for Doubtful Accounts and a credit to Accounts Receivable. The purpose of the write off is to support accounting accuracy objectives and create a tax savings for asset owners. Write-offs reduce tax liability by creating (non-cash) expenses that result in lower reported income.

MACRA (the Medicare Access and CHIP Reauthorization) Act

This act of 2015 makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP): •Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers' services. •Making a new framework for rewarding health care providers for giving better care not more just more care. •Combining our existing quality reporting programs into one new system.

The HITECH (The Health Information Technology for Economic and Clinical Health) Act

This act was enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. Under this Act, funding will be available to EPs and eligible hospitals (collectively, "Providers"). Funds will be distributed through Medicare and Medicaid incentive payments to Providers who are "meaningful EHR users." In addition, with regard to the Medicaid program, federal matching funds are also available to state governments to support their administrative costs associated with these provisions. In general, the incentive payments begin in 2011, and gradually decrease through 2014. Moreover, beginning in 2015, Providers will be subject to financial penalties under Medicare if they have not adopted and are not actively utilizing Certified EHR Technology in compliance with the "meaningful use" definition The MACRA QPP will help us to move more quickly toward our goal of paying for value and better care. The Quality Payment Program has two paths:

Employment at Will Doctrine

This document states that there is a legal presumption that the employment relationship can be severed either by the employee or employer for any reason at any time....Except, when there is a written or implied contract of employment. Employee handbooks usually have a disclaimer which states....."This hiring is not an explicit or implied contract."

What is included in an EOB (Explanation of Benefits statement)? Who generates, and who receives? Is an EOB issues for both approved and denied claims?

This informs the recipients about claims payment or action taken relating to a filed claim, from the insurance provider. It will contain information as date of service, description, and place of service, and amounts charge/allowed. It will also show items relating to the patient as co-payment amount, deductible, and co-insurance. If a practice is "out of network" or does not participate with the insurance carrier, the patient responsibility will be much higher. An EOB is issued for both approved and denied claims.

Merit-Based Incentive Payment System (MIPS)

This is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program in which Eligible Professionals (EPs) will be measured on: • Quality • Resource use • Clinical practice improvement • Meaningful use of certified EHR technology

Understand the concept of primary care medical home (PCMH), why they have been developed, purpose they serve

This is a physician practice and patient partnership that provides accessible, interactive, family focused, coordinated and comprehensive care. It is about managing care inside and outside of the office. Some basic core concepts: (1) Team-based coordinated care of the whole patient directed by the physician (2) Patient involvement (self-management of chronic condition and involvement in decision making (3) Planned, proactive visits (4) Enhanced access for patients (email communication or expanded hours) (5) Use of technology (EMR) (6) Different reimbursement methodology. It was developed for patients and physicians who want to ensure that decisions respect patients' wants, needs, and preferences, and that patients have the education and support they require to make decisions and participate in their own care.

Define Protected Health Information (PHI) policy as related to HIPAA

This is a policy that protects against "Identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. "Individually identifiable health information" is information, including demographic data, that relates to: • The individual's past, present or future physical or mental health or Condition: • The provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security.

What do hospitals hope to accomplish by purchasing medical practices/employing doctors?

This is done in an effort to move away from fee-for-service reimbursements. Another reason is Larger institutions have more bargaining clout with insurers. They promote a system that pays for treatment focusing on outcomes and cost containment. Another reason hospitals are employing more doctors is to get their incentive payments. Also, Hospitals move to buy doctors practices, because care increasingly shifted from in-patient hospital care to an outpatient setting.

Credentialing and what is reviewed

This is the process of checking the credentials of health care practitioners and facilities, protect consumers from fraud by ensuring the practitioners and facilities have the proper qualifications to deliver health care services. A physician's curriculum vitae that should contain the general identifying information relating to an applicant and the complete education and training history of the applicant. The work history should include all of the applicant's affiliations with hospitals they have privileges at. In addition, all professional associations, with months and years noted. All current and past state licenses, professional certificates and practice specialty information (e.g. board certification). An applicant's malpractice claim history, medical liability insurance information, and any information related to the practice (e.g. address, tax identification number, fax number, etc.). The providers continuing medical education documentation is also required.

Professional Liability (malpractice) Insurance

This is to guard against rick, and to protect potential liability (monetary, negligence, criminal) the medical practice must purchase this type of insurance. It protects against: Negligence is the commission or omission of an act that a reasonably prudent person would or would not do under a given circumstance. A bad medical outcome is not necessary proof of negligence. The patient's attorney must show that the damages were due to an error that would not have been committed by a physician exercising reasonable care and skill. A physician is responsible for the personal care of the patient, and also for the care provided by the employees. A tort is an act where the physician sets out to, and does intentional harm to the patient. Much less common than negligence.

What is an ICD Code?

This is used to provide a standard classification of diseases for the purpose of health records. The World Health Organization (WHO) assigns, publishes, and uses this to classify diseases and to track mortality rates based on death certificates and other vital health records. Medical conditions and diseases are translated into a single format with the use of this.

Value-Based Reimbursement

This model includes pay for performance, where providers receive incentives for meeting quality targets. Shared-saving contracts, in which payers share with providers the cost savings achieved through this model to provide care. Bundled payments, in which healthcare facilities and providers agree to a single payment for all care and service associated with a specific condition or treatment. The health system's effort to move towards this model is fueled by improved patient satisfaction, improved compliance with evidence based-measures, and a reduction in errors. The goal is for providers and the payer to share the upside and downside risk of managing a population.

What is insurance verification? What information to be obtained during the insurance verification process?

This occurs when the insurance information is checked again when the patient comes in for the appointment. The verification includes: Do we have a contract with the insurance company? Is each doctor in the practice covered? Is the patient currently covered (check eligibility)? What is the co-pay, co-insurance, deductible? Are the services we plan to provide the patient covered in his/her policy?

What is a RAC (Recovery Audit Contractor) audit? Who conducts?

This program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to healthcare providers under fee-for-service (FFS) Medicare plans. The United States Department of Health and Human Services (DHHS) is required by law to make the program permanent for all states by January 1, 2010 under section 302 of the Tax Relief and Health Care Act of 2006. In section 306 of the Medicare Modernization Act of 2003, the United States Congress directed the DHHS to conduct a three-year demonstration program to detect and correct improper payments in the Medicare FFS program. DHHS, through its Centers for Medicare and Medicaid Services (CMS) branch, began the program in 2005, using this program to perform the actual work of reviewing, auditing, and identifying improper Medicare payments. At the inception of the program, it focused on Medicare payments in the states of California, New York, and Florida. The program eventually expanded to all states. By the end of the demonstration, (2003-2007) the program had recovered nearly $693.6M on behalf of CMS.

What is personal protective equipment (PPE)

This refers to protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection. The hazards addressed by protective equipment include physical, electrical, heat, chemicals, biohazards, and airborne particulate matter.

Purpose/Functions of Patient Portal

This service has improved satisfaction and streamlines administrative services for providers and staff. It is a way to deliver access to information and related services directly to the patient. It is a secured messaging system between patients and providers, online bill pays, and patient lab results. It also allows patients to view clinical noted from physicians in all primary and specialty areas. It minimizes information overload for patients because information is stored in one place.

Define Medicare and who is eligible

This started in 1965 under President Lyndon Johnson. A federal health insurance entitlement program compliments the Social Security, passed in 1935. The beneficiary eligibility include individuals 65+, younger individuals with disabilities, and individuals with end stage renal disease.

Gender Discrimination

Title VII of the Civil Rights Act of 1964 is a federal law that prohibits employers from discriminating against employees on the basis of sex, race, color, national origin, and religion. It generally applies to employers with 15 or more employees, including federal, state, and local governments.

What is a compliance plan? Why is it necessary?

To help guard against fraud and abuse, hospitals and medical practices should develop this plan. The key is to make staff aware of what fraud and abuse "looks like" and to guard against fraud and abuse, before an outside entity does. The goal of this corporate plan is to work with employees, physicians, volunteers, and business associates to insure that they conduct activities in full compliance with applicable federal, state, and local laws, regulations, policies, and ethical standards. The committee comprises a chairperson, and multidisciplinary membership throughout the medical practice.

Federal Anti-Discrimination Laws

applies to employers with 15+ employees. Overseen by the Equal Employment Opportunity Commission, a Federal Govt. agency

Health Reimbursement Accounts (HRA):

are insurance plans partially self funded by the insured's employer, who pays a premium up to a cap. The employer receives business expense tax savings when distributions are made. They do not have any health insurance requirements and look like traditional insurance to the insured. They are designed at the discretion of the employer.

Flexible Savings Account (FSA):

are set up by employers to allow employees to use pre-tax dollars, set aside through payroll deduction, to pay for unreimbursed qualified medical expenses. While usually funded by employees, employers may also contribute. Like HRAs, there is no insurance requirement for participation. Money in this type of account must be withdrawn for services provided within the calendar year in which the money is set aside. Any unused funds are forfeited to the employer. Unlike, HSAs, they are not portable.

Scope of practice

describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. This can be determined by education and training, governing body, and the institution.

Health Maintenance Organization (HMO)

focuses on preventive care. Primary care physician is the gatekeeper in the network established by the insurance carrier, which means that referrals are required to see a specialist, and pre-authorizations to be admitted to a hospital. Going out of network usually prohibited. Per some plans, the primary care doctor paid on a captitated basis, which means a set fee, is received per member per month, to manage the care of the patient with a focus on prevention. Kaiser Permanente is a nationally known one.

Practice management software (PMS):

is a category of healthcare software that deals with the day-to-day operations of a medical practice. Such software frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payors, perform billing tasks, and generate reports. This is often connected to electronic medical records (EMR) systems. While some information in this software and an EMR overlaps — for example, patient and provider data — in general the EMR system is used for the assisting the practice with clinical matters, while this software is used for administrative and financial matters. Medical practices often hire different vendors to provide the EMR and this system. The integration of the EMR and this software is considered one of the most challenging aspects of the medical practice management software implementation.

Business associate agreement under HIPAA (U.S. Health Insurance Portability and Accountability Act of 1996)

is a contract between a HIPAA covered entity and a HIPAA business associate (BA). The contract protects personal health information (PHI) in accordance with HIPAA guidelines.

Accountable Care Organizations (ACO)

is a healthcare organization that ties payments to quality metrics and the cost of care. In the USA are formed from a group of coordinated health care providers. This concept adopts alternative payment models. It must abide the rules in five key areas in order to link the amount of shared savings this concept can receive: (1) Patient/caregiver experience of care, (2) Care coordination, (3) Patient safety (4) Preventive health, and (5) At risk population elderly health.

Alternative Payment Models (APMs)

is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients' outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM. APMs give us new ways to pay health care providers for the care they give Medicare beneficiaries. For example: • From 2019-2024, pay some participating health care providers a lump-sum incentive payment. • Increased transparency of physician-focused payment models. • Starting in 2026, offers some participating health care providers higher annual payments.

Carrier

is the one that writes and administers the health insurance policy

Third Party Administrator

is the outside company that administers the plan, processes the claims, etc. for the self insured.

Pre Determination

means discovering the maximum dollar amount that the carrier will pay for services (surgery, consulting services, radiology.)

Define Medicaid, who it covers, basic elements

provides benefits to low income groups with no or limited health insurance. Federal government provides general guidelines and funding, but Medicaid programs are administered by each state. Fee schedule is usually less than Medicare, maybe 75-80% of Medicare fee schedule. Usually $3.00 co-pay. The indigent population, along with low reimbursement makes it unpopular with most doctors. Covers basic preventive services, "bare bones coverage"

General Liability Insurance

provides for coverage in case of injury by a patetin or visitor on the premises / non-medically related. (Patient trips over loose carpet and breaks a leg)

What do we mean by "professional courtesy"....is this now illegal?

taking care of the families of other physicians without charge. It is illegal to write off, or forgo co-payment for another doctor or their family.

Beneficiary

the person eligible to receive benefits under the health insurance policy.

Sexual Discrimination

this equals harassment, decisions based on pregnancy, unequal pay for unequal work, discrimination vs. transgender employees. Sexual Harassment=...unwelcome sexual advances...requests for sexual favors....verbal or physical contact of a sexual nature (Clarence Thomas and Anita Hill) And accuser must show that.... advances were made...they were unwelcome...harasser threatened retaliation. Also can apply to "same sex complaints" Supervisor vs. co-worker as harasser makes a difference

Examples of RAC (Recovery Audit Contractor) Program risk areas to the practice which can be audited.

was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to healthcare providers under fee-for-service (FFS) Medicare plans. -Billing for services not documented (may be billed on the fee ticket, but not documented in the medical record - Duplicate billing.....billing for the same service twice - Up-coding....billing for a higher code than what was documented in the medical record, per services provided. Example billing for a complicated 99215 patient visit, when a routine 99213 was appropriate - Improper use of provider numbers, meaning the billing was submitted under another physician's name in the practice that did not actually provide the service. (A new physician is hired by the practice, and his/her credentialing information has not been approved by the insurance companies. The practice, in order to obtain payment, may be tempted to submit his/her billing under the name of another physician who did not provide the services) - Waiver of co-pays...by law/per insurance contract, the practice must collect the designated co-pays listed in the insurance card - Professional courtesy.....which means physicians cannot write off services proved to other physicians

Understand each step in the revenue cycle process: (10) Use of Collection Agencies (Collector Function)

• After repeated attempts, some patients simply will not pay their responsibility for the patient account. In this case the account should be referred to an outside collection agency. • The account is written off as bad debt, with the amount taken off of the patient account • The collection agency will use a variety of methods to collect these funds from the patient. The collection agency will usually retain 30-50% of the amount collected, with the other portion going to the medical practice. • Once an account is written off, the patient should not be allowed back into the practice.

Understand each step in the revenue cycle process: (3) Charge Capture (Physician Function, reviewed by biller)

• Assigning appropriate charges for every billable procedure delivered to the patient by the provider so money can be collected • Capturing the correct charge means the doctor is listing an accurate diagnosis and procedure code on the fee ticket. The Fee Ticket or in the electronic medical record charge capture at the time of service. Untimely or inaccurate charge capture by the physicians can result in a real slow down in the revenue cycle.

Understand each step in the revenue cycle process: (9) Rejections. Denials, and Appeals (Biller function)

• Insurance companies can reject or deny claims for a variety of reasons. It could be a result if a pre-existing condition, a cosmetic rather than a medically necessary procedure, or the purchased coverage did not cover the type of procedure performed • Private insurance companies must follow state regulations in regards to a practice or a patient filing an appeals process. Medicare also has an appeals process. Like anything else, depending on the individual case, the appeal may or may not be successful in receiving payment form the insurance company or Medicare

Understand each step in the revenue cycle process: (4) Charge Entry (Biller function)

• Logical follow up to charge capture, where accurate charges must be posted in the computer system every day to the patient account. Charges posted should balance to the fee ticket, and to the completed batch. • Every day a missing ticket report should be run to make sure all billable encounters have been submitted. Encounter forms need to be matched to the charges posted that day to make sure none are missing.

Understand each step in the revenue cycle process: (7) Working Claims/Patient Responsibility (Biller/collector function)

• One patient balance is determined from the EOB, self pay amounts should be reclassified to patient responsibility in the patient account system. • Encourage the staff to be assertive, not apologetic about collecting money from patients. • Collecting money is difficult. Train staff so they can be direct, non-argumentative, intelligent, confident, businesslike, courteous, and flexible. • If necessary set up payment installment plans for patients, and monitor compliance on a monthly basis.

Understand each step in the revenue cycle process: (5) Generating and Submitting Claims (Biller Function)

• The electronic claims should be filed every day to ensure the shortest time frame possible between the date of providing service and submitting the claim for payment. • The billing department must work continuously with the billing software vendor and claims clearinghouse on a continuous basis to make sure that billing information for the practice is up to date and correct (as tax ID, practice address, current physicians). The clearinghouse is an interface between the practice and the payer, both private and governmental. The clearinghouse validates the claim as complete and accurate before it is sent to the payer. • A claim is "scrubbed" by the clearinghouse. If it is not "clean" (inaccurate patient or practice information) it will be rejected, resulting in re-work and delays. The right combination of the billing group number (tax ID), place of service, physician, correct codes and modifiers must all be present and correct. • In addition, the practice must follow timely filing provisions, which means that if a claim is not filed within 90 days with a commercial insurance, or by December 1 the following calendar year to Medicare, it can and probably will be rejected.

What are some strategies that the front desk can communicate/implement to maintain good customer satisfaction?

•A proper greeting with a smile •Treat each patient as the most important person in the room •Avoid mentioning a patient's name and diagnosis in the same sentence •Stick to what you're qualified to do •Don't criticize another doctor in front of a patient •Don't let the telephone take over the office •Don't chomp or munch in the presence of a patient •Don't argue with patients •As much as possible, stay positive. •Be sensitive to patient's feelings. •Always search for something extra you can do •Waiting room should be clean, bright, and well organization. •Dress and appearance should be appropriate •Be courteous and helpful •Knowledgeable •Conduct patient satisfaction surveys to ensure customer satisfaction

Understand each step in the revenue cycle process: (11) End of Day Procedures (Front Desk Function)

•At the end of the day, we must "balance out" Cash, check, credit cards should be matched and posted to the appropriate patient account, using payment documentation and comparing to the fee ticket, patient schedule, and sign in sheet

Key components in a managed care contract in addition to rates.

•Begins when the medical practice contracts with the health insurance carrier. •Each contract is unique, and sets out the terms of the agreement between the payer (insurance company) and the provider. •The fee schedule (usually spelled out in reimbursement by CPT code) is an integral part of the contract. •The impact on fees paid and received not only includes the rate of reimbursement, but also the volume of patients for each CPT code •The fees can be "take it or leave it" (Medicare/Medicaid) or can be negotiated (the private insurance companies as Blue Cross, Aetna, United, Cigna, etc) or a self insured company using a third party administrator. •A poorly negotiated contract with low rates can have a very negative impact on the practice. •It is important that the practice have a good working relationship with the "payer field representative" •Beside the fee schedule, other major points in the contract include: - Date and term of the contract - Renewal and termination provisions - Timely filing rules - Claims processing - Appeals process for unpaid claims

Identify the important forms and documents collected from/distributed to the patient at the time of check in

•Drivers license and copy of I.D. Card •Patient demographic sheet •List guarantor (who is responsible for the bill/ "owner" of the insurance policy" •Details on insurance plan •Assignment of benefits •Patient medical history •Receipt/understating of HIPAA privacy policy, authorization release of Protected Health Information to desired individuals they have listed •Distribution of Office Policies/now the patient can also be directed to the web site

Understand each step in the revenue cycle process: (8) Posting Claims. (Biller Function)

•Once the EOB is received, the billing department must record, or post the payment to the patient's account in the billing system. After the insurance payment is posted, then it can be determined the patient responsibility for the bill. Likewise the patient's personal payment must also be posted to the patient account. • Overpayments/Credit Balances......

Tasks to reconcile end of the day deposits from front desk receipts

•Prevent embezzlement •Person who takes the cash is responsible to balance, but a second person verifies •Balance..... cash, check ,cc collections=receipts given to patients, checked against the appointment schedule at the end of the day •Make daily deposits •Separate petty cash account from the cash drawer for patient services

Basics of development of an appointment template

•Schedule realistically, what can be managed by doctor and staff, not packing in the maximum amount of patients •Start of time, stay on time....> 20 minute wait is usually the point of irritation for the patient •If we are running late, keep them informed as to why/when appt. can be expected. •Leave open slots....add -ons, and catch up time •Define what appointment time means when communicated to the patient...arrival at practice, enter the exam room, physician sees the paitent..etc.

Examples of clinical functions performed by certified medical assistants /outside organization who certifies them?

•Taking medical histories • Explaining treatment procedures to patients • Preparing patients for examination • Assisting the physician during exams • Collecting and preparing laboratory specimens • Performing basic laboratory tests • Instructing patients about medication and special diets • Preparing and administering medications as directed by a physician • Authorizing prescription refills as directed • Drawing blood • Taking electrocardiograms • Removing sutures and changing dressings

Understand each step in the revenue cycle process: 2. Collection of Patient Fees at the Time of Visit (Front Desk Function)

•The insurance card will list the co-pay amount to be collected from the patient for that day •Based on that day's appointment schedule, the billing dept. should communicate to the front desk any co-insurance, deductible, or outstanding balances from prior bill that the patient owes. Every effort to be made to collect this from the patient prior to seeing the physician.

Define win-win vs. win-lose negotiations

•This type of negotiation is when the winner is happy and the loser wants out immediately •This type of negotiation is when both parties do not get exactly want they want, but they can both live with the deal.