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crcr-section 2
Pre Service Financial Care
| Question | Answer |
|---|---|
| what are 3 types of patients | scheduled, unscheduled, and non-acute care |
| Scheduled Patients | healthcare facility knows the patient is coming |
| Scheduled inpatient | most facilities use medicare standards to determine patient status for major surgery & obstetrical patients & direct admit. Insurance categorize as thss as elective admission & managed care & may require approval prior to appointment |
| Direct Admit | physician calls ahead to a hospital facility for services |
| Manage Care | comprehensive health plans that attempt to reduce cost through contractual agreement with the provider |
| Scheduled outpatients | services do not involve an overnight stay and patient does not meet inpatient criteria |
| Scheduled Recurring Patients | these patients receive ongoing treatment and is considered outpatient. One registration is created and charged on one account for multiple days of service |
| What happens to Scheduled Recurring Patients receive treatment for 30 days or longer | the appointment can be registered on a monthly basis with a monthly claim and payment services must be considered as one episode if care with the same ordering physician and diagnosis |
| Types of scheduled recurring patients | physical therapy, outpatient therapy, speech therapy, cardiac rehab chemo therapy, radiation and , intravenous |
| How insurance plans treat recurring patients | the health plan determines how the patient is billed. This is based on the number of treatments, or a set annual amount or, a specific time period |
| Unscheduled Patients are also called | urgent patients, unscheduled outpatients, observations and newborns |
| Unscheduled urgent patients | usually receive service in the emergency room. If the patient meets acute criteria for they are admitted to the hospital |
| direct urgent patients | a physician sends the patient directly to the hospital because of the medical condition meets acuity level of admission |
| unscheduled outpatient/ walk ins | Patient comes at their convenience and receives service on a first come first serve basis. Does not require pre approval from health plan but may require the patient to receive services at a contracted in network facility |
| unscheduled Emergency Patients | health plans cover regardless of whether the are contracted with the facility up until the patient is stabilized. If the patient requires inpatient services the plan my require once stabilized to be transferred to a contracted in network facility |
| Unscheduled observation patients | used to evaluate patients for admission, to resolve a medical problem to discharge patient . Treatment is less than 24 hours. Used to treat complications in outpatient surgery/ procedure. Must originate from the ER or sent as a direct urgent patient |
| New Born | a baby delivery in the hospital |
| What are non acute types of patients | Skilled nursing, hospice, home health, DME, clinic |
| Skilled Nursing (SNF) | the patient no longer meets the criteria for acute care but needs rehab services such as orthopedic surgical patients that need physical therapy. Medicare will pay after a three day inpatient stay. This can be waived if the facility is a ACO |
| Hospice Care | For patients in the last stages of incurable health with a life expectancy of six months or less. Helps the patient with pain relief and symptom management but the disease is no longer treated |
| Medicare Certified Hospice Program | these programs are required to provide nursing pharmacy an physician services to the patient round the clock If admitted to the hospital the program is billed not Medicare |
| Home Health Services | Given in patients home for an illness or injury. There must be a physicians order and the patient must meet a criteria to be covered |
| Durable Medical Equipment (DME) | will be used over and over again and but be obtained by a Medicare approved supplier for Medicare to pay |
| Clinic | devoted to the diagnosis and treatment of outpatient |
| Scheduling | Allows provider to prepare for visit |
| Patient Identification | demographic information and health provider information is validated and updated |
| Critical Patient Information | Full legal name, date of birth, sex, and social security number |
| MRN | Medical Record Number |
| What is the MRN | it is a unique number assigned to a patient |
| MPI # | Master Patient Index Number |
| CPI# | Corporate Patient Index Number |
| What is a MPI# or CPI# | used for individual episodes to enable to enables the provider to identify all services provided to an individual patient in the healthcare system |
| What is important information to review with patient prior to the procedure | the patient should be aware of pre service testing, patient instructions, arrival instructions, services that will be provided date and location of scheduled appointment |
| Order Requirements | the test and services are provided with a valid physician order . |
| Verbal Orders | can be taken if accepted by a qualified staff member. Must be authenticated by the ordering physician with a written signature or what is acceptable by CMS as long as the demographic information is complete and the order information is complete |
| What procedures are do not require a physicians order | those with Medicare health plans or other health plans that need a flu vaccine, pneumonia vaccine or mammogram screen |
| CPT | Current Procedural Terminals |
| Medically Necessity | Paid for by Medicare and Health plans |
| LCD | Local Coverage Determinations |
| NCD | National Coverage Determinations |
| What is LCD and NCD | used to determine which diagnosis signs or symptoms are payable. if its not medically necessary by Medicare then the Medicare Advance Beneficiary Notice is given to the patient |
| ABN | Advance Beneficiary Notice |
| What Is a ABN | used to document that the patient was informed that Medicare would not cover treatment and give the patient advanced notice of the cost of service |
| When is an ABN needed | When items or services are expected to be denied, when services are not medically necessary, when the service is not delivered in the most appropriate setting and when it is custodial in nature |
| What must appear on an ABN | It must be on an approved CMS-R-131 form. It must have service the physician ordered , the estimated cost, the date of service, and the non-coverage reason. It should state that Medicare may not pay |
| What is pre registration | a process that is completed for all patients before services. Correct demographic information and insurance is key to accurate and timely billing |
| What are the benefits of pre registration | patient access staff will have complete and valid information needed to finalize pre access activities before the patient arrives |
| comprehensive Pre Registration Data | Demographic information, guarantor information, health planning, complete insurance information and emergency contact information |
| Validation of data | used with historical data |
| Insurance verification | updating the accuracy of the health plan and communicating it to the patient. Eligibility of benefits and health plans benefits are reviewed as well |
| Sequencing Plans | Coordination of benefits |
| COB | Coordination of benefits |
| What are methods of insurance verification | electronic web portal or telephone |
| EDI | electronic interchange standards |
| 270 Healthcare eligibility benefit inquiry | it is outbound from the provider to the health plan to identify the subscriber in the enrollee database |
| Healthcare Eligibility benefit response | 271 transaction which will respond back to the provider |
| Medicare Secondary Payer Screenung | MSP |
| What is an MSP | questions on a survey used to help clarify if the patients situation |
| Incomplete pre registration | causes return mail, insurance denials, unnecessary health plan follow up and e-billing resulting in higher net work cost |
| Medicare | Government Sponsored program which is financed by federal taxes and general revenue fund |
| Medicaid | federally aided state operated programs to provide health and long-term care for low income individuals or families |
| Tricare | a health care program of the US department of defense and the military formally CHAMPUS uniform service healthcare program for active duty service member and families including the national guard and the reserves |
| IHS | Indian Health Service |
| What is IHS | an agency within the department of health and human services responsible for providing federal insurance to native Americans last resort payer other programs come first |
| Blue Cross/Blue Shield | the nations oldest and largest family of health benefits companies and the most recognized brands in the health care industry |
| Managed Care Plans | comprehensive health plans that attempt to reduce cost through contractual agreements with providers and through case management initiatives. includes HMO PPO EPO POS |
| Commercial Indemnity Plans | cover almost all services without authorization requirements a percentage of is reimbursed after the deductible is met |
| Self insured plans | the cost of medical care are born by the employer on a pay as you go basis. Employer has stop loss to protect the employer. Generally a TPA will process claim after the employer gets the claim |
| Liability Claims | auto, home, or business insurance may include medical coverage clause that covers individual healthcare when associated with an accident or injury. Healthcare facilities will bill this plan as a result of accident or injury |
| Benefit Period | sixty days of no hospital service or skilled nursing care service |
| Medicare Part A | Hospitalization. a deductible is due each time the beneficiary is re-admitted to the hospital after the sixty day benefit period |
| Full Coverage Period | total benefits are paid for up to sixty days . This renews with each new benefit period |
| 30 Day Coinsurance | used after a full sixty days has been used. There is a daily out of pocket charge equal to 25% of the of the current deductible amount |
| LTR | Lifetime reserve days |
| What is LTR | used after the 60 full coverage and 30 day coinsurance have been exhausted. It is 60 days of a daily out of pocket at 50%. This never renews |
| Medicare Part B | financed by beneficiary premiums and general revenues. Provides physician services, outpatient and other services. It has an annual deductible and the beneficiary is responsible for all services except for lab work |
| OPPS | Outpatient Prospective Payment System |
| What is OPPS | determined by federal regulation. a payment system used by CMS |
| Medicare Claim Submission | can be sent electronically with 837-I or by paper UB-04. Physicians use 837-P and CMS 1500 on Paper |
| Medicare Claim Status | is received by medicare administration contractor and medicare advantage plans. Its either paid or denied. claims are filed with in one calendar year after the date of service |
| HICN | Health Insurance claim number issued by social security administration for medicare beneficiaries |
| Medicare Advantage Claims | must be filed within the specific health plan's qualifying time limit per the provider contact |
| Dis-allowance Letter | sent to the beneficiary if hospital insurance benefits do not pay for services with a right to appeal descriptions and instructions |
| EOB | explanation of benefits |
| Medicare Part C | medicare advantage, a managed care plane that includes part a and part b may include part D |
| Medicare Part D | prescription coverage. private insurance plans set up by CMS |
| PPACA | patient protection and affordable care act of 2014 |
| What is PPACA | allows state to receive additional funding if benefits are extended to low income individuals and families under 65 with incomes 133% of the poverty level. this covers low income adults with no children |
| Medicaid Billing | must have case# some beneficiaries have to do the spend down before billing. Pays covered medical services after third party benefits are exhausted. |
| Special Documentation for Medicaid | abortion sterilization hysterectomy new borne must have baby's birth weight and other state requirement |
| How does Tricare work | brings together healthcare resources from uniform services and civilian health services so that they have high access to high quality healthcare services |
| Tricare Billing Requirements | hospitals use 857-I and 837-P for physicians. must be submitted with in one year of service if this insurance is secondary there is a 90 day claim period and 10% penalty if authorization is not given |
| Tricare Prime | an HMO program with military treatment feature has POS option that covers the active duty and the family |
| Tricare Remote | for military and family that live 50 miles or 1 hour away from a duty station |
| Tricare Prime Overseas | manage care option for active military living out of the country in a non remote areas |
| Tricare Prime Remote Overseas | designated for remote overseas locations for active duty and family |
| US Family plan | additional option available through networks of community based nonprofit healthcare systems in six areas of the US |
| Tricare Young Adult | an option for unmarried adult children who have aged out of regular Tricare Coverage Individual must be at least 21 and not over 26. Comprehensive medical and pharmacy benefits |
| Tricare Fee for Service | available to all nonactive duty beneficiaries throughout the US has outpatient deductible and coinsurance requirements |
| Tricare reserve select | Premium based plan coverage is world wide to reservicest and family |
| Tricare returned Reserved | (TTR ) premium based health plan for qualified retired reserve members and family |
| Tricare for Life | Supplemeny to medicare A&B |
| Managed Care Health Plans | An agreement with physicians and other healthcare providers to offer a range of services to plan members at a reduced cost. Use controls such as pre certification for admissions and outpatient services |
| HMO | Health Maintenance Organization |
| What is an HMO | a health plan that provides comprehensive healthcare service on a prepaid basis to a voluntary enrolled people. uses a primary care physician (PCP) coordinates care and refers beneficiary to specialist or acquires authorization for hospital services |
| What happens if a beneficiary uses an out of network doctor in an HMO | patient is responsible for total charges |
| In-netowork | a group of providers that have contact with a health plan and agree to accept the plans contract in rate as payment in full |
| Out- of Network | Patient is responsible for care and will pay more |
| PPO | Preferred provider Organization |
| What is a PPO | a third party payer that contracts with a group of medical providers who furnish services at lower than usual fees in return for guarantee fees and a certain volume of patients |
| Executive Provider Organization | EPO |
| What is EPO | a form of a PPO which has a select group of providers chosen to provide benefits to one or more limited number of entitles usually a single payer |
| POS | Point of service |
| What is POS | allows the member to select providers without being out of network. Beneficiaries are generally enrolled in a HMO but have the option to out of network for an additional cost. The PCP makes referrals but members can refer themselves |
| Consumer Directed Healthcare Plans | CDHP |
| What is CDHP | a set of health insurance arrangements whing the individual has a high deductible with a personal health account used to pay healthcare expenses not covered by health insurance |
| PHA | Personal health account |
| Medicare Advantage | Medicare Part C. The result of the Prescription Drug Improvement and Modernization Act |
| Medicaid HMO | A plan available to patient enrolled in state medicaid program. Focuses on preventive care but use managed care concepts to coordinate care |
| Pre Authorization/ Pre certification | required for elective hospital admissions |
| Referals | Completed by PCP to notify HMO that the patient is being sent to a specialist |
| Notifications | Providers notify the health plan that the patient is requesting medical services |
| Site of Service Limitation | care plans for common diseases and procedures Including appropriate settings for care fans will only pay for the service in an approved setting |
| Case Management | internal hospital program and insurer based program which seeks to confirm appropriate levels of care patients condition |
| Discharge Planning | as soon as the patient is admitted.. the expected outcome of treatment |
Created by:
greenaka1908