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Billing/ Coding

Introduction to Revenue Cycle

accounts receivable (AR) patients and insurance companies paying for medical services,
cash flow movement of monies into or out of a business
accounts payable (AP) practice’s operating expenses, such as for rent, salaries, supplies
revenue cycle all administrative and clinical functions that help capture and collect patient payments
health information technology (HIT) computer information systems that record, store, and manage patient information
practice management program (PMP) account software used for scheduling appointments, billing, and financial record keeping
electronic health record (EHR) computerized lifelong healthcare record for an individual that incorporates data from all sources
PM/EHR software program that combines both a PMP and an EHR into a single product
medical insurance a written policy stating the terms of an agreement between a policyholder and a health plan
policyholder person who buys an insurance plan
health plan individual or group plan that provides or pays for medical care
benefits health plan payments for covered medical services
payer health plan or program
third-party payer private or government organization that insures or pays for healthcare on behalf of beneficiaries
schedule of benefits list of medical expenses covered by a health plan
medical necessity payment criterion that requires medical treatments to be appropriate and provided in accordance with generally accepted standards
provider person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business
covered services medical procedures and treatments that are included as benefits in a health plan
preventive medical services care provided to keep patients healthy or prevent illness
non-covered services medical procedures that are not included in a plan’s benefits
excluded services services not covered in a medical insurance contract
indemnity plan health plan that offers protection from loss
healthcare claim electronic transaction or a paper document filed to receive benefits
premium money the insured pays to a health plan for a policy
deductible amount the insured must pay for healthcare services before a health plan’s payment begins
coinsurance portion of charges an insured person must pay for covered healthcare services after the deductible
out-of-pocket expenses the insured must pay prior to benefits
fee-for-service payment method based on provider charges
managed care system combining the financing and delivery of healthcare services
managed care organization (MCO) organization offering a managed healthcare plan
health maintenance organization (HMO) managed healthcare system in which providers offer healthcare to members for fixed periodic payments
capitation a fixed prepayment covering provider’s services for a plan member for a specified period
network a group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members
out-of-network provider that does not have a participation agreement with a plan
preauthorization prior authorization from a payer for services to be provided
copayment specified amount a beneficiary must pay at the time of a healthcare encounter
primary care physician (PCP) physician in a health maintenance organization who directs all aspects of a patient’s care
referral transfer of patient care from one physician to another
preferred provider organization (PPO) managed care organization in which a network of providers supplies discounted treatment for plan members
Consumer-driven health plans (CDHPs) medical insurance that combines a high-deductible health plan with a medical savings plan
self-funded (self-insured) health plan organization pays for health insurance directly and sets up a fund from which to pay
medical insurance specialist staff member who handles billing, checks insurance, and processes payments
medical coder staff member with specialized training who handles diagnostic and procedural coding
diagnosis code number assigned to a diagnosis
procedure code code that identifies medical treatment or diagnostic services
patient ledger record of a patient’s financial transactions
compliance actions that satisfy official requirements
adjudication health plan process of examining claims and determining benefits
professionalism acting for the good of the public and the medical practice
Requirements for Success Communication skills; Attention to detail; Flexibility; Honesty and integrity; Ability to work as a team
Attributes Appearance; Attendance; Initiative; Courtesy
ethics standards of conduct based on moral principles
etiquette standards of professional behavior
certification recognition of a superior level of skill by an official organization
Managed care plans, first introduced California in 1929, are now the predominant type of insurance
Basic types of managed care plans Health maintenance organizations; Point-of-service plans; Preferred provider organizations; Consumer-driven health plans
participation contractual agreement to provide medical services to a payer’s policyholders
HMO cost-containment methods: Restricting patients’ choice; Requiring preauthorization for services; Controlling the use of services; Controlling drug costs; Cost-sharing; Requiring referrals:
Identify three ways that medical insurance specialists help ensure the financial success of physician practices Following all procedures carefully; Communicating effectively with patients and with those who work in the practice; Using health information technology skills to work with practice management programs and electronic health records.
Differentiate covered services under medical insurance policies Covered services: May include primary care, emergency care, medical specialists’ services, and surgery Are eligible for members Are listed under the schedule of benefits of an insurance policy
Differentiate covered services under medical insurance policies Noncovered services: Are identified by the insurance policy as services for which it will not pay
Compare indemnity and managed care approaches to health plan organization Under an indemnity plan, the payer protects the member against loss from the costs of medical services and procedures. Managed care offers a more restricted choice of providers and treatments in exchange for lower premiums, deductibles, and other charges.
Explain how a preferred provider organization works Create a network of hospitals and other providers for members to use at negotiated, reduced fees. Are the most popular type of healthcare. Generally require the payment of premiums and copayments from patients.
Describe the two elements that are combined in a consumer-driven health plan Consumer-driven health plans (CDHPs) combine a high-deductible, low-premium PPO with a pretax savings account to cover out-of-pocket medical expenses up to the amount of the deductible.
Define the three major types of medical insurance payers. Private payers of health benefits are either insurance companies or self-insured employers. Most private health insurance is employer sponsored. Government-sponsored healthcare programs include Medicare, Medicaid, TRICARE, and CHAMPVA.
steps in the revenue cycle Preregister patients Establish financial responsibility Check in patients Review coding compliance Review billing compliance
steps in the revenue cycle Check out patients Prepare and transmit claims Monitor payer adjudication Generate patient statements Follow-up payments and collections
Analyze how professionalism, ethics, and etiquette contribute to career success Office members acquire the proper skills and develop the necessary attributes in order to perform their work successfully. Pair these characteristics with a strong code of ethics and correct etiquette.
Evaluate the importance of professional certification for career advancement Medical staff personnel advance their careers through membership in a professional organization and by receiving a certification by that organization. Certifications are earned through a combination of education, experience, and an exam.
Created by: baybro9933