Automated Medical Office Chapter 2 Setting Up The Practice

Front 1

Setting up the Providers

Back 1

*Information for each provider can consist of many different pieces of information

*Physicians name and address/phone

*Personal information(SS#)

*All license information(State, NPI, UPIN, DEA)

*Insurance identifiers

*Tax ID and Banking info

*Typically an office may assign each provider a number to be used for billing and reporting purposes

Front 2

What's in the Address Files?

Back 2

*These files can consist of addresses for:
-Insurances
-Employers
-Schools
-Attorneys
-Facilities
-Other

Front 3

The Purpose of Health Insurance

Back 3

*is to help an individual family help to offset the cost

*it helps to protect against financial lost

*Medical emergencies, and medial care itself can be very expensive

Front 4

Group Policies

Back 4

*Insurance policy is written to cover a large group of individuals

*Usually providers more coverage at lower premiums

Front 5

Individual Policies

Back 5

*is written to cover an indiviual or a family

*done on an individual basis and not done on a group of umbrella it offers less coverage and the premium will be higher

*individual coverage will be higher with less coverage

*group policies are lower premiums and more coverage

Front 6

Government Policies

Back 6

*Large groups of people are covered by government policies
-Medicare
-Medicaid
-TRICARE
-CHAMPVA
-Workers Comp

Front 7

Medicare

Back 7

*Federal Health Insurance program

*Coverage for:
-65 years of age or older
-Permanently disabled
-Blind
-ESRD

*Part A- hospital insurance(automatic)

*Part B-medical insurance(voluntary)

Front 8

Medicaid

Back 8

*is a federa and state health insurance program

*benefits depends on the state that the patient resides in(each state is setup differently)

*benefits can vary from one place to another

*designed to cover medical indigent patients

*providers has the ability to either decline or accept a medicaid patient

*if medicaid patient is accepted the provider must accept the payment from medicaid as payment in full for services

*medicaid is a last payer

*low paying insurance

Front 9

BCBS

Back 9

*Many different plans are available and vary in each state
-Traditional-fee for service
-Managed care-capitated
-Point of service-In network

*The patients BCBS identification card will help in determining their benefits

*Providers can bill directly to the local BCBS for out of state BCBS coverage

Front 10

TRICARE

Back 10

*Coverage is for active duty service members and their eligible family members

*TRICARE offers three coverage options:
-Standard-Fee for Service plan
-Extra-PPO plan
-Prime-Managed care plan (HMO)

Front 11

CHAMPVA

Back 11

*Civilian Health and Medical Program of the Veterans Administration

*Coverage for spouses and/or dependent children of veterans with total, permanent service connected disabilities

*Coverage for surviving spouses and/or dependent children of veterans who died as a result of a service related disability

Front 12

Commercial

Back 12

*is a private nature

*payments may be sent to the subscriber unless other arrangements have been made for the payment to be sent directly to the provider

*if payment goes to patient make sure to collect their funds upfront of services

Front 13

HMO Managed Care

Back 13

*providers both being physicians and hospitals have contracted with an insurance company

*offers services at a fixed but at a negotiated price

*patients are required to select a primary care physician(PCP)

*the PCP is a member of the HMO managed care plan(is responsible for the patients care)

*if the patient steps out of the HMO network and use someone outside of the network that is not their primary care physician and not have been referred to the HMO palns usually do not pay(its than the responsibility of the patient)

*it becomes a challenge when the patient does have to be referred out for diagnostics testing for specialty

Front 14

PPO

Back 14

*Preferred Provider Organization

*has a contractual relationship with an insurance company

*it allows you to go in or out of network

*it is not necessary the benefits of the patient to go to an out of network provider beause of the higher out of pocket cost

*usually deductibles will double, copays will double, alot higher cost for patients

Front 15

Workers Comp

Back 15

*State law to protect employees against loss of wages and cost of medical care occupational injury or illness

*Laws will differ in each state

*Benefits include medical, loss of income, survivor benefits

*Employer may use third party or be self insured

Front 16

Coordination of Benefits

Back 16

*COB is a mechanism used to designate the order when multiple carriers are billed and pay benefits

*the purpose is to limit the payment to a maximum of 100%

*If an individual is covered under more than one policy, their policyholders own plan will be primary

Front 17

The Birthday Rule

Back 17

*This rule is applied when a minr is covered under more than one policy to determine which payer is primary

*The policyholder who's birthday, month and date, comes first in the year is primary

*This rule is in effect for the parent who has custody of the dependent and not remarried

*If the custodial parent has remarried, that parents plan is primary

*If the sourt has decreed one parent to be responsible, that parents paln is primary

Front 18

Transaction Codes

Back 18

*There are many different kinds of Transaction codes used in the accounting system of a business
-CPT, ICD9 and HCPCS codes
-Payment codes
-Adjustment codes
-Modifiers
-Internal vs. External codes

*Codes can be attached to defaults, fee schedules and inventory control

Front 19

CPT Codes

Back 19

*Five digit numeric code used to bill for services provided to a patient
-E/M
-Anesthesia
-Surgery
-Radiology
-Pathology
-Medicine

Front 20

ICD9 Codes

Back 20

*is an international classification of visas

*codes can range from 3-5 digits in length

*they are used for billing to classify patients illness or injury

*every procedure code that gets billed has to have an ICD 9 code attached to it(this is proven the medical necessity of the particular procedure being done)

Front 21

HCPCS Codes

Back 21

*is Health Care Common Procedure Coding System that was designed primarily for medicare

*many private insurances have adopted to HCPCS Codes

*5 character code that is used for billing service

*it consists of alpha and numeric characters(they are used for billing of services, supplies, and durable medical equipment)

*it is used primarily for medicare billing

*have to know the rules to the insurance to know whether or not HCPCS codes are applicable

Front 22

Payment Codes

Back 22

*are used to identify how the particular service has been paid for and who paid for them

*can identify with patients whether or not they paid cash, check, or credit card

*with an insurance company we can identify which insurance paid-by putting in medicaid, BCBS

*

Front 23

Adjustment Codes

Back 23

*An internal codes used to apply and distinguish any adjustment made to the account
-Insurance
-Professional Courtesy
-Hardship
-Refund
-Small balance write off

*Adjustment codes can be automatically set with some software programs

Front 24

Modifiers

Back 24

*something that gets added to a code

*CPT codes identifies the service

*two digit modifier can be numeric or alpha-numeric or alpha-alpha

*the two digit modifier attached to the procedure codes ultra the service code

*it can increase the dollar amount and it can decrease the dollar amount

*make sure you have a full understanding of the modifiers before attaching them to the service codes

*not all procedure codes wil have a modifier