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28 Cards in this Set
- Front
- Back
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UCR Fees
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Physician's Fee Profile
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Insurance Fee Schedule
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*A listing of excepted charges or established allowances for medical services referred to asan allowable amount
*The "Allowable" amount is full amount to be reimbursed by the insurance company *Each insurance company will have their own fee schedule *Providers can negotiate for different allowable amounts at the time of their contract *Fee schedules are designed using different formulas -UCR,RVS,RBRVS |
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Insurance Allowances
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*Participating Physicians
-The insurance pays the allowable amount of the negotiated charge -The provider accepts this as paid in full and adjusts the difference of the patients account, with exception to patients obligations under the contract(i.e. copay, deductible) -The difference cannot be billed to the patient for covered services -Non-covered services or ineligible benefits can be billed to the patient *Non-Participating Physicians -Payment may be sent to provider or to patient -The provider may obtain payment in full from patient at the time of service -The difference between the charges and payment are billed to the patient |
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Discussing Fees in Advance
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*Fees should be discussed about prior to services being rendered
*They should also be explained beyond what the physician may charge(lab fees, co-surgeon, anesthesiologist) *Allows the patient to be better prepared for what their responsibility of costs may be *Be available answer questions that the patient may have *Have patience and make sure individual has an understanding of the complexity of service and costs involved *Less chance of patient complaining later of a misunderstanding |
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Giving Estimates
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*Make sure patient understands that the quote is only an estimate of the services and not the actual cost
*Many variables exist(complications, extra services) *In accordance of discussing advance fees, this also better prepares the patient of what to expect |
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Responsibility of the Bill
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*The insurance contract exists between the carrier and the patient
*The Guarantor of the account is ultimately responsible for the entire bill *It may be necessary to educate the patient on their insurance policy |
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Account Language
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*Debit-an entry constitutes an addition to an expense or deduction from revenue
*Credit-an entry that constitutes an addition *Posting-an entry of figures into an accounting system *Account balance-the amount owed on an account *Receivables-money received on an account *Receipts-amounts paid on patients account *Disbursements-money that is paid out *Payables-balances due to a creditor |
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Understanding Credit Balances
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*Credit on a patients account can be a result of:
-Payment in advance -Over payment -Duplicate payment -Error *Patient can be given the option to receive a refund or leave the credit balance there to use for fees of future services *Know whether or not "true" credit before indicating this to the patient |
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Payment at Time of Service
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*Time of service payment should always be encouraged
*When this practice is followed: -Patients get into the habit of paying -Increases cash flow of the office -Decreases follow up of funds **Payment is expected at the time services are rendered unless other financial arrangements have been made** |
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Getting Paid
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*can be done different ways
*time of service and sometime for patients who son't have insurance can get discounts on certain procedures that are done all the time-time of service discount *depends on the physician and the facility *the insurance companies are the greatest third party payers *do feeschedule allowances, reimburse physicians for what the fee schedule says *Guarantor who is utlimatel responsible for the amount do *employers-workers comp or self insured |
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Adjustments
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*Common adjustments:
-Insurance write off -Professional discount -Payments -Bankruptcy *Some adjustments are automatic when insurance payments are applied *All adjustments should be made prior to bill being sent to patient to avoid refunds |
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Refunds
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*Due to an overpayment on the account
*Verify who should receive the refund(guarantor or insurance) *Have a policy in place within the office: -Who processes refunds? -Day when checks are processed? |
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Non Suffecient Funds
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*Steps to reverse NSF transaction:
1. Reverse payment from account 2. Add any applicable fees charged by the office 3. Contact patient by phone immediately 4. Send a letter for demand of payment 5. Document patients account 6. File any necessary paperwork |
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Sending the Bill
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*Encounter Form-
-Copy of current visit form given to patient -All necessary information on form -Patient's fees should be collected at time of service *Computer generated statements -Allows for bulk statement billing -Can be programmed for aging balances and messages -Tracks date sent *Photocopied -Least used -Functional for quick mailing |
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Guidelines in Billing
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*First bill itemized
-A statement is a confirmation of what a patient owes -The 1st bill should include an itemization of what services where rendered and how funds were applied *Once a month -Stay consistent in sending out the bills on a regular basis *Cycle billing -Allows the office to divide the cycle to avoid once a month peak workloads -Efficient for large practices *Billing third parties -Insurances need to be billed daily/weekly -Most insurance carriers have time limits for filing *Billing minors -A minor cannot be help responsible unless, emanciapted -Use care when creating a minors account |
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Extending Credit
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*may have payment plans, and a process for this setup in a medical office for payment plans to take place
*installment billing could be done for large surgeries or long term care to be involved *a policy of any kind should be in the office so it can be referenced for the protocol *make sure to have an signed agreement placed in the patients record and a copy is given to the patient in their future reference *makesure the patient know what they are responsible for and when they are responsible for it *if the office applies finance charges to the extended credit you need to make sure to follow the truth of extending act *having a payment plan needs to be assigned to 1 individual or make sure to keep close eye on the payment plan *if at any time a payment should default you need to know the steps to be put in place of how to retrieve the money *make a phone call to the patient and then send it over to collections |
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Internal Billing
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*Duties performed within the office of the provider:
-Collection of monies -Mailing statements -Billing to third parties -Posting monies -Follow up of accounts -Patient's bill inquiry calls *Have more control and knowledge of what is happening at all times with the accounts *May require additional staff to cover duties *Funds could be interrupted if Biller-retires/quits/illness/PTO |
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External Billing
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*Duties performed outside the provider's office:
-Collection of monies -Mailing statements -Billing to third parties -Posting monies -Follow up of accounts -Patient's bill inquiry calls *Allows thephysician and staff to stay more focused on patient care only *No additional coverage required for PTO |
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Hardship Cases
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*The physician is the decision maker for hardship cases
*All possible opportunities should be reviewed prior to making the decision situation(insurance settlement, atate aid, etc) *Full documentation should be entered into the patients record *If the fee is reduced: -Bill the entire amount balance on each statement -After all scheduled payments have been applied, adjustment for negotiated amount can be adjusted |
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Professional Courtesy
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*is an reduction or an eliminator of fees acquire by professional services
*usually a courtesy that is extended to collegues and sometimes their families *decision is determined by the provider that is given those services *not put into an office policy, it is determine by the provider *sometimes physicians will accept an insurance only payment-have an service were they've done and bill it off to the insurance company *never offer to medicare patients-if you're not gonna charge the patient you're not gonna charge the insurance *make sure the physician documents it that they are the actual decision maker *not every status will be covered |
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Collection Letters
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*Collection letter starts as a friendly reminder
*Composition of a series of letters that will increase in intensity for demand of payment *The letters should always treat the patient with respect and consideration *If all attempts to collect have failed, turn over to a collection agency *Signing of the collection letters is usually done by a designed person in the office |
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Telephone Collection
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*it helps to keep the collection internal
*having that direct contact with that patient is more personal than a letter *could require additional staff for duties of collections *if a large staff group you could assign a couple people to work the collection and keep that in house *helps to keep better control of the account as well as helping the practice keep the money being collected *when accounts are turned over to the collection agency the money is lost |
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Face to Face Collection
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*Personal contact with patient can often be more effective than any letter or phone call
*Able to interpret body language *Could be more information is wanted or a misunderstanding of their responsibility on the bill *Remember, the patient can't hang up on you or throw you away |
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Claims Against Estates
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*Handling bills of decreased patients bill:
-Courtesy extended during bereavement, but not more than 30 days -Address the statement to: *Estate of(patient) *%(spouse or next of kin) *Last known address *Payment could be delayed due to legal complications *States have different time limits and statutes *Flag account of patients demise |
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Bankruptcy
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*when a patient files bankruptcy the papers come in form a bankruptcy court identifying that the portion of the medical bill itself is being declared in this particular bankruptcy
*you can no longer send statements for the defined period of time *make sure that the accounts have been noted and flaged in any new services need to be collected on or any insurance that exist *if a patient files bankruptcy doesn't mean that they can not be seen anymore but you need to make sure the provider is reimbursed for their services |
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Small Claims Court
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*An inexpensive way to collect on delinquent accounts
*Limits vary from state to state *Can be handled by a designated member of the staff *No attorney's fees *Saves time of regular court action *Commission monies not scarified to collection agency *Complete information for filing can be obtained from the small claims court |
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Outside Collection Agency
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*Every attempt should be made to collect on delinquent accounts prior to sending to a collection agency
*Review the list of patients to be sent to collection agency *The practice will sacrifice a 40-60% commission *Choose a reputable collection agency *No more statements are sent from provider's office *Document and flag account *Refer patient to agency with questions *Any money received in the office accounts in collection must be reported to agency |
