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step 1 preregistered patients

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the first step in billing and reimburstment cycles is to gather information to preregister patients before their office visit

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medical insurance represents

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an agreement between a person or entity known as the policy holder and a health plan

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policy holder

answer

a person or entity who buys an insurance plan; the insured

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health plan

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a plan, program, or organization that provides health benefits

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premium

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the periodic amount of money the insured pays to a health plan for insurance coverage

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medicare

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medicare is a federal health plan

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medicaid

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federal and state governments

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tricare

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is a government program that covers medical expenses for dependants of active duty members of the military.

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champva

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veterans

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workers comp

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people with job related illnesses or injuries

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payer

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private or government organizations that insures or pays for healthcare on behalf of beneficiaries

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fee-for-service

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health plan that repays the policyholder for covered medical expenses

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deductible

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amount due before benefits start

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coinsurance

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percentage of charges that an insured person must pay for health care services after payment of the deductible amount

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managed care

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a type of insurance in which the carrier is responsible for both the financing and the delivery of health care

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preferred provider organizations

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managed care network of health care providers who agree to perform services for plan members at discounted fees

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health maintance organization

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a managed health care system in which providers agree to offer health care to the organizations members for fixed payments

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capitation

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payment to a provider that covers each plan members health care services for a certain period of time

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copayment

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a fixed fee paid by the patient at the time of an office visit

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patient information form

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a form that includes a patients personal employment and insurance data needs to complete an insurance claim

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diagnosis

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physicians opinion of the nature of the patients illness or injury

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procedure

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medical treatment provided by a physician or other health care provider

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coding

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the process of translating a description of a diagnosis or procedure into the standardized code

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diagnosis code

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a standardized value that represents a patients illness, signs, and symptoms

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code

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found in the international classification of diseases

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procedure code

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a code that identifies a medical service

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encounter form aka super bill

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a list of the procedures and charges for a patients visit

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electronic health record (EMR electronic medical record)

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a computerized lifelong healthcare record for an individual that incorporates data from providers who treat the individual

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procedure

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is a code selected from the current procedural terminology

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practice management program (PMP)

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a software program that automates many of the administrative and financial tasks in a medical practice..includes scheduling

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medical coder

answer

a person who analyzes and codes patient diagnoses, procedures and symptoms

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adjudication

answer

series of steps that determine whether a claim should be paid

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remittance advice....EOB

answer

an explanation of benefits transmitted electronically by a payer to a provider

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explanation of benefits

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paper document from a pyer that shows how the amount of a benefit was determined

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statement

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a list of services performed for a patient, along with the charges for each service

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accounting cycle

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the flow of financial transactions in a business

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accounts receivable

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monies that are flowing into a business

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health information technology

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technology that is used to record, store, and manage patient health care information

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practice management programs contain

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a computerized scheduling feature to keep track of patient appointments

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patient data

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personal information about a patient, as well as information about the patients medical insurance coverage.

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transaction data

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the date of visit, the location of the treatment, the diagnosis and procedure codes, charges, and the payments made at the time of the visit

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clearing house

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a company that receives claims from a provider, prepares them for processing, and transmits them to the payers in HIPPA-complaint form. Clearinghouses also translate claim data to fit the standard format required for physicians claims, not to fit health plan or office billing systems (edited by a computer)

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audit/edit report

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a report from a clearing house that lists errors to be corrected before a claim can be submitted tot he payer. If no flags appear the claim is forwarded on

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walkout statement

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a document listing charges and payment that is given to a patient after an office visit. If a patient makes a payment at the time of an office visit they should always GET A WALKOUT STATEMENT

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auto posting

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an automated process for entering information from a remittance advice (RA) into a practice management program

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electronic medical records (EMR)

answer

the compertized records of one physicians encounters with a patient over time (lab work, x-rays, tests)

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electronic record keeping can reduce

answer

medical errors and improve patient saftey, improve the over all efficiency, allow two or more people to work with a patients record at the same time. computers are only as good as their users if you accidentally put in the name ORourke instead of O'Rourke a person might be able to know what you meant but the computer would not

question

health insuance portability and accountablity act of 1996 (HIPPAA)

answer

federal act that set forth the guidelines for standardizing the electronic data interchange pf administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information

question

electronic data interchange

answer

the exchange of routine business transactions from one computer to another using publicly avaiable communications protocols

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electronic fund transfer (EFT)

answer

the electronic routing of funds between banks

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X12-837 health care claim (837P)

answer

HIPPA standard format of electronic transmission of a professional claim from a provider to a health plan

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CMS-1500 (08/05)

answer

the mandated paper insurance claim from for exempt practices.

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National provider identifier (NPI)

answer

a standard identifier for health care providers consisting of ten numbers

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HIPAA privacy rule

answer

regulations for protecting individually identifiable information about a patients health and payment for health care that is created or recieved by a health care provider. Medical practices must have written Notice of Privacy practices, required to display in a prominent place in the office and must in good faith effort to obtain a patient written acknowledgement of having received and read the notice in the form of a signed acknowledgment of receipt of notice of privacy practice

question

HIPAA Security Rule

answer

regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected healthcare information. Examples of technical safeguards include passwords

question

Audit trail

answer

a report that traces who has accesses electronic information, when information was accessed, and whether any information was charged

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