Healthcare Billing and Reimbursement Collections (Pg. 77-79)

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Questions and Answers

What is the primary purpose of the Resource-Based Relative Value Scale (RBRVS)?

To stabilize the payment system for physician services. (correct)

To regulate hospital employment rates.

To establish patient treatment plans.

To determine insurance premium rates.

What must a medical facility do when it discovers a patient overpayment?

Notify the patient regarding how they want the refund handled. (correct)

Keep the overpayment for administrative costs.

Ignore the overpayment as it is a minor issue.

Immediately issue a refund without notification.

How should a medical facility handle insurance overpayments?

Contact the insurance company for an explanation. (correct)

Treat it as an error and ignore it.

Return the payment immediately without verification.

Keep the funds to cover operational costs.

What information is typically reviewed during the credentialing process?

The applicant's education and malpractice history. Signup and view all the answers

What does 'accounts receivable' represent for a company?

The amount owed to the company for credit services provided. Signup and view all the answers

What is a potential outcome if a medical office does not handle overpayments properly?

Legal repercussions for committing Medical Fraud. Signup and view all the answers

What does recredentialing involve?

Reviewing existing documentation for accuracy and completeness. Signup and view all the answers

What is a common practice if accounts receivable are not collected in-house?

Transferring the debts to a collection agency. Signup and view all the answers

Which of the following is NOT a reason for utilizing the RBRVS payment system?

To eliminate the need for physician training. Signup and view all the answers

When handling an insurance overpayment, what is the best practice for the medical facility?

Contact the insurance company for clarification before proceeding. Signup and view all the answers

Which of the following is NOT required to be communicated to a debtor within 5 days after the initial contact by a creditor?

The debtor's credit score Signup and view all the answers

What is the primary purpose of a patient statement?

To provide a detailed bill of services rendered Signup and view all the answers

In what scenario can a physician issue a dismissal letter to a patient?

If a patient's behavior disrupts the medical practice Signup and view all the answers

How do collection agencies typically earn their compensation?

By taking a percentage of the funds recovered Signup and view all the answers

What is the significance of an Advance Beneficiary Notice (ABN) for Medicare recipients?

It ensures the patient is aware of potential out-of-pocket costs Signup and view all the answers

What role does precertification serve in the healthcare process?

It is a prior approval for specific medical services or admissions Signup and view all the answers

What is the primary content of remittance advice?

A letter confirming payment of an invoice Signup and view all the answers

Which of the following statements about payment plans is true?

Payment plans can include financing for various types of loans Signup and view all the answers

What is the purpose of claims editing tools in medical billing?

To assist in editing and customizing claims Signup and view all the answers

Why might a debt become overdue leading to collection processes?

When immediate payment is not feasible for the patient Signup and view all the answers

Study Notes

Resource-Based Relative Value Scale (RBRVS)

The RBRVS is used by the Centers for Medicare & Medicaid Services (CMS) and most other payers.
It’s based on the idea that physician service payments should vary based on the cost of resources used for the service.

Payer and Patient Refunds

Patient Overpayments: If a patient makes an unnecessary co-payment, the medical facility can either:
- Notify the patient and let them choose how to receive a refund.
- Issue a check to the patient for the overpayment.
- Keeping an overpayment constitutes medical fraud.
Insurance Overpayments:
- The medical facility should verify if there is an overpayment by contacting the insurance company.
- If an error occurred, the claim should be reprocessed and corrected.
- It’s recommended to obtain written documentation of the overpayment for record keeping.

Provider Credentialing

The process of verifying a provider's qualifications to participate in a health plan requires reviewing documentation.
Information reviewed includes education, training, clinical privileges, experience, licenses, accreditations, certifications, malpractice history, and insurance.
All providers must undergo the credentialing process, which includes verification of the accuracy and completeness of the submitted information.

Accounts Receivable

Accounts receivable refers to the money owed to a company for goods or services provided on credit.
This balance is recorded in the company’s general ledger under the "Accounts Receivable" account.
Uncollected accounts are typically turned over to a collection agency.

Fair Debt Collection Practices Act

This Act applies to third-party debt collectors and covers debts related to personal, family, or household needs.
When a creditor first contacts you about a debt, they have 5 days to provide written information regarding:
- The total amount owed.
- The creditor to whom the debt is owed.
- Instructions on disputing the debt.

Patient Statements

Patient statements are printed bills that detail the amount owed, service dates, charges, transaction descriptions, and patient demographics.
They contribute to cost reduction, time savings, and efficient billing.

Patient Dismissal

A dismissal letter is a written notice from a physician to dismiss a patient from their practice.
If a patient’s behavior disrupts the medical practice, the physician has the right to refuse service.

Professional Courtesy

Professional courtesy refers to professional behavior exhibited between members and staff of the same profession.
This practice originated with providing services to other physicians without charging for them.

Collection Agencies

When bills remain unpaid, they are usually turned over to a collection agency.
These agencies contact the bill owner and are typically paid a percentage of any recovered funds.

Collections

The patient aging report is used to track overdue accounts.
Collection efforts often involve sending letters and making phone calls to attempt to receive payment.
Unpaid accounts are ultimately sent to a collection agency.

Bankruptcy

Bankruptcy is a legal process where individuals or businesses that cannot pay their bills seek relief.
The court determines whether to discharge those debts, meaning they are no longer required to be paid.

Payment Plans

Payment plans are agreements to pay back outstanding debts over time.
They may apply to various debts including mortgages, car loans, and student loans.
Borrowers commit to paying a specific amount each month until the debt is settled.

Pre-Authorizations

Managed care providers may require pre-authorization before a patient sees a specialist.
A pre-authorization number is issued upon approval of the service and should be entered into the practice management system for claim processing.
Pre-authorization numbers may also be referred to as certification numbers.
Referrals, written requests for medical services, are often required for specialized care.
Referrals are managed differently by each insurance plan, so it’s essential to confirm with the patient’s insurance provider before scheduling appointments.

Claim Editing Tools

These tools offer comprehensive claim editing capabilities, including editing functions and customization options.

Remittance Advice

A remittance advice is a letter sent to a supplier to confirm payment.
It may accompany a payment check if applicable.

Advance Beneficiary Notice (ABN)

The ABN is a document that Medicare recipients must sign when there is a possibility that Medicare won’t cover a service or procedure.
This document is signed before the service is performed to ensure the patient understands potential financial responsibility.
Staff members who handle billing should be well-versed in ABNs to explain them clearly to patients and facilitate communication with insurance carriers.
An ABN would be used, for example, when Medicare only covers a limited number of treatments (like steroid shots) over a specific timeframe.

Precertification

Precertification is the authorization required for a specific medical procedure or institutional admission for medical care.
It’s a mandatory requirement for payment by all healthcare organizations.

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Description

Test your knowledge on the Resource-Based Relative Value Scale (RBRVS), payer and patient refunds, and provider credentialing. This quiz covers essential concepts that are crucial for understanding healthcare billing processes. Improve your understanding of healthcare reimbursement and the importance of accurate billing practices.