Healthcare Patient Financial Responsibility

Pre-Visit Procedures

• Confirm third-party payer (insurance) information and eligibility after screening questions are answered
• Inform patients about policies governing patient financial responsibility, including copayments due at the time of service
• Recommend patients arrive 15 minutes before their appointment time to complete or update required paperwork

Requirements for Visit Duration

• Factors influencing visit duration: provider habits and preferences, office processes, and type of appointment
• Schedule appointments in 15-minute intervals, reserving necessary slots based on provider type and preference
• Appointment types and approximate times:
  • New patient: 60 min
  • Established patient (follow-up, sick, consultation): 15 min
  • Comprehensive: 45-60 min
  • Preventive care (complete physical exam, annual wellness exam, chronic care management): 45-60 min
  • Urgent: 20 min
  • Other entities: 30 min

Prioritize Appointment Needs Based on Urgency

• Determine appointment priority by asking appropriate questions
• Schedule urgent visits as soon as possible, not for next available time slot
• Organization's screening process determines if situation is life-threatening or urgent
• MA can provide general recommendations for nonprescription treatments under organization's direction and policy

Patient Check-In

• Patient check-in begins with arrival, confirming identity, eligibility, and insurance details
• Request photo identification to ensure accuracy
• Verify demographics and update information as needed
• Scan insurance card and valid state photo identification into the system
• Offer option to decline photo or ID scanning

Manage Electronic and Paper-Based Medical Records

• Many healthcare providers use electronic records for accuracy, efficiency, and government requirements
• Paper charting can be inconvenient, lacking real-time adjudication interoperability
• Store and file documents alphabetically by patient's last name
• Arrange paper records in reverse chronological order, with most recent medical services at the top

Sections of the Medical Record

Administrative Section

• Patient demographic information (name, address, phone number, birthdate, sex, insurance information, place of employment)
• Notice of Privacy Practices (NPP)
• Advance directive
• Consent forms
• Medical release forms
• Correspondence and messages
• Appointments and billing information

Clinical Section

• Health history
• Physical examinations
• Allergies
• Medication record
• Problem list
• Progress notes
• Laboratory data
• Diagnostic procedures (electrocardiograms, radiology reports, spirometry reports)
• Continuity of care (consultation reports, home health reports, hospital documents)

Monitor Patient Flow Sheets, Superbill, or Encounter Forms

• Patient flow sheet: records and tracks patient health data, such as vitals or lab results
• Encounter form/Superbill: records diagnosis and procedures covered during the current visit
• Encounter notes: clinical notes including history of present illness and current medications list
• Laboratory report: includes results from lab tests performed
• Radiology reports: includes results and interpretation from radiology services provided
• Diagnosis and procedure codes must be linked to substantiate medical necessity

Clinical Quality Measures and Responsibilities During the Visit

• Gather specific information from the patient to facilitate an efficient visit
• Clinical quality measures identify treatments, processes, experiences, and outcomes
• Discuss:
  • Changes in health status
  • Medication reconciliation and refills
  • Allergies
  • Health conditions screening
  • Fall risks
  • Mental health and developmental issues
  • Update medical history
  • Educate patients on recommended preventive services and timelines
  • Discuss necessary or recommended immunizations

Patient Appointments

• Medical assistants (MAs) are responsible for scheduling, canceling, and rescheduling appointments, which can be managed electronically or on paper.
• Electronic scheduling can be done using a computer, kiosk, or tablet, while paper scheduling requires handwritten schedule information in a book or on a form.
• Patients can schedule appointments online through the healthcare organization's website or their own patient portal.
• Scheduling requires balancing the patient's needs with the provider's time, allowing for interruptions and urgent medical issues.

Schedule Methods

• Specific time scheduling gives each patient an individual time for their appointment.
• Wave scheduling allows multiple patients to be seen at the same time, prioritizing patients based on their arrival time.
• Double-booking allows providers to schedule appointments for two patients at the same time and provide medical services concurrently.

Managing Electronic and Paper-Based Medical Records

• Some healthcare providers still use paper-based filing systems (charts) for medical records, which can be inconvenient and lack real-time adjudication interoperability.
• Electronic records are more accurate, efficient, and required by government regulations and incentives.
• Medical records include administrative and clinical sections, with the administrative section containing patient demographic information, notice of privacy practices, and consent forms.

Storage of Medical Records

• Electronic health records are typically stored in the cloud, backed up in real-time, and easily accessible.
• Paper medical records are kept on-site, with archived records stored in a convenient off-site location for easy retrieval.
• Medical record retention times vary by state, and records must be stored appropriately and for the minimum amount of time specified by each state.

Review of a Chart

• Charting refers to the systematic recording of patient observations and information in their medical records.
• Electronic health records automatically record the individual's information, date, and time, while paper records require handwritten text.
• Electronic health records facilitate efficient communication and seamless coordination of care.

Review Patient Records Prior to the Visit

• Previsit planning involves reviewing the patient's medical record to determine important dates for preventive testing and immunizations, and to ensure timely completion of patient care management tasks.
• The MA reviews the patient's medical record to see if any preventive and diagnostic testing, immunizations, or exams are due.
• Electronic orders for diagnostic testing or prescriptions can be generated in the order section of the patient's EHR.

Clinical Quality Measures and Responsibilities During the Visit

• Clinical quality measures help identify treatments, processes, experiences, and outcomes, and may include patient engagement and safety, care coordination, and utilization of health-care resources.
• During the patient interview, the MA gathers specific information from the patient, including changes in health status, medication reconciliation, allergies, and health conditions.
• The MA educates patients on recommended preventive services and timelines, discusses necessary or recommended immunizations, and helps reinforce instructions and ensure comprehension.

Patient Appointments

• Medical assistants (MAs) are responsible for scheduling, canceling, and rescheduling patient appointments, which can be managed electronically or on paper.
• Electronic scheduling can be done using a computer, kiosk, or tablet, while paper scheduling involves handwritten schedule information in a book or on a form.
• Patients can schedule appointments online through the healthcare organization's website or their own patient portal.

Scheduling Methods

• Specific time: each patient is given an individual time for their appointment.
• Wave scheduling: multiple patients are seen at the same time, prioritized by their arrival time, providing greater flexibility within each hour.
• Double-booking: providers schedule appointments for two patients at the same time, providing medical services concurrently.

Requirements for Visit Duration

• Many factors influence the amount of time needed for the appointment, including the provider's habits and preferences, office processes, and the type of appointment being scheduled.
• Schedules are frequently divided into 15-minute intervals, with the MA reserving the necessary number of appointment slots based on the type of appointment and approximate time required.

Prioritizing Appointment Needs Based on Urgency

• The MA determines appointment priority by asking the appropriate questions, prioritizing patients with urgent needs, and scheduling them as soon as possible.
• The organization's screening process determines whether the situation is life-threatening and requires referral to an emergency department or if it is urgent and can be accommodated within the office schedule.

Patient Check-In and Check-Out

• Patient check-in begins when the patient arrives, involving confirmation of identity, eligibility, and insurance details, as well as update of demographic information.
• The MA will ask the patient to confirm their demographics, request a photo identification, and scan the insurance card and identification into the system.
• Patient check-out involves reviewing the after-visit summary, inquiring about any questions or concerns, and collecting any necessary payments.

Required Documentation for Patient Review and Signature

• Patients review and sign necessary paperwork, including demographics and medical history, Notice of Privacy Practices, Patient's Bill of Rights, Assignment of Benefits, and medical record release forms.

Follow-up on Patient Calls and Appointment Confirmations

• The MA makes outgoing calls to patients in response to appointment requests or confirmations, laboratory and imaging results, post-procedure follow-up calls, or returning patient inquiries.
• Patients are informed about laboratory and diagnostic test results through the patient portal, phone, or mail, with the provider's organization having a policy in place to contact patients by phone if they have abnormal results.
• Confirming and reminding patients of their scheduled appointments can help reduce no-show rates.

Types of Office Visits and Requirements

• New patients are those who have not received services from the same provider or group within three years and have a known complaint or condition.
• Established patient status includes those who have received services from the same provider or group within three years, including a known complaint/condition.
• Comprehensive appointments involve new or established patients with multiple complaints, injuries, or worsening chronic conditions at the highest coding level.
• Preventive care includes physical exams, annual wellness checks, and chronic care management.
• Urgent appointments are medically necessary within 24 hours.
• Other entities include non-patient related activities, such as depositions, sales, representatives, staff meetings, and training.

Determining the Type of Appointment

• To determine the type of appointment, consider the medical resources required to complete the appointment.
• Ask about the reason for the visit to determine the type and length of the appointment.
• Review the patient record to learn more about the appointment.

Patient Check-In and Check-Out

• Patient check-in begins when the patient arrives for their appointment and should be polite and professional.
• Confirm the patient's identity, eligibility, and insurance details.
• Request a photo identification, such as a valid state identification card or driver's license, to ensure accuracy.
• Check patient registration forms and scan the insurance card and valid state photo identification into the system.
• Determine any copayments or patient financial responsibilities that must be collected before medical services are provided.
• Patient check-out includes reviewing the after-visit summary (AVS) and inquiring about any questions or concerns.
• Collect any necessary follow-up and additional financial responsibilities.

Required Documentation for Patient Review and Signature

• Review and complete necessary paperwork, including demographics and medical history, Notice of Privacy Practices (NPP), Patient's Bill of Rights, and medical record release forms.
• New patients have more paperwork than established patients because they have signed documents on file.

Follow-up on Patient Calls and Appointment Confirmations

• The majority of outgoing calls to patients are in response to appointment requests or confirmations, laboratory and imaging results, post-procedure follow-up calls, or returning patient inquiries.
• Confirming and reminding patients of their scheduled appointments can help reduce no-show rates.
• Inform patients of the practice's no-show and late cancellation policy.
• Record all patient interactions and follow-ups in the patient record.
• Maintain confidentiality by not disclosing unauthorized protected health information (PHI) and follow confidentiality guidelines.

Monitor Patient Flow Sheets, Superbill, or Encounter Forms

• Patient flow sheet records and tracks patient health data, such as vitals or lab results.
• Encounter form/Superbill records the diagnosis and procedures covered during the current visit.
• Diagnosis and procedure codes must be linked to substantiate medical necessity.
• The encounter form is commonly generated electronically and contains a compilation of frequently utilized diagnosis and procedure codes.

Patient Appointments

• Patient appointments can be managed electronically or on paper, and patients can schedule appointments online through the healthcare organization's website or patient portal.
• Effective and accurate scheduling is crucial for the organization's workflow and success, resulting in staff, patient, and provider satisfaction.
• Scheduling methods include specific time, wave scheduling, and double-booking.

Scheduling

• Specific time scheduling gives each patient an individual time for their appointment.
• Wave scheduling allows multiple patients to be seen at the same time, prioritizing patients based on their arrival time.
• Double-booking allows providers to schedule appointments for two patients at the same time and provide medical services concurrently.

Patient Check-In

• Patient check-in begins when the patient arrives for their appointment and should be polite and professional.
• The MA confirms the patient's identity, eligibility, and insurance details, and requests a photo identification.
• The MA checks patient registration forms, ensures they have been signed and uploaded to the patient's account, and scans the insurance card and valid state photo identification into the system.

Patient Registration

• Patient registration forms are checked to ensure they have been signed and uploaded to the patient's account.
• The insurance card and valid state photo identification are scanned into the system.
• Some healthcare facilities photograph the patient and upload it to their medical records to verify the patient's identity and reduce the possibility of identity fraud.

Insurance and Billing

• The MA determines any copayments or patient financial responsibilities that must be collected before medical services are provided.
• The MA confirms insurance eligibility and determines any copayments or patient financial responsibilities.

Laboratory and Diagnostic Test Results

• Patients have immediate access to their results through their patient portal.
• Healthcare providers notify patients about the findings via the patient portal, phone, or mail.
• The provider's organization may have a policy in place to contact patients by phone if they have abnormal results, or to instruct the patient to call the office after a certain amount of time to follow up on the results.

Patient Communication

• Confirming and reminding patients of their scheduled appointments can help to reduce no-show rates.
• Reminders can be sent in a variety of ways, including automated calls or patient portal messages, appointment cards, email or text messages, or a combination of the above.
• Inform patients of the practice's no-show and late cancellation policy.

Patient Records

• The patient medical record is a legal document, and corrections to a paper record are made by adding a correcting entry or addendum, or by drawing a line through data and inserting new data.
• All information in the medical record should be kept confidential and private, with access limited to those authorized.
• Compliance should always be maintained.

Monitor Patient Flow Sheets, Superbill, or Encounter Forms

• Patient flow sheets record and track patient health data, such as vitals or lab results.
• Encounter forms/Superbill record the diagnosis and procedures covered during the current visit.
• Encounter notes include history of present illness and current medications list.
• Laboratory reports include results from lab tests that were performed.
• Radiology reports include results and interpretation from radiology services provided.

Electronic Health Records (EHRs)

• EHRs facilitate efficient communication within the medical institution and between other institutions that have incorporated EHR systems to assist in patient care.
• Medical records of patients are utilized to aid in delivering efficient medical treatment and invoicing a third-party payer.
• EHRs can also be employed to bolster research endeavors aimed at enhancing overall well-being.

Review Patient Records Prior To The Visit

• In team-based care settings, the MA frequently assumes additional responsibilities, including previsit planning.
• Previsit planning can begin several days before the appointment and include reviewing the patient's medical record to determine important dates for preventive testing and immunizations, ensuring timely completion of patient care management tasks, and examining prescriptions that have expired or will expire soon.
• Electronic orders for diagnostic testing or prescriptions can be generated in the order section of the patient's EHR.