Insurance and Billing

Key Insurance Terms

• Allowed Charge: The highest amount a payer will reimburse a provider for a service
• Birthday Rule: Determines which parent's insurance is primary for a dependent child based on whose birthday falls earlier in the year
• CMS: The Centers for Medicare and Medicaid Services, oversees Medicare and Medicaid
• Deductible: The annual amount an insured person must pay before their insurance starts covering costs
• Exclusions: Procedures or treatments that an insurance policy does not cover
• EOB/EOP: Explains claim details, including amounts allowed, disallowed, subscriber liability, and non-covered services
• Fee-for-Service: A traditional health plan that reimburses policyholders for their healthcare costs
• Fee Schedule: A practice's list of charges for common services and procedures
• Participating Physician: A physician enrolled in a managed care plan who agrees to abide by its rules
• Preauthorization: The process of a provider confirming with an insurance carrier whether a procedure is covered
• Premium: The base or yearly cost of health insurance
• Referral: Authorization for a patient to seek treatment from another practice, for insurance purposes
• Benefits: Insurance payments for medical services

Government Programs

• Medicare: National health insurance for Americans aged 65 and older
• Medicaid: A federally funded, state-run program offering healthcare assistance to low-income individuals, the disabled, and families
• TRICARE: Provides healthcare benefits for active duty and retired military personnel and their dependents
• CHAMPVA: Covers medical expenses for dependents of veterans with service-related disabilities or those who died in the line of duty

Medicare specifics

• Part A: Covers inpatient care, skilled nursing facilities, home health, hospice, mental health services, and respite care
• Part B: Covers outpatient procedures and supplies and requires patients to pay an annual deductible
• Part C (Medicare Advantage Plans): Includes PPOs, HMOs, fee-for-service plans, and MSAs
• Part D: Prescription drug plan

Managed Care Organizations

• PPO (Preferred Provider Organization): A network of providers offering care at negotiated rates; members can go outside the network but may pay more
• HMO (Health Maintenance Organization): Provides specific services to members for a capitation payment or negotiated fee-for-service rate

Key Billing Concepts

• Copayments: Collected at the time of service
• Balance Billing: Billing a patient the difference between the provider's usual fee and the insurance-allowed charge, is not allowed for participating physicians
• Coordination of Benefits: Limits total insurance payments to 100% of the covered charges
• Remittance Advice: Another name for EOB/EOP

Claim Transmission Methods

• Direct transmission to the payer
• Using a Clearinghouse
• Direct data entry

Data Elements on X12 837 Health Care Claim

• Provider
• Subscriber
• Patient
• Claim details
• Services

Payment Systems

• RBRVS (Resource-Based Relative Value Scale): The payment system used by Medicare, calculates fees based on relative value units, geographic adjustment, and conversion factors
• Capitation: A monthly payment to providers for each patient covered, regardless of how often the patient seeks services

Learning Outcomes for Insurance and Billing

• Define basic insurance terms
• Compare different types of managed care plans like fee-for-service plans, Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs)
• Outline the key requirements of Medicare, Medicaid, TRICARE, and CHAMPVA
• Describe allowed charges, contracted fees, capitation, and how the RBRVS formula operates in healthcare payments
• Obtain information required for insurance claims
• Properly complete a CMS-1500 form
• Describe how to submit insurance claims electronically
• Understand a payer's remittance advice

Functions of Front Office Staff

• Patient Registration: Signing in patients, collecting ID and insurance cards either in paper or electronic format
• Payment Collection: Handling payments like copayments via cash, check, debit, or charge card
• Observance: Paying attention to patients who should not wait due to symptoms like chest pain and shortness of breath

Office Opening Procedures

• Arriving 30 minutes before the opening time
• Unlocking the entrance safely and deactivating security systems
• Checking answering machines for reported emergencies
• Turning on necessary electronics

Office Closing Procedures

• Setting the stage for the next day via cooperation and communication among staff
• Turning off equipment according to policy and checking exam rooms
• Making sure that all confidential information is stored securely
• Notifying answering service or turning on the answering machine

Components of a Medical Office Safety Plan

• OSHA Hazard Communication
• Electrical Safety
• Fire Safety
• Emergency Action Plan
• Chemical Safety
• Bloodborne Pathogen Exposure
• Personal Protective Equipment
• Needlestick Prevention

OSHA Hazard Communication Standard

• Safety Data Sheets (SDS) must be accessible, including sections like identification, hazards, composition, first-aid, fire-fighting, accidental release, handling/storage, exposure controls, physical/chemical properties, stability/reactivity, and toxicological information
• Chemical containers must have hazard labels

Electrical Safety Guidelines

• Avoid using extension cords
• Repair or replace damaged equipment
• Avoid using electrical devices with wet hands

Fire Safety Guidelines

• Be vigilant about flammable materials
• Use fire safety equipment, following the PASS acronym (Pull, Aim, Squeeze, Sweep)
• Practice fire drills and know evacuation routes

Chemical Safety Guidelines

• Labeling and proper storage of hazardous substances are necessary
• Wear protective gear and work in well-ventilated areas
• Waste control procedures followed for cleaning spills

Ergonomic and Physical Safety

• Ergonomics: Proper lifting and posture, taking breaks to avoid repetitive stress injuries
• Physical Safety: Walk instead of run, clean up spills immediately, properly dispose of dropped medication

Laboratory Safety

• No eating or drinking in the lab
• Protective gear must be worn, and the location of eyewash and shower stations must be known

Reception Area Design Considerations

• Size and Schedule: Space must be adjusted based on patient flow
• Utilization of Space: Must be adjusted based on the type of practice
• Furnishings: Comfortable, stain-resistant, well-spaced, and no sharp edges
• Lighting and Temperature: Lighting cannot be too bright or too dim, and the temperature must be comfortable

Maintaining Cleanliness

• Housekeeping: Cleaning daily
• Removing Odors: Odors from body fluids and chemical odors are managed
• Infectious Waste: OSHA guidelines followed for biohazardous waste

Office Accessibility

• Parking and Entrances: Adequately lit spaces, including spots for those with handicaps, must be accessible for everyone
• Safety and Security: Building exits and systems like cameras and building passes
• Special Needs Accommodation: Accommodations for service animals, ramps, and patients who are vision or hearing impaired

Reception Area Key Points

• Maintain cleanliness for appeal and safety
• Use large-piece wooden puzzles instead of stuffed animals
• Minimize drafts with double doors
• Post advertisements for local pharmacies on the bulletin board
• Use firm furniture with arms for older patients to provide added support
• Create a strong, positive visual impression of the office

Safety Compliance

• Eyewash stations must be checked monthly
• Hazard labels must include a signal word
• Dispose of infectious waste promptly
• Use disinfectants regularly and install smoke detectors to meet OSHA requirements
• Biohazard symbols should be bright orange-red and clearly marked

Patient Interactions

• Schedule patients with autism spectrum disorder first or last in the day with, visual aids
• Use a gait belt to transfer patients, securing the wheelchair close to the exam table
• Include billing and insurance policies in the patient information packet
• Use specialized telecommunications for deaf patients
• Comply with the Americans with Disabilities Act for employment practices

Cleaning and Maintenance

• Large offices utilize a cleaning service
• Cigarette signs deter smoke to prevent odors
• Perform daily tasks such as keeping things in place, cleaning dirty areas, and disinfecting

Safety for Elderly Patients

• Furniture should be straight-backed and well-lit, and the place should be warm
• Overcrowding should be avoided, and new reading materials must be provided

Fire Safety (PASS)

• Pull the pin
• Aim at the base of the fire
• Squeeze the trigger
• Sweep side to side

Letter Components

• Letterhead: Preprinted stationery with contact information and the company logo
• Date Line: Date of when the letter was sent.
• Inside Address: Recipient’s name and address
• Attention Line: Used when addressing a company but sending it to a specific person
• Salutation: The greeting
• Subject Line: Content of the document
• Body: The written content of the letter.
• Complimentary Closing: The formal closing, ie "Sincerely"
• Signature Block: The writers name and business title.
• Identification Line: Initials of the person responsible for writing the letter followed by the typist’s initials
• Notations: Used for enclosures and copies sent to others

Additional Tools

• Dictionary: Words’ origins, definitions, pronunciations, spelling, and parts of speech.
• Thesaurus: Synonyms and antonyms.
• Physician’s Desk Reference (PDR): Prescription Information.
• Template: Ensures consistency and accuracy.