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Questions and Answers
What is the role of the billing management in the revenue cycle?
Patient payments for deductible, copayment, and coinsurance are typically posted and statements are generated.
True
What are some common reasons for claim rejections?
Incorrect patient information, incomplete or missing information, wrong insurance, services not covered
Billing errors are common, and the medical administrative assistant provides valuable support by reviewing claims prior to ____________.
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Match the following revenue cycle steps with their descriptions:
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Describe when the revenue cycle starts and when it ends.
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Briefly describe how practice management systems impact the health care organization.
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Why might a preauthorization be necessary prior to performing a procedure?
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Describe when a referral would be needed for patient care.
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What is typically collected from the patient during the check-out process?
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What is included in the after-visit summary (AVS)?
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What is the purpose of real-time adjudication?
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Why is it important to verify patient demographic and insurance information?
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What should the CMAA review to ensure medical necessity?
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What should the CMAA do if they identify errors in the claim information?
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Why is it important to review claim information carefully?
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What should the CMAA thank the patient for?
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What is the purpose of the after-visit summary?
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What should the CMAA encourage the patient to do after returning home?
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Study Notes
Revenue Cycle Key Points
- The revenue cycle begins with patient registration and scheduling and ends when the claim is paid in full.
- Electronic claims submission is required by many third-party payers, with allowances for paper claim submission from small practices.
- The billing application submits claims to the third-party payer for reimbursement, and patient payments for deductible, copayment, and coinsurance are posted.
Billing Management
- Billing management monitors payments billed and received each calendar month.
- A rejected claims report can be run to show potential trends in denials, identifying rejections and reasons for errors.
- The practice can correct errors and resubmit for payment, when applicable, within filing deadlines.
Copayment
- Many third-party payers require a fixed copayment at the time of service, which is a patient financial responsibility.
- Copayments are typically assigned to provider visits and are defined by the plan.
Billing Potential Errors
- Billing errors, such as diagnosis and procedure codes incorrectly translated from the encounter form, are common.
- The medical administrative assistant reviews claims prior to submission to prevent errors.
Patient Eligibility Verification
- Medical practices verify insurance eligibility for patients when appointments are made and when services are provided.
- This process is automated using a payer device or an app integrated into the practice management system.
Payment Tracking
- Most EHR or practice management systems offer monitoring of claims payment status.
- Payments are often made by direct deposit, which is the most efficient payment method for receiving claims reimbursement.
Prepare Documentation for Billing
- The revenue cycle begins when the patient contacts the healthcare organization for an appointment and does not end until the services and procedures provided are paid in full.
- Practice management systems (PMS) are used to perform revenue cycle tasks and streamline front office and back office workflows with automation.
Phases of the Revenue Cycle
- Registration and scheduling: The patient calls for an appointment, and the CMAA gathers patient information, determines the type of appointment needed, and enters the appointment on the provider's schedule.
- Patient check-in: The patient completes registration forms, HIPAA, and other compliance and policy forms, and the CMAA verifies the information.
- Utilization management review: Also known as utilization review (UR), this process ensures the patient has the appropriate referral, precertification, predetermination, or preauthorization as needed.
- Health care encounter and documentation: The provider reviews the patient's medical history, performs a physical exam, orders diagnostic or lab tests, and develops a treatment plan.
- Charge capture and coding: The CMAA captures procedure codes and corresponding diagnosis codes for the encounter in preparation for billing.
- Patient check-out: The patient proceeds to check-out, and the CMAA collects copays, schedules return appointments, and provides an after-visit summary (AVS).### Utilization Review Management
- Utilization review management involves verifying coverage and obtaining authorizations for certain services and procedures before performing them.
Charge Capture and Coding
- Charge capture and coding is the process of entering CPT, HCPCS, and ICD-10-CM codes associated with a patient encounter to prepare a claim for submission to the insurance payer.
- Accurate coding is essential for reimbursement, as services are not paid unless charges are entered correctly and submitted to the payer.
Preauthorization Requests
- A preauthorization request is submitted to determine the medical necessity of a service and allow the payer to decide on coverage.
- The purpose of a preauthorization request is to allow the payer to assess the appropriateness of the service.
- The payer will approve, modify, or deny the request, and provide an authorization number, specific CPT and/or HCPCS codes, and other specifications such as the number of visits and authorization expiration date.
Referrals and Preauthorization
- A referral may be necessary for patient care when a patient needs specialized care and treatment, such as when a primary care provider refers a patient to a specialist.
- Preauthorization may be necessary prior to a service because the insurance payer does not want to be responsible for reimbursement on services they consider not medically necessary.
CMAA Study Guide
- The Certified Medical Administrative Assistant (CMAA) study guide provides a focused review for the certification exam.
Revenue Cycle Key Points
- Electronic claims submission is required by many third-party payers, with exceptions for small practices.
- Billing applications submit claims to third-party payers for reimbursement.
- Patient payments for deductible, copayment, and coinsurance are posted, and statements and itemized receipts are generated.
Billing Management
- Billing management monitors payments billed and received each calendar month.
- A report allows analysis of reimbursement trends and identification of potential errors.
- A rejected claims report can be run to show trends in denials and identify reasons for rejection.
Copayment
- Many third-party payers require a fixed copayment at the time of service, which is a patient financial responsibility.
- Copayment amounts are determined by the third-party payer.
- Copayments are typically assigned to provider visits and are defined by the plan.
Billing Potential Errors
- Billing errors, such as incorrect diagnosis and procedure codes, are common and can be prevented by reviewing claims prior to submission.
- Errors in demographic information or billing data can cause claims to reject and hold up the billing process.
Patient Eligibility Verification
- Medical practices verify insurance eligibility for patients when appointments are made and when services are provided.
- This process can be automated using a payer device or an app integrated into the practice management system.
Payment Tracking
- Most EHR or practice management systems offer monitoring of claims payment status.
- This process tracks claim submissions, claim status, and payment sent to the provider.
- Payments are often made by direct deposit, which is the most efficient payment method.
Prepare Documentation for Billing
- Patient demographic and insurance information must be verified before billing claims.
- CPT, HCPCS, and ICD-10-CM codes must be reviewed to ensure accurate linking and demonstration of medical necessity.
- Corrections must be made according to the organization's policies and procedures.
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Description
Learn about the key points in revenue cycle management, including electronic claims submission, third-party payers, and reimbursement processes.
