Module 5: Administrative Assisting Flashcards
(111 cards)
1
Q
Referrals
A
An order from a provider for a patient to see a specialist or to obtain specific medical services.
*May be required when a patient is seeking services outside the realm of the primary care provider.
Can be completed by a phone call, creation/sending via the EHR, or visiting the payer website or provider portal, or it could have a formal written process depending upon the policies of the third-party payer
2
Q
Electronic Referrals
A
The health care organization can submit an electronic request to refer a patient to a specialty medical provider.
This can be done using the electronic health record or practice management software.
The electronic referral must be completed on a secure site and can only be emailed or sent using a secure service where encryption is used to ensure that it cannot be downloaded or viewed by an unauthorized user.
*Many third-party payers have a specific electronic form that must be used by the medical provider to provide a referral to a patient. Some third-party payers have the form accessible on their website. Once again, documentation would be attached to support the medical necessity of the referral. A copy of the request and follow-up of the referral would be included in the patient health records.
3
Q
Third-party payer for referrals
A
Referrals could have a formal written process depending upon the policies of the third-party payer
The third-party payer can help to determine the route to take with a referral for a patient because proper reimbursement is contingent on their policies.
Many third-party payers require the patient to schedule an appointment with their primary care provider to discuss the need for a referral.
4
Q
Referrals and HIPPA
A
For compliance purposes, referrals are considered part of the HIPAA exclusions for Treatment, Payments, and Operations (TPO), so a separate, signed release of medical information form is not required unless the organization has a policy stating otherwise.
5
Q
Practice management system (PMS)
A
The administrative side of the EHR:
Software used to electronically manage administrative functions, such as scheduling appointments, integrating patient documentation from electronic health records, coding, billing, and revenue cycle tasks such as running aging reports and managing the accounts receivable.
6
Q
EMR vs EHR
A
Electronic medical record (EMR): a digital version of a patient’s medical and health care information within a specific health care organization.
Electronic health record (EHR): a record of patient medical and health care information accessible to providers and other staff members with log-in credentials regardless of location, which contributes to more efficient patient workflow.
*EHR results in more accuracy and efficiency and a greater continuity of care for the patient. This integration allows for lab and diagnostic test orders to be entered and viewed by the patient and their providers in real time
7
Q
Real-time adjudication (RTA)
A
A tool that allows for a submission of the coded visit to the insurance company by participating providers for reimbursement decisions by third-party payers while the patient is present.
8
Q
Centers for Medicare & Medicaid Services (CMS)
A
A federal agency that oversees the Medicare program and assists states with Medicaid programs.
The CMS publishes documentation guidelines to ensure timely, accurate, and efficient documentation occurs:
- The publications are provider-type specific to give detailed information on documentation requirements.
- The publications include guidance with documentation errors that commonly occur and possible resolutions.
- Ex: incomplete progress notes, orders, or procedures and how to address updating the documentation.
*The lack of proper documentation can have a detrimental effect on the overall patient care and also can result in denied or inaccurate reimbursements from the third-party payers.
9
Q
Paper Medical Records
A
There are various storing and filing methods, but alphabetic filing (by the patient’s last name) is the most common. Inside the chart, paper records are assembled in reverse chronological order, with the most recent medical services on the top.
Disadvantages:
- can be cumbersome
- only allows access of one user at a time
- no real-time adjudication (RTA) interoperability among health care providers.
- searching for and locating charts can be time consuming.
10
Q
Storage of Medical Records: Electronic
A
Typically stored using cloud storage; most back up in real time and are easily accessed and retrieved.
Electronic records and backup data must be stored at a location offsite in case the original data source is lost or damaged
11
Q
Storage of Medical Records: Paper
A
Current records are stored on site, and archived records would be stored at a convenient offsite location to allow for retrieval as necessary.
Archived records may need to be retrieved for the purpose of medical history, general patient care, or in the event of a legal matter, such as a subpoena.
12
Q
Benefits of a good schedule
A
Effectively and accurately maintaining the schedule will positively contribute to the workflow and success of the organization, resulting in staff, patient, and provider satisfaction.
13
Q
Matrix
A
The designed time frame for appointments based on the method of appointment durations.
14
Q
Scheduling Methods
A
- Specific time
- Wave scheduling
- Double-booking
- Clustering
15
Q
Specific time
Type of scheduling method
A
A specific time gives each patient an individual time for their appointment.
16
Q
Wave scheduling
A
This system schedules two or three patients during a designated hourly time period, perhaps the top of the hour or within the first 30 minutes, and then patients are seen based upon who arrives first. This gives more flexibility within each hour.
17
Q
Double-booking
A
A type of scheduling in which two or more patients are scheduled within the same time slot and then provides medical services concurrently.
It is beneficial if one has labs or tests that need to be done and the provider can alternate between their care.
18
Q
Clustering
A
Patients are scheduled in groups with common medical needs
Ex: schedule all new patients on Tuesdays or all wellness exams on Fridays
19
Q
New Patient Appointment
A
The initial patient appointment or the first encounter after a 3-year absence from the organization. Includes known complaint/condition
Approximate Time Required: 60 min
20
Q
Types of Office Visits/Appointment
A
- New patient
- Established patient (could include follow-up, sick, or consultation)
- Comprehensive
- Preventive care (complete physical exam, annual wellness exam, chronic care management)
- Urgent
- Other entities
21
Q
Established Patient Appointment
A
Received services from the same provider or same group (and same specialty) within 3 years—includes known complaint/condition
- could include follow-up, sick, or consultation
Approximate Time Required: 15 min
22
Q
Comprehensive Appointment
A
New or established patient for a specified complaint at highest coding level, multiple complaints, injuries, or worsening chronic conditions
Approximate Time Required: 45 to 60 min
23
Q
Preventive Care Appointment
A
Thorough review of body systems including preventive care and screenings
Complete physical exam, annual wellness exam, chronic care management
Approximate Time Required: 45 to 60 min
24
Q
Urgent Appointment
A
Medically necessary within 24 hr
Approximate Time Required: 20 min
25
Other Entities (Appointment)
Non-patient related (depositions, sales, representatives, staff meetings, training)
Approximate Time Required: 30 min
26
Determine the Type of Appointment Needed
Determining the type of appointment needed will help ensure the appropriate amount of time has been scheduled for the patient visit.
1. When a patient calls for an appointment, always ask the reason for the visit to determine the type and amount of time needed for the appointment.
2. Review the patient record to gather more information about the appointment. Is the patient coming in for chronic care management, a wellness exam, or a follow-up of a current condition?
3. Once the reason for the visit is determined, ask the patient their preference of time and day for the appointment and then give them a few options of availability.
4. Another consideration of scheduling is to ask if they prefer a virtual (telehealth) or an in-person visit.
27
Screening Questions to Identify Type of Appointment Needed
Questions can include:
1. patient name and contact information
2. reason for the visit
3. nature of the current condition
4. other health care–related questions that relate to the nature of the current condition
28
Screening
Refers to asking questions to determine the patient’s signs and symptoms as well as the history of the current condition to prioritize the medical services.
- Important process to help determine the type of appointment that is needed.
- Used to determine if there is a need to route the call, such as forwarding to the clinical staff or another department such as the billing department.
The health care organization will have established written policies and protocols for questions to ask when screening calls.
29
Eligibility
Meeting the stipulated requirements to participate in the health care plan.
30
Copayment
A set amount determined by the plan/payer that the patient pays for specified services, usually office visits and emergency department visits.
31
Steps to Screening
1. Ask questions to determine what type of appointment is needed
2. Once the screening questions have been asked, verify the third-party payer (insurance) information and eligibility.
3. Inform the patient of policies regarding patient financial responsibility requirements, such as copayment due at the time of services.
32
How early should you ask a patient to arrive prior to their appointment?
It is best practice to also ask patients to come in at least 15 minutes earlier than the appointment to allow for time to fill out or update required paperwork.
33
Prioritize Appointment Needs Based on Urgency
A patient who calls in with a request for an urgent visit for minor injuries or acute conditions not requiring emergency care would be prioritized.
This is not an appointment that would be scheduled for the next available time slot; instead, fit them in as soon as possible.
The screening process (as established by the organization) will determine if the situation is an emergency (life-threatening) and should be referred to an emergency department or if it is urgent and could be accommodated by the office schedule.
34
Patient check-in
Starts when the patient arrives for their appointment.
1. Verify the patient’s identity, eligibility, and insurance information.
- Ask to see a photo identification, such as a valid state identification card or driver’s license, to ensure that the name and birth date matches the information on the insurance card and patient medical record.
2. Verify their patient demographics and ask if anything has changed so information can be updated if needed.
3. Patient registration forms will be checked to confirm they have been signed and uploaded to the patient account. The insurance card and valid state photo identification will be scanned into the system.
4. Some health care facilities will take a picture of the patient to upload into the medical record. This helps to verify patient identity and decrease the possibility of identity fraud. Patients have the option to agree to or decline having a picture taken or photo ID scanned.
5. When verifying the patient insurance eligibility, the MA will also determine any copayments or patient financial responsibilities to be collected before medical services are rendered.
- It is far more efficient to collect the amounts due up front than after the appointment or once the patient has left.
- The patient should have been informed of amounts due at the time of service when the appointment was made.
6. Provide any assistance needed for patients when they are being escorted to the exam room. The patient should be asked if they need any accommodations or assistance; it should never be assumed.
35
Claim denials often result from what?
Missing, incomplete, or inaccurate demographic information, and the check-in process is the time to ensure accuracy.
36
Patient check-out
Process occurs after the medical encounter has been completed.
1. Review the after-visit summary (AVS) and ask if the patient has any questions or concerns.
2. Any follow-up needed should be noted and highlighted for the patient, including scheduling follow-up appointments or assisting with scheduling diagnostic tests or lab work.
3. In the event of additional patient financial responsibility, such as deductible or coinsurance owed, it would be collected during check-out.
*The patient check-out should be just as cordial and professional as the greeting prior to the appointment.
37
After-visit summary (AVS)
Information that includes follow-up appointments, provider orders, instructions, educational resources, and financial account information.
38
Deductible
The amount that must be paid before benefits are paid by the insurance company.
39
Coinsurance
The percentage of the allowed amount the patient will pay once the deductible is met.
40
Notice of Privacy Practices (NPP)
Document that identifies how the provider will distribute and disclose a patient’s protected health information.
41
Administrative Sections of the Medical Record
- Patient’s demographic information (name, address, phone number, birthdate, sex (assigned at birth), insurance information, place of employment)
- Notice of Privacy Practices (NPP)
- Advance directive
- Consent forms
- Medical release forms
- Correspondence and messages
- Appointments and billing information
42
Clinical Sections of the Medical Record
- 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)
43
Editing/Correcting a paper record
Done by adding a correcting entry or addendum or by drawing a line through data and adding new data—it should never be permanently deleted.
Paper records must have the physical writing of the person with their name, date, and time.
*The patient medical record is a legal document. All information included in the medical record should be kept confidential and private and accessed only by those authorized. Compliance must always be maintained.
44
Patient flow sheet
Records and tracks patient health data, such as vitals or lab results
45
Encounter form/Superbill
A record of the diagnosis and procedures covered during the current visit; also known as superbill.
*has a list of the diagnosis and procedure codes most commonly used by the practice.
46
Encounter notes
Clinical notes that include history of present illness and current medications list
47
Laboratory report
Includes results from lab tests that were performed
48
Radiology reports
Includes results and interpretation from radiology services provided
49
Diagnosis code(s) (ICD-10-CM)
International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes based on the provider’s diagnosis
*why the patient is in need of medical services
They are assigned for billing purposes with the third-party payer and are a part of the medical record for the patient.
Diagnosis codes are three to seven alphanumeric characters long and begin with a letter. They describe the condition, cause, manifestation, location, severity, and type of injury or disease.
- Ex: N39.0- Urinary tract infection, site not specified.
Code Identifies:
- Diseases
- Injuries
- Medical conditions
- Patient status affecting health care
- Other reasons for health care encounters
Ex:
- Hypertension, Falls, poisoning, Signs/symptoms, Screenings, Vaccinations, Implanted medical devices or hardware
50
ICD-10-PCS vs ICD-10-CM
ICD-10-PCS codes are for hospital/inpatient only.
51
Procedure code(s) (CPT® and HCPCS)
Are assigned according to what medical services were provided relating to the diagnosis code to bill professional services.
Procedure codes include medical procedures and services provided, such as an exam or laboratory work.
Procedure codes are five digits and can have a two-digit modifier to provide additional information.
They are assigned from the CPT, HCPCS, and ICD-10-PCS code sets.
52
Diagnosis and procedure codes
Play an important factor in keeping accurate patient medical records and are the basis for accurate reimbursement from the third-party payer.
These codes are selected for a claim to be created to bill for the medical services.
Must link to support medical necessity
- Ex: how a sore throat would support a strep test.
53
Charting
The process of documenting patient findings in their health records. This includes evaluations, determinations, treatments, and any follow-up needed.
- It supports continuity of care and incorporates any communications with other medical professionals as well as the patient.
54
Editing an EHR
With electronic health records, the system automatically documents the person; date; and time when additions, modifications, or corrections are made.
55
Chart review
Performed to make sure the encounter, prescriptions, follow-up, and communications are all completely and accurately documented.
Ensure that the documentation process is efficiently and accurately reviewed before closing the record.
56
Utilization review
A process used by payers to inform providers about policy payments, benefits, and authorizations.
Elective and costly procedures, therapies, diagnostic imaging, prescriptions, and laboratory tests can require utilization review before they are scheduled or provided. This includes services, such as a hip replacement surgery, or providing durable medical equipment, such as a walker.
57
Precertification
A request to determine if a service is covered by the patient’s policy and what the reimbursement would be.
Can be obtained by verifying the patient’s benefits and can be performed during the eligibility check.
Precertification does not authorize the service or guarantee reimbursement because it does not determine medical necessity. Medical necessity must be established for the services to be approved.
58
Preauthorization
Approval of insurance coverage and necessity of services prior to the patient receiving them.
Typically required by the patient’s insurance company to determine medical necessity for the proposed services.
- Ex: certain medical procedures, therapies, diagnostic procedures, consultations with a specialist, non-emergency surgery, and hospitalizations.
The provider’s information; patient’s demographic and insurance information; a description of the service requested; the patient’s diagnosis, including ICD-10-CM code and the relevant CPT codes/HCPCS codes along with any additional information to justify the need for the service; and proposed time that the service will be performed will need to be detailed on these forms.
59
Verifying eligibility
Patient eligibility must be verified when an appointment is scheduled and on the date of service.
Verifying patient eligibility is ensuring that the patient’s policy is in effect and the third-party payer covers the medical services.
- When a patient receives services or calls to schedule an appointment, verify demographic detail and ask if there are any updates to the information. This includes name, address, phone, and insurance information.
- When the patient presents to receive medical services, verify a government-issued photo identification card and scan a copy of the insurance card into the system.
60
What methods can be used to verify patient eligibility?
Patient eligibility can be verified by either calling the insurance or using an eligibility application in the EHR or the payer's web-based verification service.
This helps to determine the amount of patient financial responsibility so that it can be communicated with the patient and payment collected.
61
Insurance Authorization Steps
1. The first part of the process is to verify eligibility.
*This will determine if the patient has health insurance coverage and will be able to receive the benefits during the proposed period.
a) When a patient receives services or calls to schedule an appointment, verify demographic detail and ask if there are any updates to the information. This includes name, address, phone, and insurance information.
b)When the patient presents to receive medical services, verify a government-issued photo identification card and scan a copy of the insurance card into the system.
2. The second part is to verify if the patient’s insurance covers the proposed service.
3. Lastly, complete the insurance’s requirements for obtaining authorization to provide the service to the patient.
62
Medical necessity
Reasonable and appropriate services based on clinical standards per CMS and the OIG.
63
CPT Codes
Current Procedural Terminology codes that identify medical services and procedures performed by a provider. (type of procedure code)
Code Identifies:
- Medical services
- Procedures performed by the provider
Ex:
- Office visit
- Laboratory test
- Lesion removal
64
HCPCS Codes
Healthcare Common Procedure Coding System codes that identify supplies and procedures not described by CPT codes. (type of procedure code)
Code Identifies:
- Supplies
- Procedures
- Services not described by CPT
Ex:
- Medical supplies
- Therapies
- Transportation
65
Insurance tiers
Some payers classify plans by tiers, which represent levels of coverage by the plan.
The lower-level plans result in higher out-of-pocket expense to the patient.
- Ex: the lowest-tier plan can have a lower monthly premium, but coverage could be 60% by the payer and 40% by the patient.
The highest-level plan can have a higher monthly premium, but the coverage could be 90% by the payer and 10% by the patient.
66
Interoperability
The ability of computer systems or software to exchange and make use of information.
- Supports the importance of documentation and sharing patient information using common standards.
- Includes storage, interpretation, and exchanging of information.
- Helps to ensure health care organizations and professionals have access to the patient health record to provide timely and appropriate care.
- Sharing and exchange of patient health records reduces unnecessary services and tests and prevents duplication of services.
The documentation must be accurate and in support of these goals. Patients have access to their own medical information, and it can be used for continuity of care. Proper documentation will also assist in proving that the appropriate standards of care were provided.
67
Provider Reimbursement
Effective documentation is essential to receiving optimal reimbursement.
Goverment regulations such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA):
- Programs and payment models like these can provide financial incentives to medical providers in support of quality of care being provided; it puts a concentration on quality, not quantity, of medical services.
* Ex: medication reconciliation, to record and evaluate the medications a patient is taking
- Preventive screening measures are included as proactive health care to improve patient outcomes and can reduce the need for future medical services and decrease the costs associated with future care.
* Ex: provide smoking cessation education to a patient who wishes to quit smoking.
Medical providers are reimbursed based on achievement of the program goals.
68
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Government regulated programs that implemented changes in the reimbursement methods of payment for Part B providers.
- The details about the patient condition, care, and screenings provided are used to report quality metrics and qualifying conditions for risk-adjustment payment models.
- Quality metrics, risk adjustment, and value-based care require that the documentation is an accurate representation of the medical screenings and services provided.
69
Medication reconciliation
a process of identifying the most accurate list of all medications the patient is taking compared to the medical record obtained from a patient, hospital, or other provider
70
Government Regulations
Regulations in place to ensure proper coding and documentation supports the medical services provided:
1. Interoperability
2. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
71
Common Insufficient Documentation Errors
- Incomplete progress notes
- Unauthenticated medical records (missing signatures and dates)
- No evidentiary radiographs to support medical necessity
- Insufficient documentation supporting conservative medical management was attempted
- Documentation that did not support certification of the plan of care for physical therapy
- Incorrect coding of Evaluation and Management (E/M) services to support medical necessity
72
Lack of proper documentation
Can have a detrimental effect on the overall patient care and also can result in denied or inaccurate reimbursements from the third-party payers
73
Advance Beneficiary Notice of Noncoverage (ABN)
A form used for fee-for-service (FFS) Medicare beneficiaries when the service may not be covered.
- The patient must be informed that it may not be covered and has the option to agree to be financially responsible for the payment.
- The ABN form is presented and signed before the services are provided.
- The ABN assigns the service as patient responsibility if Medicare denies the service.
*If an ABN is not signed prior to service and Medicare denies the claim, the patient is not responsible for the amount and the provider will not be paid. Medicare uses Healthcare Common Procedure Coding System (HCPCS) modifiers to convey the ABN status on the claim.
74
Reconciliation
The process of ensuring that the accounts are all balanced and accurate.
The amounts must be accurate and recorded routinely to the correct patient account so that current balances are updated and the patient financial responsibilities are provided via a statement to collect the amount due.
75
Revenue Cycle
A series of administrative functions that are required to capture and collect payment for services provided by a health care organization.
76
Parts of an effective revenue cycle
The patient records, documentation, coding and billing, claim submission, payment posting, and follow-up (can vary by organization)
Effective communication positively contributes to healthy revenue cycle management, including communicating within the health care team, with patients, and with third-party payers.
*The revenue cycle for a health care organization includes all finance-related aspects. The entire health care team has a direct impact on the potential revenue that will be earned and collected.
77
Incentive Models
Part of the transition from strictly FFS (fee for service) to value-based programs.
Incentive models include FFS reimbursement but have added incentives/disincentives based on provider performance of achieving certain quality and clinical measures and providing patient satisfaction.
Areas of concentration include preventive care and screenings, minimizing risks such as preventing hospital readmissions, or other condition-specific measures that can improve the overall health care outcome of patients.
Ex: Pay for Performance (P4P), Accountable Care Organizations (ACO), and Patient -Centered Medical Home (PCMH).
78
Aging report
A report that lists outstanding balances that have not been paid by either the patient or the insurance payer.
*Used so that the older debts can be addressed first.
This information can also be used to identify potential collections from delinquent accounts.
79
Accounts receivables (A/R)
Include any amount of money that is anticipated to be paid to it, including medical services billed
80
Contractual adjustment
The difference between the billed and allowed amounts for medical services or any write-off amounts.
81
Health Record Auditing
Done to ensure that documentation is complete, correct, and signed by the provider and that the details support the codes (e.g., CPT, HCPCS, and ICD-10-CM) reported for reimbursement and quality purposes
Health records are chosen by type or at random and undergo a thorough review by the auditor. Any noted discrepancies in the record are resolved by the provider and then signed off. The documentation is then compared to the related billing claims, and any differences are corrected by the billing staff.
Types of Audits:
- Internal/Prospective
- Retrospective
- Concurrent
82
Internal Audits
Audits done within the health care organization by the staff.
Internal audits are often prospective audits, meaning they are performed prior to billing.
This type of audit supports an organizations compliance policy by supporting coding and billing accuracy, aiding in the detection of potential fraud or abuse, documentation improvement opportunities, and the revenue cycle by ensuring that all services rendered are correctly billed
83
Retrospective Review
Audits done after the claims have been billed.
These audits may be performed internally for statistical or quality purposes or externally by a third-party payer.
Retrospective audits can be randomly chosen health records or targeted to specific data parameters.
84
Concurrent Review
Type of audit performed at inpatient facilities.
These audits are done during a patient's stay to ensure documentation completeness and efficacy of treatment.
85
Billing
Billing patients, insurers, and third-party payers for medical services rendered is an essential component to the revenue cycle.
Utilizing the EHR and practice management software makes the process easier and more efficient.
- Practice management software allows for generating patient statements for their financial responsibility of the overall costs by generating to the patient portal or paper for mailing.
86
Cycle billing
Billing in segments throughout the month
Ex: accounts with last name starting with A through F are billed in the first week of the month, G through M the second week, and so on.
87
Biling Timing
Determined by the health care organization and can use monthly billing or cycle billing.
88
Billing Frequency and Method
Determined by the size of the organization:
- Smaller facilities can use monthly or bimonthly billing
- Larger facilities would rely on cycle billing.
89
Clearinghouse
An intermediary organization that is contracted by the provider that accept and process the claims data, performs edits comparable to payer edits, assists with reducing claim errors, and submit for the third-party payer.
Can be private or public companies and serve as go-betweens between providers, billing groups, and payers for transmitting electronic claim information into specific forms required by the payers.
Beneficial for scrubbing claims prior to final submission and reducing the number of errors in claims and allows you the opportunity to correct before submission to the payer.
Most claims will be submitted electronically. Claims are prepared using the practice management software that uses information captured directly from the patient encounter.
90
Third-Party Payer Billing Requirements
The claims must be prepared following third-party guidelines before submitting them to the third-party payer or clearinghouse:
- These guidelines can include requirements such as timely filing, meaning that a clean claim must be submitted within a certain number of days from the date of service to be eligible for reimbursement.
- Some payers allow for up to one year from the date of service, but many have much shorter filing requirements.
- Another payer-specific example includes providing the date of injury on the worker’s compensation claim for a patient who was injured or became ill as a result of performing their job.
91
Adjudicated claims
The process by which insurance companies thoroughly review healthcare claims before reimbursement or payout.
During this process, they decide whether to pay the claim in full, pay a partial amount, or deny it altogether.
*Can result in a denial or incorrect reimbursement, which requires follow-up to determine the reason for the denial or partial payment and the proper action to take.
92
Claim denial due to service is not covered
verify the correct diagnosis and procedure codes were billed and supported medical necessity.
*Claims should be resubmitted after any needed corrections to the original claim have been made.
93
Reimbursement errors
If an incorrect reimbursement was received, verify the claim was processed correctly, submit a request to the payer to review it, and adjust the payment.
Errors include:
- issues related to in-network status
- the failure to recognize a preauthorization number.
*Claims should be resubmitted after any needed corrections to the original claim have been made.
94
Claim denial for patient eligibility
If the claim is denied for patient eligibility, submit a copy of the patient eligibility verification performed and resubmit for reconsideration.
*Claims should be resubmitted after any needed corrections to the original claim have been made.
95
Claim denial due to medical necessity
If the claim is denied stating the service “does not meet medical necessity,” it can be necessary to attach supporting documentation and submit with an appeal.
*Claims should be resubmitted after any needed corrections to the original claim have been made.
96
Reasons for a claim to be denied
- medical necessity
- patient eligibility
- reimbursement errors
- service not covered
*When the denial cannot be determined or is unclear, the MA can contact the third-party payer for clarification and to determine any appropriate action needed.
97
No-show
When a patient has a scheduled appointment and does not show up or contact the medical office.
98
Appointment Reminder Methods
Confirming and reminding patients of scheduled appointments can decrease no-show rates.
Reminders can be done in a variety of ways, including automated calls or patient portal messages, appointment cards, email or text messages, or a combination of these.
*Inform patients of the practice’s no-show and late-cancel policy.
99
Placing outgoing calls to patients
1. Open the patient’s medical record.
2. Have all the information needed available prior to placing the call.
3. Allow enough time and double-check the telephone number.
4. The MA should identify themself and confirm if this call time is convenient.
5. Only provide information to the patient or authorized individuals who are identified on the patient’s signed privacy agreement.
100
Follow-Up Patient Calls
All patient communication and follow-up must be documented in the patient record.
The MA will need to screen calls and determine the order of follow-up depending upon the reason for the call.
Always maintain confidentiality, not releasing unauthorized protected health information (PHI), and follow confidentiality guidelines when conducting conversations with patients over the telephone.
101
Leaving a voicemail with a patient
1. The MA should state only the name of the individual the message is intended for, date and time of the call, their name and the name of the practice, return call back number, and hours for returned calls.
2. Follow any office policy and procedure guidelines regarding office privacy agreements signed by the patient.
*Only leave the name of the practice if it does not reveal the purpose of the call.
102
Written correspondence
When written correspondence is received by the health care organization, determine the appropriate person or department that will follow up.
*Scan a copy of the correspondence and the response in the patient’s medical record, as the information is part of the legal record.
Can be created using a template, which is a sample form that requires specific personalization dependent upon the reason for the contact.
- This includes appeal letters, interoffice memos, faxes, and emails.
- It must be HIPAA compliant, free from spelling errors, and grammatically correct.
*Written communication is a direct reflection of the health care organization.
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Data Entry and Data Fields
Electronic health records and PM systems use data entry fields in their applications
Each of the fields must include data that is correct for the intended purpose.
- Fields can include demographic information such as name, patient gender, address, and insurance information.
The fields will be set specifically to accept information, such as a birthdate including numeric characters and insurance information accepting alphanumeric data.
- Some of the fields include drop-down menus that enable a person to select from a list of choices. Drop-down menus can help to increase the accuracy of data entered as they do not allow for typographical errors.
Reports can also be generated using the data that is entered into the system, such as determining patients who are due for an annual wellness exam.
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What impact does data can have on the medical records?
Data has an impact on the patient’s overall health care and billing process; it is a legal record. This information is used to maintain health records and for scheduling, billing, and any purpose that includes health data, such as research.
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The supply chain
The methods used, the companies that provide the supplies, and how supplies are delivered is called the supply chain.
A supply chain consists of a relationship between a company and its suppliers to produce and distribute a specific product to buyers.
There is a complex process of ordering, receiving, stocking, and organizing supplies as well as documenting and verifying correct amounts.
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Inventory supply log
Form that tracks the amount of inventory the office has and can be used to predict anticipated amounts needed based on the history.
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Ordering Supplies
Supplies are generally ordered electronically through suppliers.
1. first review the inventory supply log of office supplies to make sure the number of supplies ordered is appropriate.
- The supplier’s website will generally provide all supply information including item numbers, price, and description. Some offices may choose to have a supplier issue a printed catalog to have on hand.
2. Supplies are sent different ways, so not all supplies require a signature. If a signature is required, a form will be sent by the supplier to ensure appropriate delivery of supplies.
3. Once supplies arrive, check to make sure the supplies sent match what was ordered and in the correct amount.
- If any errors are noted with the supply delivered, notify either the practice manager or the supplier directly.
4. Delivery orders need to be checked as soon as possible because they can contain supplies that must be refrigerated, such as vaccinations. The practice can have an electronic inventory system to log in and document the items received.
*Inventory should be verified on a routine basis, per policy. Document the item, the vendor, the cost, and how often the item may need to be ordered.
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Stocking Supplies
1. Do not keep supplies stored in the shipping box because the box was transported outside and can bring germs or insects into the building.
2. Remove supplies from the shipping boxes and place them in the storage room.
3. A minimum number of supplies (threshold) is usually determined by the type of office and the total patients seen each day. It is always better to have adequate supplies on hand than to be without.
*When stocking supplies, some of the supply boxes can be heavy. Make sure to use proper body mechanics when lifting and/or moving boxes.
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Par level (threshold)
Minimum amount of inventory an office will have on the shelf before placing another order.
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Patient Portal
The patient portal gives patients a way to access their own records, including progress notes, lab results, radiology reports, immunizations, patient financial responsibility, and medications.
Sometimes this is referred to as the “digital front door.”
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Equipment inspection logs
All administrative and clinical equipment should have routine preventive checks to ensure safety and proper working condition.
- Examples of administrative equipment: printers, computers, copy machines, and fax machines.
- Examples of clinical equipment: electrocardiographs, centrifuges, blood glucose monitors, and electronic blood pressure machines.
This is documented in equipment inspection logs, which also provide the timeline of recommended and required maintenance.
These inspections will help to minimize risk of potential injury in the health care organization and ensure that the equipment is free from
