Flashcards in Week 2 Deck (68):
If a new patient calls to schedule, what should you do?
take the time to outline policies (payment, scheduling and cancellations)
if possible, verify the insurance benefits before the aptient arrives for their first appointment
request for treatment
usually patient initiates by phone
ask them to arrive 15-20 minutes before the appointment
when the patient requests treatment, what are some things you should go over with them?
have patient come early
welcome packet guidelines
patient financial respsonsibility letter
patient information form
medical and health history forms
informed consent form
financial hardship policy and application
written and printed policies available for patient guidelines
medical and health history forms (necessary)
what do you need to do to establish patient financial responsibility?
insurance information obtained (copy card front and back)
insurance verification (phone or internet)
financial policy explained
if insurance hasn't been verified, what needs to happen?
DC may have to give patient an estimate of medical fees
medicare has the ABN form
advanced benefitiary notice or waiver of liability
what should you require from patients during the inital visit?
copy of insurance card (front and back)
referrals or pre-authorization (if necessary)
have patient sign forms (request for records/release, assignment of benefits)
you already verified the person's insurance, do you still need a copy of their insurance card?
what else do you need to do when you get their insurance card?
ask for a valid form of ID
what questions should you ask of patients who are established?
has any info changed since our last visit?
has insurance changed since last visit?
have you had any changes in your health history?
why do you need to ask all the questions to the established patients?
to verify if information has changed
see if their condition has changed
treatment plan requirements
what the treatment plan will be
how many visits
how long the plan is
expected outcome and how you will measure it
date of onset is when for medicare?
the first date you saw the patient
documentation needed after appointment
document what happened
complete a fee slip (superbill)
collect any money owed from the patient
remin patient of next appointment (write down on card or have them write it down)
a form sent to the patient (proider) stating what has been paid by insurance and what patient owes
how do you get a reimbursement?
service must be
covered under payer's health benefit plan
medically necessary according to apyer
appropriately documented in patient's medical record
define medically necessary services
have been established as safe and effective
are consistent with symptoms or diagnosis
are necessary and consistent with generally accepted medical practices
are furnished at the most appropriate, safe and effective level
patient needs to understand that most insurances will not pay 100% of the bill
patient needs to understand they need to accept responsibility for their portion of the bill
5 most common features of cost sharing
out of pocket max
flow chart for payment
submit a claim
is claim paid (follow up in 30 days if not, if yes, match EOB)
is payment correct? (have policy in place if no)
send to collections
rejected or denied?
file and appeal
appeal again (if you can)
write off disallowed amount
if there is overpayment, what do you do? underpayment?
overpay- pay back ASAP
how often do you follow up on payments?
at least every 30 days
run reports in 30, 60. 90 day intervals
try to work out regular payments with patient before you send to collections
send to collections
should be outlined in payment policy and not an emotional decision
pay for a company to collect money for you (50% of what is collected)
insurance adjusted amount or network savings
then balance bill to patient
essential benefits list
ambulatory patient services
maternity and newborn care
mental health and addiction treatment
rehabilitative and habilitative services and devices
preventative and wellness services and chronic disease management
pediatric services, including oral and vision care
amount that patient has to pay in a time period before benefits will be paid (typically per calendar year)
after deductible, who pays?
created to contain costs and maintain quality
AKA HMO, PPO
(health maintenance organization or preferred provider organization)
actively manages medical aspect of patient care, financial aspect of patient care
selected providers furnish package of services to enrollees
explicit criteria for selection of providers
quality assurance, utilization review, outcome measures
appropriate care, cost-effective mix
billing manuals and instructions
be sure to understand extra costs involved with MCO
1500 claim form
AMA, CMS and payer organizations created it
most insurances use this
where can you look for claim form?
HSA acronym meaning
health savings account
health reimbursement arrangement
medicare medical savings acount
voluntary empolyee benefit association
multiple employer welfare arranement
permits eligible individuals to save and pay for health care expenses on a tax free basis
empowers patients to spend their own money
money is held in a tax exempt trust or custodial account
to qualify, patient must have a high deducible health plan
for medicatre patients
eliminates need for medigap
patient can pay for services not covered by medicare
patient can "save up" for future expenses
patient can determine how, when and where the money is spent
may promote better doctor patient relationships
empolyees ina geographic area band together
create member owned healthcare plans
growth and impact has been small but is growing
two or more unrelated employers may establish a healthcare plan
can use insurance or another type of funding
designed to give small employers access to low cost health coverage
positives for cash practice
eliminayion of administrative waste
less paperwork and overhead cost
no insurance forms/bills
no referral approval/authorization
lower fees to patients
risks for cash practice
fewer patients initially
having false illusions that quality is not important
may become a target of unfair fee allegations by 3rd party payers
personal injury examples
accidents in a home where patient doesn't reside
accidents occuring on a business site not work related
sources of payment for bodily injury
personal injury protection
will disburse payments from case
health insurance/HMO/PPO is used if..
fault-based, no-fault or attorney is exhausted
coers damages caused by negligence or fault of insured
covers patient when person liable is uninsured or underinsured
limited to medical expenses
covers insured regardless of vehicle
available for other policies
using medpay will usually not result in premium increase for insured
personal injury prtection
similar to medpay but also covers lost wages
may be mandatory in "no fault" state
medical leins/healthcare lien
attorney represents patient
filing a lien is usually a simple procedure
may prevent bill being discounted by lawyer
insurance company may put patient and DC name on check
what is a HIPAA exemption example?
work related illness or injury
what information do you need for worker's comp cases?
date and time of injury/illness and how it occured
what do you need to verify for workers comp?
empolyer knows of incident and report has been filed with insurance company
name of industrial insurance carrier
empolyer's WC policy #
what should the first report of injury contain?
accident or illness description
physician's assessment of patient
verification of other previous related illness/injury
estimated return to work status
permanent impairment or disability as a result of accident/injury
DCs are treated as physicians and a patient with FECA might choose a DC as provider (doesn't cover preventative care)
might now cover DC care
civialian health and medical program of uniformed services