3 An Introduction to the Administrative Applications of Computers: Practice Management, Scheduling, and Accounting

Medical Informatics Clinical applications Special-purpose applications Direct patient care Special-purpose applications Education, pharmacy Administrative Office and materials management, scheduling, accounting, and financial applications

Medical Informatics Telemedicine Delivery of health care through telecommunications

Administrative Applications: Practice Management Software Designed to computerize administrative functions in a health care environment Allows organization of patient data, case data, and provider data Enables electronic scheduling, electronic progress notes, creation of lists of codes for diagnosis, treatment, and insurance

Administrative Applications of Computer Technology in the Medical Office Administrative applications include: Office management tasks Scheduling Accounting Administrative tasks in a medical office include: Coding and billing Insurance Payment

Practice Management Software Allows bucket billing (billing one insurer after another until the patient is billed) Organization of information in relational databases Each type of information is organized in its own table and can be accessed easily Tables can be linked

Figure 3. 1 MediSoft electronic appointment book Figure 3.1 MediSoft electronic appointment book. Source: Courtesy of MediSoft.

Figure 3. 2 MediSoft new appointment entry screen Figure 3.2 MediSoft new appointment entry screen. Source: Courtesy of MediSoft.

Figure 3. 3 Patient transaction entry (MediSoft 14) Figure 3.3 Patient transaction entry (MediSoft 14). Source: Courtesy of MediSoft.

Bucket Billing or Balance Billing Balance billing is unique to the health care environment A claim is filed with the primary insurer Response and check are received A claim is filed with secondary insurer Only after claims have been filed with all insurers, and responses received, is the patient billed

Database An organized collection of data created and maintained using database management software (DBMS)

Database A file contains related information on an entity. A file can have many tables, each containing related information. Tables can be linked by a common field. Tables are made up of records.

Database A record contains information on one item in the table. Records are made up of fields. A field is a piece of information in a record. A key field uniquely identifies a record.

Coding and Grouping Systems CPT: procedure codes ICD: disease codes MEDCIN: codes for symptoms, history, exams, tests, diagnosis, and treatment SNOMED: provides a common language LOINC: laboratory and clinical codes NDC: drug

CMS-1500 CMS-1500 is the most commonly used claim form.

Figure 3.4 CMS-1500 Form.

Accounting Transactions: charges, payments, and adjustments Case: condition that brings a patient to the doctor's office

Scheduling Making appointments in today's medical office involves using an electronic appointment book resembling the one on the next slide. 

 Figure 3.1 MediSoft electronic appointment book. Source: Courtesy of MediSoft.

Insurance Types of medical insurance Indemnity (fee-for-service) plans Health maintenance organizations Preferred provider organizations

Insurance Types of medical insurance Government insurance Medicare, Medicaid, CHAMPVA, TRICARE, CHAMPUS, Workers' Compensation Government insurance is administered by the Centers for Medicare and Medicaid Services www.cms.hhs.gov

Claim Request for payment from an insurer Can be submitted: Electronically through a clearinghouse On paper

Figure 3.5 UB-04 Form. Source: Independence Blue Cross/Blue Shield.

Figure 3. 5 (continued) UB-04 Form Figure 3.5 (continued) UB-04 Form. Source: Independence Blue Cross/Blue Shield.

Figure 3. 5 (continued) UB-04 Form Figure 3.5 (continued) UB-04 Form. Source: Independence Blue Cross/Blue Shield.

Figure 3. 5 (continued) UB-04 Form Figure 3.5 (continued) UB-04 Form. Source: Independence Blue Cross/Blue Shield.

Response to Claims An ERA (electronic remittance advice) accompanies a response to an electronic claim. An EOB (explanation of benefits) explains why certain services were covered and others not.

Bucket Billing Bucket billing allows the medical office to accommodate two or three insurers, who must be billed in a timely fashion before the patient is billed. Relational databases allow information input in one part of the program to be linked to information in another part of the program.

Bucket Billing Reports can be generated with the information provided in the relational database.

Accounts Receivable Accounts receivable—any invoices or payments from the patient or the insurance carriers to the practice

Superbill (Encounter Form) List of diagnoses and procedures common to a practice

Figure 3.6 The Superbill or Encounter Form lists procedures and tests common to the practice.

Patient Protection and Affordable Care Act (2010) On March 23, 2010, the Patient Protection and Affordable Care Act was signed into law by President Obama. The law expands health insurance coverage to 32 million more people by requiring them to buy health insurance.

Patient Protection and Affordable Care Act (2010) It also expands Medicaid coverage, and reforms current insurance practices. U.S. citizens and legal residents would be required to buy “minimal essential coverage.”

Patient Protection and Affordable Care Act (2010) Out of the estimated 25 million people who would be required to buy insurance, about 19 million could be eligible for subsidies.

Patient Protection and Affordable Care Act (2010) Anyone with an income below 4 times the federal poverty level ($22,000 for a family of 4, $10,800 for an individual; 4 times the federal poverty level: $88,000 for a family of 4, $44,000 for an individual) would be eligible for some sort of subsidy.

Patient Protection and Affordable Care Act (2010) Anyone with an income below 3–4x the poverty level would not have to pay more than 10% of their income for health insurance.

Patient Protection and Affordable Care Act (2010) The bill closes the donut hole in drug coverage for those over 65, with a $250 rebate in 2010. In 2011, people in the “hole” could purchase brand name drugs at a 50% discount. By 2014, states must expand Medicaid to cover childless adults.

Patient Protection and Affordable Care Act (2010) The bill reforms some of the practices of the private insurance industry: Children cannot be denied coverage because of preexisting conditions. No one can be denied coverage for preexisting conditions starting in 2014. Children can stay on their parents' insurance plans until age 26.

Reports Procedure day sheet Payment day sheet Patient day sheet Practice analysis report Patient aging report