1. 3 Patient Encounters and Billing Information Lecture 2

2. 3.6 Determining the Primary Insurance 3-18 Primary insurance—health plan that pays benefits first Secondary insurance—second payer on a claim Tertiary insurance—third payer on a claim Supplemental insurance—health plan that covers services not normally covered by a primary plan

3. 3.6 Determining the Primary Insurance (Continued) 3-19 To determine a patient’s primary insurance, medical insurance specialists: – Examine the patient information form and insurance card – Follow the coordination of benefits guidelines – Follow any rules that may apply – Communicate with the patient as needed

4. 3.6 Determining the Primary Insurance (Continued) 3-20 Coordination of benefits (COB)—explains how an insurance policy will pay if more than one policy applies – HIPAA Coordination of Benefits—transaction sent to a secondary or tertiary payer (X12 837) Birthday rule—guideline that determines which parent has the primary insurance for a child Gender rule—coordination of benefits rule for a child insured under both parents’ plans

5. Establishing Financial Responsibility (cont’d.) Entering insurance info in the PMP Communications with payers – All communications with payers should be documented in the patient’s… FINANCIAL (not medical/clinical) record 5OT 232 Ch 3 lecture 2

6. 3.7 Working with Encounter Forms 3-21 An encounter form (electronic or paper) is completed by a provider to summarize billing information for a patient’s visit – Aka ‘Superbill’ – Lists the medical practice’s most frequently performed procedures with their procedure codes – Blank spaces for diagnoses codes, and often includes other various information – Paper forms may be preprinted or computer-generated Charge capture—procedures that ensure billable services are recorded and reported for payment

7. 3.8 Understanding Time-of-Service (TOS) Payments 3-22 HIPAA tip – page 97 Practices routinely collect these charges at the time of service: 1.Previous balances 2.Copayments 3.Coinsurance 4.Noncovered or overlimit fees 5.Charges of nonPAR providers 6.Charges for self-pay patients 7.Deductibles for patients with CDHPs

8. 3.8 Understanding Time-of-Service (TOS) Payments (Continued) 3-23 Accept assignment—participating physician’s agreement to accept allowed charge as full payment Self-pay patient—patient with no insurance Partial payment—payment made during checkout based on an estimate

9. Collecting Time-of-Service (TOS) Payments Other TOS Collection Considerations Due to circumstances, funds can be delayed to practice – Adjudicated amounts – Annual deductible payments – Differences in participation contracts So increase TOS collections – Deductibles – Partial payment % of estimated amount owed 9OT 232 Ch 3 lecture 2

10. 3.9 Calculating TOS Payments 3-24 Real-time claims adjudication—process used to generate the amount owed by a patient at the time of service Wave of the future Must be coded first Get paid within 24 hours Real-time benefit information—process used to generate information about a patient’s benefits at the time of service Financial policy—practice’s rules governing payment from patients

11. 3.10 Collecting TOS Payments and Checking Out Patients 3-25 The PMP is used to record the financial transactions from patients’ visits: – Charges—amounts providers bill – Payments—monies the practice receives – Adjustments—changes to patients’ accounts Information from the encounter form is entered into the PMP to calculate charges and compute balances Payment methods may include cash, check, and a credit or debit card

12. Financial Policy Usually displayed in reception area or in new patient info packet Should explain – Unassigned claims – Assigned claims – Copayments Estimating what the patient will owe – Based on deductible & allowed charges Financial arrangement for large bills – Payment plan – Interest or not? 12OT 232 Ch 3 lecture 2

13. 3.10 Collecting TOS Payments and Checking Out Patients (Continued) 3-26 Payment Methods – Some sort of receipt is given as proof of payment – Insurance questionable Patient or provider handles after patient pays in full Walkout receipt—report that lists the diagnoses, services provided, fees, and payments received and due after an encounter – Insurance questionable Patient or provider handles after patient pays in full