1. Patient Encounters and Billing Information3
Patient Encounters and Billing Information

2. Learning Outcomes When you finish this chapter, you will be able to:
3-2
When you finish this chapter, you will be able to:
3.1 Explain the method used to classify patients as new and or established.
3.2 List the five types of information that new patients provide before their encounters.
3.3 Discuss the procedures that are followed to update established patient information.
3.4 Explain the process for verifying patients’ eligibility for insurance benefits.
3.5 Discuss the importance of requesting referral or preauthorization approval.

3. Learning Outcomes (Continued)
3-3
When you finish this chapter, you will be able to:
3.6 Explain how to determine the primary insurance for patients who have more than one health plan.
3.7 Summarize the use and typical formats of encounter forms.
3.8 Identify the seven types of charges that may be collected from patients at the time of service.
3.9 Explain the use of real-time claims adjudication tools in calculating time-of-service payments.
3.10 Describe the billing procedures and transactions that occur during patient checkout.

4. Key Terms accept assignment
3-4
accept assignment
Acknowledgment of Receipt of Notice of Privacy Practices
adjustment
assignment of benefits
birthday rule
cash flow
certification number
charge capture
chart number
coordination of benefits (COB)
direct provider
encounter form
established patient (EP)
financial policy
gender rule
guarantor
HIPAA Coordination of Benefits
HIPAA Eligibility for a Health Plan

5. Key Terms (Continued) HIPAA Referral Certification and Authorization
3-5
HIPAA Referral Certification and Authorization
indirect provider
insured
new patient (NP)
nonparticipating provider (nonPAR)
participating provider (PAR)
partial payment
patient information form
primary insurance
prior authorization number
real-time claims adjudication (RTCA)
referral number
referral waiver
referring physician
revenue cycle management (RCM)
secondary insurance

6. Key Terms (Continued) self-pay patient subscriber
3-6
self-pay patient
subscriber
supplemental insurance
tertiary insurance
trace number
walkout receipt

7. Chapter 3 Introduction
3-7
Cash flow—movement of monies into or out of a business
Revenue cycle management (RCM)—the actions that ensure the provider receives the maximum appropriate payment

8. 3.1 New Versus Established Patients
3-8
New patient (NP)—patient who has not seen a provider within the past three years
Established patient (EP)—patient who has seen a provider within the past three years
Figure 3-1, page 77

9. 3.2 Information for New Patients
3-9
When the patient is new to the practice, five types of information are important:
1. Preregistration and scheduling information
2. Medical history
3. Patient/guarantor and insurance data
4. Assignment of benefits
5. Acknowledgment of Receipt of Notice of Privacy Practices

10. 3.2 Information for New Patients (Continued)
3-10
Referring physician—physician who refers a patient to another physician
Participating provider (PAR)—provider who agrees to provide medical services to a payer’s policyholders according to a contract
Nonparticipating provider (nonPAR)—provider who does not join a particular health plan
Patient information form—form that includes a patient’s personal, employment, and insurance company data

11. 3.2 Information for New Patients (Continued)
3-11
Other terms for the policyholder of a health plan include:
Insured
Subscriber
Guarantor
Assignment of benefits—authorization allowing benefits to be paid directly to a provider

12. 3.2 Information for New Patients (Continued)
3-12
Acknowledgment of Receipt of Notice of Privacy Practices—form accompanying a covered entity’s Notice of Privacy Practices
HIPAA requirement
Direct vs. Indirect
clinician who treats a patient face-to-face
clinician who does not interact face-to-face with the patient
Not required for TPO
Patients must be informed once
Signed or not kept in file

13. 3.3 Information for Established Patients
3-13
When EPs arrive for appointments, they are asked if any pertinent personal or insurance information has changed
EPs should review their information forms for accuracy at least once per year
Any changes to an EP’s information should be entered in the practice management program (PMP)
Check for current Notice of Privacy Practices
Make sure one in file hasn’t expired
Existing patients get new cases or records for new cc
Chief complaint
Chart number—unique number that identifies a patient

14. Communications w/Patients
Most important – document EVERYTHING
OT 232 Ch 3 lecture 1

15. 3.4 Verifying Patient Eligibility for Insurance Benefits
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1st step in establishing financial responsibility
Abstract info from PIF & insurance card
Patient information form
Then contact the payer to verify
Patient’s general eligibility for benefits
Amount of copay
Whether the visit is for a covered service that is medically necessary
All must be checked before patient sees provider

16. Verify Patient Eligibility for Insurance Benefits (cont’d.)
Factors affecting general eligibility
Premiums
Income
Employment
PCP
Checking Out-of-Network Benefits
Additional charge or 100% responsible?
Verifying the amount of copayment
Usually listed on card, but January appointments?
OT 232 Ch 3 lecture 1

17. 3.4 Verifying Patient Eligibility for Insurance Benefits (Continued)
3-15
Determine whether the planned encounter is for a covered service
Electronic benefit inquiries & responses
HIPAA standard forms can be used (pg 59?)
HIPAA Eligibility for a Health Plan—transaction in which a provider asks for and receives an answer about a patient’s eligibility for benefits (X12 270/271)
Trace number—number assigned to a HIPAA 270 electronic transaction
PMPs log transactions
Be careful of info sent

18. 3.5 Determining Preauthorization and Referral Requirements
3-16
Preauthorization is requested before a patient is given certain types of medical care
Usually required
Controls access to specialists
HIPAA standard transaction
Prior authorization number—identifying code assigned when preauthorization is required (also called a certification number)
Referrals
Often required
HIPAA Referral Certification and Authorization: transaction in which a provider asks a health plan for approval of a service and gets a response (X12 278)
Referral number—authorization number given to the referred physician
Providers must handle these situations correctly to ensure that services are covered if possible
Procedures when patient is not covered
Inform patient prior to increase odds of pmt

19. 3.5 Determining Preauthorization and Referral Requirements (Continued)
3-17
Referral waiver—document a patient signs to guarantee payment when a referral authorization is pending
Used if a patient does not have the required referral document