CHAA Examination Preparation

Encounter - Session II

Pages 81-95

University of Mississippi Medical Center

What to Expect…

• This module covers various aspects of Patient Access knowledge found in pages 81-95 of the ENCOUNTER section of the 2010 CHAA Study Guide.

• A quiz at the end will measure your understanding of the content covered.

Medicare

• Medicare is the nation’s largest health insurance program which covers nearly 40 million Americans.

• This is health insurance for:– People age 65 or older– Certain disabled persons under age 65– Patients with End-Stage Renal Disease

(permanent kidney failure treated with dialysis or a transplant)

Medicare Part A, B, and D• PART A:

– typically pays for INPATIENT HOSPITAL expenses

• PART B:- typically covers OUTPATIENT HEALTH CARE

EXPENSES including doctor’s fees

• PART D:– any beneficiary with Part A/B can obtain

PRESCRIPTION drug coverage

Medicare Eligibility Requirements

Generally, patients are eligible for Medicare if:

• The patient or their spouse worked for at least 10 years in Medicare-covered employment

• They are 65 years or older• They are a citizen or permanent

resident of the United States

Admitting Medicare Patients

• ALL MEDICARE PATIENTS are required to complete a MEDICARE SECONDARY PAYER (MSP) QUESTIONNAIRE.

• The MSP Questionnaire determines if Medicare is the primary payer for the medical services or if another third-party payer is primary.

Coordination of Benefits

• The private insurance industry uses the term COORDINATION OF BENEFITS to determine the order for primary and secondary payment.

• The MSP Questionnaire should be completed based on the information provided by the patient or their representative for each claim.

Medicare Secondary Payer Questionnaire

The MSPQ is designed to draw out:

• If the illness/injury is work related• If the patient is covered by a Large Group Health

Plan• If they’re covered by their spouse’s insurance• If they qualify due to disability• If they qualify due to ESRD• If they are eligible due to Federal Black Lung,

Veteran’s Administration, or a Government Research Grant

MSPQ - Coordination of Benefits

Medicare Hospice Insurance

• Beneficiaries entitled to hospital insurance (Part A) who have a terminal illness and a life expectancy of six months or less have the option of receiving HOSPICE INSTEAD OF STANDARD INPATIENT TREATMENT.

Medicare Advantage Plans

• This is also known as Part C, MA Plans, or Medicare HMO.

• They are approved by Medicare but are operated by PRIVATE COMPANIES.

• This coverage REPLACES traditional Medicare and is NOT SUPPLEMENTAL INSURANCE.

• Most MA Plans are similar to HMOs/PPOs in that they have networks of doctors and hospitals. The one exception is Private Fee For Service Plans.

Unique Medicare Advantage Plans

• PRIVATE FEE FOR SERVICE PLANS - This MA Plan allows the patient to go to any doctor who agrees to accept the plan’s terms of payment before treatment.

• MEDICARE SPECIAL NEEDS PLANS – serves certain people with Medicare who are chronically ill, live in institutions like nursing homes, or who have special needs.

Medicaid

• Medicaid is available to CERTAIN LOW INCOME individuals and families who fit into an eligibility group recognized by STATE and LAW.

• Patients may or may not have to pay a small co-payment for some medical services.

• Medicaid is a state administered program and EACH STATE sets its own GUIDELINES regarding eligibility and services.

Medicaid Requirements

Medicaid Requirements MAY INCLUDE:• Patient’s age• Medical condition (pregnant, disabled,

blind, or aged)• Income and resources (bank accounts,

real property, assets, etc.)• Patient’s status as a U.S. Citizen or

lawfully admitted immigrant

Medicare Eligibility Requirements

• Medicare eligibility is TRICKY because it varies from state to state.

• Except in emergency services for certain persons, Medicaid does not provide health care services, even for very poor persons, unless they meet specific eligibility requirements.

• Low income is ONLY ONE TEST for Medicaid eligibility; assets and resources are tested against established thresholds.

Medicaid Coverage Beginning and Ending

• Coverage may start RETROACTIVE to any or all of the THREE MONTHS PRIOR to application if the individual would have been eligible during that period.

• Coverage stops at the END OF THE MONTH in which a person’s circumstances change.

Managed Care• Managed care is defined as any system that manages

healthcare delivery WITH THE AIM OF CONTROLLING COSTS.

• HMOs/PPOs are examples of Managed Care plans.

• They typically rely on a PRIMARY CARE PHYSICIAN to serve as a gatekeeper to health services.

• Managed Care REIMBURSEMENT is tied to “utilization management” where services are only paid for if the managed care organization deems the services as MEDICALLY NECESSARY.

Physician Orders

• A PHYSICIAN ORDER is a written document that includes:– Patient Name– Procedure– Diagnosis– Ordering Physician’s name and signature

• An ICD-9 and/or CPT code may be required as well

Medicare Medical Necessity

• The Centers for Medicare and Medicaid Services (CMS) is required by the Social Security Act to reimburse payment ONLY for services that are REASONABLE and NECESSARY.

• There must be EVIDENCE of MEDIAL NECESSITY before Medicare will pay.

• Procedures are medically justified for specific diagnosis as established by a LOCAL MEDICAL REVIEW POLICY (LMRP).– Many facilities are installing software to check medical

necessity versus checking manually.

Advanced Beneficiary Notice (ABN)

• The ABN is a WRITTEN NOTICE given to beneficiaries informing them that Medicare IS NOT LIKELY to provide coverage for certain procedures and that they may be liable for payment.

• The ABN must be VERBALLY REVIEWED and must be delivered far enough in advance for patients to consider other options.

ABNs ARE NEVER REQUIRED IN EMERGENCY OR URGENT SITUATIONS!!!!!!!!!!!!!!

Advanced Beneficiary Notice(ABN)

• Patients can NOT BE BILLED for uncovered services if the ABN is NOT SIGNED.

• The ABN must be SPECIFIC to the SERVICES being provided and the COST of services not covered.

Medical Terminology

• Patient Access Employees need to understand and accurately spell medical terms.

• They should also understand the CLASSIFICATION SYSTEMS used to translate diagnosis and procedural information into alphanumeric codes used to process insurance claims. The Classification Systems are:

» ICD-9-CM»HCPCS

Medical Terminology• International Classification of Diseases,

Ninth Revision (ICD-9-CM) – this includes classification systems for diseases, injuries, and procedures.

• Healthcare Common Procedure Coding Systems (HCPCS) – this is used to classify items and services provided in the delivery of healthcare. – Level I – codes dealing with physician services.– Level 2 - codes dealing with non-physician services.

Wayfinding

Effective Wayfinding alleviates anxiety among patients and reduces strain on staff who are less likely to have to provide directions.Wayfinding refers to:– Directions and alternate means of

transportation to the facility– Location of parking and patient drop-off point in

relation to the location of the service area– Campus maps– Visual cues such as color coding and repetitive

designs

Wayfinding

• Digital signage is becoming more popular as the use of electronic kiosks and flat panel screens that display information are increasing.

• Access Management is crucial to the improvement of wayfinding efforts by providing feedback from patients and visitors regarding current wayfinding tools.

Patient Tracking

• Because patient safety is compromised when there is high occupancy and overcrowding, the Joint Commission includes the management of patient tracking and patient flow as part of their accreditation requirements.

• Documenting the arrival and departure times allows caregivers to know where a patient is at any point of service during the encounter.

Patient Tracking

• The Joint Commission requires hospitals to have a patient flow committee, gather patient tracking data, and use that data to make changes.

• Radio Frequency Identification (RFID) technology assists patient tracking by transmitting the identity and location of any object or person wirelessly using radio waves.

Census Management• Census Management has become more

important due to the fact that hospitals are increasingly required to do more with fewer resources.

• Manually generating a paper nightly census no longer meets the needs of most hospitals.

• Electronic census management systems allows information to interface with other clinical or housekeeping systems which facilitates communication.

Customer Information

• Maintaining patient confidentiality is one of the most important duties of any health care organization.

• There are certain instances when limited information may be relayed to others without the patient’s EXPRESS permission.

Medical Record Release• Protected Health Information (PHI) – is

any information that may be used to identify the patient.

• Before releasing any information, there should be specific evidence that the requestor has a legitimate right to the information on a “need to know” basis.

• Patients have a right to know who has accessed their PHI.

Medical Record Release• Except for limited circumstances, the

patient should provide written consent for the release of any PHI.

• Protecting PHI is one of the main goals of HIPAA.

• The Provider OWNS the medical records but patients have the right to INSPECT, OBTAIN A COPY OF, and RESTRICT RELEASE of their medical records at anytime.

Opting out of the Facility Directory

• Patients can restrict access of their Protected Health Information when being treated at a facility by “opting out” of their directory.

• When they do so, a confidentiality flag is placed by the patient’s name in the MPI, alerting staff that no information is to be disclosed to callers, visitors, florists, or clergy.

Opting out of the Facility Directory

• Patient Access Employees are REQUIRED to ask if the patient wishes to “opt out” of the directory.

• They SHOULD EDUCATE THE PATIENT on the implications of their choice.

• Incarcerated and Psychiatric patients are usually deemed confidential automatically and facilities restrict all information except those required by law.