INTRODUCTION TO HEALTH CARE CAREERS

Mary Claire Cuthbert RN, CLTC

PERCEPTION

ROAD TO NOWHERE

CAREERS IN HEALTHCARE

DO YOU THINK YOU ARE INVISIBLE?

A PIECE OF THE PUZZLE!

DETAILED

COMMUNICATE

HONEST AND ETHICAL

BE ADAPTABLE

YOU MAY HAVE TO PUT FIRES OUT

AGGRESSIVELY PATIENT

DON’T TAKE IT PERSONALLY

DOING THINGS THAT ARE IMPOSSIBLE

FOLLOW MY LEAD

ARE YOU SCARED?

TERRIFIED

WILL YOU FIND YOUR WAY?

THERE IS A WAY

CLARITY AND PURPOSE

BACK AND FRONT OFFICE

Typical medical office has two main areas: Back office Front office

Back office Also known as “clinical” area Where all examinations, diagnostic testing,

and medical procedures conducted

BACK AND FRONT OFFICE

Back office (cont’d) Typical personnel:

Health care professionals e.g., doctors, nurses, physicians assistants, medical

assistants, X-ray technicians

Even though primary focus is patient care, work closely with those in front office

Sometimes sharing responsibilities

FRONT OFFICE

Front office Also known as

administrative area Hub of medical

facility Staff play key role in

proper management of medical office

e.g., administrative medical assistants, medical transcriptionists, medical insurance billers, office managers

APPOINTMENT SCHEDULING PRINCIPLES

Front office staff usually have first contact with patients when they request appointments

Partial patient information collected over phone

THE PROCESS

Patient registration Registration information/form Encounter form

Clinical assessment and treatment Physician/Provider visit

Patient departure Scheduling and billing

PATIENT REGISTRATION

Receptionist Registers patient Obtains authorizations Copies/Scans insurance

card Generates encounter form

PATIENT REGISTRATION FORM

Demographic information Insurance information Authorization/Assignment of benefits Electronic or paper format

PATIENT REGISTRATION

Electronic health (medical) record New patient

Create patient database Enter registration information Scan insurance card

Established patient Update database

ENCOUNTER FORM

Also called charge slip, routing form, or superbill Type of visit Lab tests and treatments Diagnoses Charges, payment, and balance due Patient signature/authorization

CLINICAL ASSESSMENT AND TREATMENT

Physician/Provider

Examines patient Orders lab tests and

treatments Completes clinical sections

on encounter form

DEPARTURE PROCEDURES

Schedule another appointment If necessary

Compute charges for services Collect copayment Post charges and payments

POSTING CHARGES AND PAYMENTS

Charges:Encounter forms are “source documents”

Payments:Checks, receipts, and insurance statements

are “source documents”

Charges and Payments posted to

patient account ledger and day sheet

POSTING CHARGES AND PAYMENTS

Electronic billingCharges and payments entered into patient database

Billing Specialist

generates: Statements

Receipts

Claim forms

Transaction journals b

DIAGNOSTIC AND PROCEDURE CODES Remember Source Documents are

Encounter form Medical record

Medical coder Reviews encounter form and medical record Assigns codes Enters codes into database

INSURANCE CLAIM FORM

CMS-1500 Patient and insurance information

CMS-1500 blocks 1-13 Treatment and provider information

CMS-1500 blocks 14-33 Charges

CMS-1500 blocks 24F, 28, 29, and 30

INSURANCE CLAIM FORM

Billing specialist

Submits claim Paper

Completes claim form using source documents Electronic

Generates claim form using patient database

INSURANCE CARRIER/COMPANY

Reviews claim for errors “Clean” claim

Provider (or patient) receives payment “Dirty” (denied) claim

Payment withheld Provider and patient notified

DENIED CLAIMS

Technical (data entry) errors Missing or incorrect information Transposed numbers Incomplete codes

Coverage Service not covered by health insurance Patient not covered by policy at time of service

RESOLVING DENIED CLAIMS

Technical errors Billing specialist corrects errors Claim resubmitted

Coverage Billing specialist may contact patient Charges billed to patient

OTHER CLAIMS PROBLEMS

Delinquent or pending Payment from insurance carrier overdue Claim lost or misplaced

Billing specialist Contacts insurance company

Phone, e-mail, or written inquiry May resubmit claim

STATE INSURANCE COMMISSION

Responsibilities Monitor financial strength of insurance companies Protect interest of insured and policyholders Maintain complaint records Resolve insurance conflicts

STATE INSURANCE COMMISSION

Referrals Pattern of problems with payment for services Unresolved primary payer status conflicts

Provider or patient may submit complaint Billing specialist may assist patient