1. Summary of ten steps of the billing processes and procedures. (explain each process)
In addition include:
a. Content and use of Registration or Encounter Forms,
b. Explanation of Benefits (EOB), and Remittance Advice (RA),
c. Advance Beneficiary Notice (ABN),
d. Participation Contracts,
e. The adjudication process for payers and providers.
A. Pre-registering patients: The main function of the first step is to schedule and update appointments as well as gather personal and insurance information about new and existing patients. New patients provide personal and insurance information to the scheduler, and pre-existing patients update any personal or insurance information with the practice that has changed.
B. Establishing financial responsibility: The second step is viewed as the most important because it determines what services will and will not be covered by medical insurance. It also determines if the patient or the insurance company is responsible for the payment of services. In a lot of cases, payment plans will be offered to patients with high out-of-pocket self-pays, like specialized procedures that insurance will not cover. Even if medical insurance is used, a copayment is generally required by the patient. Many physicians participate in more than one insurance contract, which are judged by the financial arrangements that are offered by the plan. Managed care systems are the most popular with physicians.
C. Check in patients: In this step, new and returning patient information is verified, outstanding balances are reviewed, insurance information is taken and placed in the patient’s file, necessary paperwork such as privacy and release of information statements are signed by the patient, and out-of-pocket expenses...
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Department of Health and Human Services, Health Care Financing Administration. (2000). Program memorandum intermediaries/carriers (Transmittal AB-00-116). Retrieved from http://www.aarc.org/members_area/advocacy/federal/AB00116.pdf
Anonymous. (2007). Mpro: michigan's quality improvement organization. Retrieved from http://www.mpro.org/
Anonymous, . (2011). American college of radiology. Retrieved from http://www.acr.org/Hidden/Economics/FeaturedCategories/Coverage/cac/lcd.aspx
Anonymous. (2011, May 31). Hipaa privacy rule accounting of disclosures under the health information technology for economic and clinical health act. Retrieved from http://www.federalregister.gov/articles/2011/05/31/2011-13297/hipaa-privacy-rule-accounting-of-disclosures-under-the-health-information-technology-for-economic#p-3 http://www.openclinical.org/medicalterminologies.html
Overall these sources proved to provide a great deal of information to this nurse. All sources pertained to HIPAA standards and regulations. This nurse sought out an article from when HIPAA was first passed to evaluate the timeline prospectively. While addressing the implications of patient privacy, these articles relate many current situations nurses and physicians encounter daily. These resources also discussed possible violations and methods to prevent by using an informaticist and information technology.
The first step is to pre-register the patient's insurance information into the computer system and making a copy of their insurance cards. The patient's insurance information would then be verified. The patient would then be seen by a medical professional to examine the patient, discuss any test results or provide a diagnosis. Once the patient is ready to check out any payment due would be collected. The medical coder would then go over the patients' medical record and assign any diagnosis codes or procedural codes and then a claim form (CMS 1500) would be completed and submitted. The payment would also receive and posted at this time and document in the patient's record. The CMS 1500 will information from the patient, including the type of
... Health Information Privacy For Consumers. Retrieved April 22, 2009, from U. S. Department of Health and Human Services: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
In the medical billing and coding process there are several steps. In the medical billing process physicians prepare and sign documentation of the patients visit. The next step is to post the medical codes and transactions of the patients visit in the practice management program and to prepare claims. The process used to generate claims must comply with the rules imposed by federal and state laws as well as with payer requirements. Claims that are correct help to reduce the chance of an investigation of the practice for fraud and also the risk of liability if an investigation does occur (Valerius, Bayes, Newby & Seggern, 2008). Most physicians depend on their personnel to process their medical bills without looking at the bills before they’re submitted for payment. Some physicians who don’t review the medical billing procedures may not receive the payment they deserve (Adams, Norman, & Burroughs, 2002).
...explains and clarifies key provisions of the medical privacy regulation, this is a reliable source of information which was published last December (HIPAA, 1996). Guaranteeing the accuracy, security and protecting the privacy of all medical information is crucial and an ongoing challenge for many organizations.
The Health Insurance Portability and Accountability Act, most commonly known by its initials HIPAA, was enacted by Congress then signed by President Bill Clinton on August 21, 1996. This act was put into place in order to regulate the privacy of patient health information, and as an effort to lower the cost of health care, shape the many pieces of our complicated healthcare system. This act also protects individuals from losing their health insurance if they lose their employment or choose to switch employers. . Before HIPAA there was no standard or consistency for the enforcement of the privacy for patients and the rules and regulations varied by state and organizations. HIPAA virtually affects everybody within the healthcare field including but not limited to patients, providers, payers and intermediaries. Although there are many parts of the HIPAA act, for the purposes of this paper we are going to focus on the two main sections and the four objectives of HIPAA, a which are to improve the portability (the capability of transferring from one employee to another) of health insurance, combat fraud, abuse, and waste in health insurance, to promote the expanded use of medical savings accounts, and to simplify the administration of health insurance.
Direct Marketing Association (2002, August). The Privacy Provisions of the Health Insurance Portability and Accountability Act. Retrieved from http://www.dmaresponsibility.org/HIPPA/#III1
Protecting Personal Health Information in Research: Understanding the HIPAA Privacy Rule, NIH Publication Number 03-5388. Retrieved November 12, 2011 from http://privacyruleandresearch.nih.gov/pr_02.asp
2. When should the patient be advised of the existence of computerized databases containing medical information about the patient?
Stephen Jonas, Raymond G, Karen G, “An Introduction to the US healthcare System” 6th Edition, Page 118, 25 May 2007
Sobel, R. (2007). The HIPAA Paradox. The Privacy Rule that’s Not. Hasting Center Report, 37(4), 40-50.
The confidentiality of patient visits and medical records are essential in providing the highest quality of health care. Under penalty of law, a patient's medical records or any other information regarding the patient may only be released with his or her authorization. Exceptions to this are certain cases specified by law for example, health care providers are required to report certain communicable diseases such as measles. Many organizations and laws have been developed to maintain patient's rights of confidentiality and access to their medical record. Guided by the principle that confidentiality is essential in developing strong trust between patients and healthcare providers, the American Health Information Management Association (AHIMA) members are committed to ensuring that patient records are disclosed and only available to medical personnel and others acquired by law. In July 1999, the Health Care Financing Administration (HCFA), introduced a new Patient's Rights Condition of Participation (CPO) that hospitals must meet to be approved for, or to continue participation in the Medicare and Medicaid programs. The Health Insurance and Accountability Act of 1996 (HIPAA) addresses the security and privacy of health data and also issues standards for electronic health care transactions. The vast accumulations of personal medical data gives rise to serious privacy concerns as a result of the potential for misuse.
While the HIPAA regulations call for the medical industry to reexamine how it protects patient information, the standards put in place by HIPAA do not provide ...
– Health care providers who transmit health information in electronic form for certain standard transactions.
Levit, K. R., & Cowan, C. A. (1991). Business, households and governments: Health care costs, 1990. Health Care Financing Review, 13 (2), 83. Retrieved from: Ashford University Library