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Practice Management

Billing Cycle:
1. preregister patients
2. establish financial responsibility
3. check in patients
4. check out patients
5. review coding compliance
6. check billing compliance
7. prepare and transmit claims
8. monitor payer adjudication
9. generate patient statements
10. follow up payments and collections
New patient:
hasn’t received services from the physician within the last 3 years
Established patient:
has had an appointment within a 3 year time frame
policyholder:
a person or entity who buys an insurance plan
;the insured
health plan:
a plan, program, or organization that provides health benefits
premium
the periodic payment the insured pays to a health plan for insurance coverage
payer
private or government organization that pays for health care
fee-for-service:
health plan that repays the policyholder for covered medical expenses
**deductible:
amount due before benefits start
**coinsurance:
PERCENTAGE of charges that an insured person must pay for health care services after payment of the deductible amount
managed care:
a type of insurance where the carrier is responsible for both the financing and the delivery of health care
PPO
“preferred provider organization”
managed care network of health care providers who agree to perform services for plan members at discounted fees.
HMO
“health maintenance organization”
managed health care system where providers agree to offer health care to the organization’s members for fixed payments
capitation
payment to a provider that covers each plan member’s health care services for a certain period of time
**copayment:
FIXED FEE paid by the patient at the time of an office visit
CDHP
“consumer-driven health plan”
managed care where a high-deductible, low premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses
patient information form
form including a patient’s personal, employment, and insurance data needed to complete an insurance claim
documentation
a record of health care encounters between the physician and the patient, created by the provider
medical record:
a chronological record of a patient’s medical history and care that indicates information that the patient provides, as well as the physician’s assessment, diagnosis, and treatment plan
diagnosis
physician’s opinion of the nature of the patient’s illness or injury
procedure
medical treatment provided by a physician or other health care provider
coding
the process of translating a description of a diagnosis or procedure into a standardized code
diagnosis code
a standardized value that represents a patient’s illness, signs, and symptoms
procedure code
a code that identifies a medical service
modifier
a 2-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service
**encounter form
“routing slip” or “superbill”
list of the procedures and charges for a patient’s visit
**EHR
“electronic health record”
computerized lifelong health care record for an individual that incorporates data from providers who treat the individual
**PMP
“practice management program”
a software program that automates many of the administrative and financial tasks in a medical practice
medical coder
a person who analyzes and codes patient diagnoses, procedures, and symptoms
code linkage provides __.
medical necessity
**medical necessity
treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and is provided in accordance with generally accepted standards of medical practice
***adjudication
series of steps that determine whether a claim should be paid
RA
“remittance advice”
an explanation of benefits transmitted electronically by a payer to a provider
EOB
“explanation of benefits”
paper document from a payer that shows how the amount of a benefit was determined
statement
a list of all services performed for a patient, along with the charges for each service
accounting cycle
the flow of financial transactions in a business
AR
“accounts receivable”
monies that are flowing into a business
HIT
“health information technology”
technology that is used to record, store, and manage patient health care information
PMP
“practice management programs”
Functions of PMP include:
1. scheduling
2. claims and billing
3. reimbursement
information about many aspects of the business is recorded, including: (4)
1. information about each patient
2. information about each provider
3. data about the health plans used by the practice’s patients
4. codes used by the practice to note a diagnosis and the treatment provided
clearinghouse
a company that receives claims from a provider, prepares them for processing, and transmits them to the payers in HIPAA-compliant format
audit/edit report
a report that lists errors in a claim
**walkout statement
a document listing charges and payments that is given to a patient after an office visit
**autoposting
an automated process for entering information from a remittance advice (RA) into a practice management program
**EMRs
“electronic medical records”
the computerized records of one physician’s encounters with a patient over time
**PHRs
“personal health records”
private, secure electronic files that are created, maintained, and owned by the patient
electronic prescribing
the use of computers and handheld devices to transmit prescriptions in digital format
evidence-based medicine
medical care based on the latest and most accurate clinical research
**advantages of electronic health records: (3)
1. safety
2. quality
3. efficiency
HITECH
“health information technology for economic and clinical health act”
part of the American Recovery and reinvestment act of 2009 that provides financial incentives to physicians and hospitals to adopt EHRs and strengthens HIPAA privacy and security regulations
workflow
a set of activities designed to produce a specific outcome
computer-assisted coding
assigning preliminary diagnosis and procedure codes using computer software
**HIPAA
“health insurance portability and accountability act” of 1996
federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information
HIPAA electronic transaction and code sets standards
regulations requiring electronic transactions such as claim transmission to use standardized formats
EDI
“electronic data interchange”
the transfer of business transactions from one computer to another using communications protocols
**EFT
“electronic funds transfer”
the electronic routing of funds between banks
X12-837 Health care claim (837 P)
HIPAA standard format used by physician offices to bill for services
CMS-1500 (08/05)
the mandated paper insurance claim form
NPI
“national provider identifier”
a standard identifier for health care providers consisting of 10 numbers
HIPAA privacy rule
regulations for protecting individually identifiable information about a patient’s health and payment for health care that is created or received by a health care provider
**PHI
“protected health information”
information about a patient’s health or payment for health care that can be used to identify the person
HIPAA security rule
regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected health care information
**administrative safeguards
policies and procedures designed to protect electronic health information outlined by the HIPAA security rule
physical safeguards
mechanisms required to protect electronic systems, equipment, and data from threats, environmental hazards, and unauthorized intrusion
technical safeguards
automated processes used to protect data and control access to data
**audit trail
a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed
**breach
the acquisition, access, use, or disclosure of unsecured PHI in a manner not permitted under the HIPAA privacy rule
**the HITECH act’s impact on privacy and security:
-breach notification
-monetary penalties
-enforcement
**database
a collection of related bits of information
medisoft program date
date the program uses to record when a transaction occurred
MMDDCCYY format
the way dates must be keyed
knowledge base
a collection of up-to-date technical information
backup data
a copy of data files made at a specific point in time that can be used to restore data
restoring data
the process of retrieving data from backup storage devices
rebuilding indexes
a process that checks and verifies data and corrects any internal problems with the data
packing data
the deletion of vacant slots from the database
purging data
the process of deleting files of patients who are no longer seen by a provider in a practice
recalculating balances
the process of updating balances to reflect the most recent changes made to the data
access rights
security option that determines the areas of the program a user can access, and whether the user has rights to enter or edit data
auto log off
feature of medisoft that automatically logs a user out of the program after a period of inactivity
govt funded ins. plans
-medicare
-medicaid
-tricare
-Champva
-workers comp
on a RA/EOB
date of service
service provided
pt name
pt control #
provider ID #
funct of EHR
results mgmt
order mgmt
decision support
pt support
health info
found in data base
pt data
provider data
ins. carriers
diagnosis codes
procedure codes

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