An Introduction to a career in Health Care as a Medical Receptionist and Insurance Billler

1. Mary Claire Cuthbert RN, CLTC
INTRODUCTION
TO HEALTH CARE CAREERS

2. PERCEPTION

3. ROAD TO NOWHERE

4. CAREERS IN HEALTHCARE

5. DO YOU THINK YOU ARE INVISIBLE?

6. A PIECE OF THE PUZZLE!

7. DETAILED

8. COMMUNICATE

9. HONEST AND ETHICAL

10. BE ADAPTABLE

11. YOU MAY HAVE TO PUT FIRES OUT

12. AGGRESSIVELY PATIENT

13. DON’T TAKE IT PERSONALLY

14. DOING THINGS THAT ARE IMPOSSIBLE

15. FOLLOW MY LEAD

16. ARE YOU SCARED?

17. TERRIFIED

18. WILL YOU FIND YOUR WAY?

19. THERE IS A WAY

20. CLARITY AND PURPOSE

21. 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

22. 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

23. 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

24. APPOINTMENT SCHEDULING PRINCIPLES
Front office staff usually have first contact with
patients when they request appointments
Partial patient information collected over phone

25. THE PROCESS
 Patient registration
 Registration information/form
 Encounter form
 Clinical assessment and treatment
 Physician/Provider visit
 Patient departure
 Scheduling and billing

26. PATIENT REGISTRATION
 Receptionist
 Registers patient
 Obtains authorizations
 Copies/Scans insurance
card
 Generates encounter form

27. PATIENT REGISTRATION FORM
 Demographic information
 Insurance information
 Authorization/Assignment of benefits
 Electronic or paper format

28. PATIENT REGISTRATION
 Electronic health (medical) record
 New patient
 Create patient database
 Enter registration information
 Scan insurance card
 Established patient
 Update database

29. 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

30. CLINICAL ASSESSMENT AND TREATMENT
 Physician/Provider
 Examines patient
 Orders lab tests and
treatments
 Completes clinical sections
on encounter form

31. DEPARTURE PROCEDURES
 Schedule another appointment
 If necessary
 Compute charges for services
 Collect copayment
 Post charges and payments

32. 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

33. POSTING CHARGES AND PAYMENTS
Electronic billing
Charges and payments entered into patient database
Billing Specialist
generates:
Statements
Receipts
Claim forms
Transaction journals b

34. 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

35. 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

36. INSURANCE CLAIM FORM
 Billing specialist
 Submits claim
 Paper
 Completes claim form using source documents
 Electronic
 Generates claim form using patient database

37. INSURANCE CARRIER/COMPANY
 Reviews claim for errors
 “Clean” claim
 Provider (or patient) receives payment
 “Dirty” (denied) claim
 Payment withheld
 Provider and patient notified

38. 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

39. RESOLVING DENIED CLAIMS
 Technical errors
 Billing specialist corrects errors
 Claim resubmitted
 Coverage
 Billing specialist may contact patient
 Charges billed to patient

40. 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

41. STATE INSURANCE COMMISSION
 Responsibilities
 Monitor financial strength of insurance companies
 Protect interest of insured and policyholders
 Maintain complaint records
 Resolve insurance conflicts

42. 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