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Please see attached CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 10 Claim Management * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 10.1 Briefly compare the CMS-1500 paper claim and the 837 electronic claim. 10.2 Discuss the information contained in the Claim Management dialog box. 10.3 Explain the process of creating claims. 10.4 Describe how to locate a specific claim. 10.5 Discuss the purpose of reviewing and editing claims. 10.6 Analyze the methods used to submit electronic claims. 10-2 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 10.7 List the steps required to submit electronic claims. 10.8 Describe how to add attachments to electronic claims. 10.9 Explain the claim determination process used by health plans. 10.10 Discuss the use of the PM/EHR to monitor claims. 10-3 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms adjudication aging claim status category codes claim status codes claim turnaround time CMS-1500 (08/05) claim companion guide crossover claim data elements determination 10-4 development filter HIPAA X12 837 Health Care Claim HIPAA X12 276/277 Health Care Claim Status Inquiry/Response insurance aging report medical necessity denial National Uniform Claim Committee (NUCC) navigator buttons Teaching Notes: There are a lot of key terms, but many of them might already be familiar to your students. Give a pop quiz of the terms to see how many students know. Grade the quiz in class and use results to focus your lecture on terms that most or all students missed. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms (Continued) pending prompt payment laws suspended timely filing 10-5 Teaching Notes: See notes on Slide 5. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.1 Introduction to Health Care Claims 10-6 Timely filing—health plan’s rules specifying the number of days after the date of service that the practice has to file the claim HIPAA X12 837 Health Care Claim—HIPAA standard format for electronic transmission of the claim to a health plan CMS-1500 (08/05) claim—mandated paper insurance claim form National Uniform Claim Committee (NUCC)—organization responsible for claim content Learning Outcome: 10.1 Briefly compare the CMS-1500 paper claim and the 837 electronic claim. Teaching Notes: Provide sample completed insurance claim forms that contain errors and have student groups pinpont the errors. Discuss as a class and reinforce the fact that clean claims are critical to proper reimbursement. Ask students why they think that, in the era of electronic records, the CMS-1500 is a mandated paper form. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.1 Introduction to Health Care Claims (Continued) 10-7 Data element—smallest unit of information in a HIPAA transaction Notable features of the HIPAA 837 transaction (as compared to the CMS-1500 paper form): It has many more data elements, though many are conditional and apply to particular specialties only. It uses some different terms, and a few additional information items must be relayed to the payer. It requires a claim filing indicator code. Learning Outcome: 10.1 compare the CMS-1500 paper claim and the 837 electronic claim. Teaching Notes: When discussing the differences between HIPAA 837 and the CMS-1500, cite what some of the “many more data elements” are and why they are required. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.2 Claim Management in Medisoft Network Professional 10-8 Insurance claims are created, edited, and submitted for payment within the Claim Management area of MNP. Information contained in the Claim Management dialog box: All claims that have already been created Status of existing claims Options for editing, creating, printing/sending, reprinting, and deleting claims Navigator buttons—buttons that simplify the task of moving from one entry to another Learning Outcome: 10.2 Discuss the information contained in the Claim Management dialog box. Teaching Notes: Show Figure 10.5 in the textbook, the Claim Management dialog box, and ask students to look over it and provide feedback. What do they notice? How is it organized? Is it intuitive? Explain that there are FIVE navigator buttons, and direct students’ attention to Figure 10.6 in the text for a visual connection. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.3 Creating Claims 10-9 Claims are created in the Create Claims dialog box of MNP; to create a claim: Click the Create Claims button in the Claim Management dialog box; the Create Claims dialog box will open. Apply the appropriate filters; any box that is not filled in will default to include all data. Click the Create button to create the claims. Filter—condition that data must meet to be selected Learning Outcome: 10.3 Explain the process of creating claims. Teaching Notes: When discussing filters, provide concrete examples of what a filter might be. Discuss filtering by transaction dates, billing codes, location, etc. Ask students to discuss the advantages and disadvantages of using filtering. Have students complete Exercise 10.1. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.4 Locating Claims 10-10 To locate a claim in MNP: Click the List Only… button in the Claim Management dialog box; the List Only Claims That Match dialog box will be displayed. Apply the appropriate filters. Click the Apply button. The Claim Management dialog box is displayed, listing only the claims that match the criteria that were selected. Claims can now be edited, printed, or transmitted from the Claim Management dialog box. Learning Outcome: 10.4 Describe how to locate a specific claim. Teaching Notes: Ask students to brainstorm some possible reasons why a claim may need to be relocated (It might need to be checked for accuracy; it might need to be reviewed before resubmission if it has been rejected previously; etc.) Note again that you can apply various filters to make it easier to search for a claim: chart number, insurance carrier, etc. Have students complete Exercise 10.2. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.5 Reviewing Claims 10-11 Claims should be checked before transmission. Most PM/EHRs provide a way for billing specialists to review claims for accuracy. In MNP, this task is accomplished by using the Edit button in the Claim Management dialog box to load the Claim dialog box. The more problems that can be spotted and solved before claims are sent to carriers, the sooner the practice will receive payment. Learning Outcome: 10.5 Discuss the purpose of reviewing and editing claims. Teaching Notes: It is important to note for students that, when reviewing a claim in MNP, the baseline information (date of creation, chart number, claim number, patient name, case number) CANNOT be edited, only the information contained in the tabbed sections – carriers, transactions, comments. Have students complete Exercise 10.3. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.6 Methods of Claim Submission 10-12 Three most common methods of transmitting electronic claims: Direct transmission to the payer—Claims created in the PM/EHR are sent to the payer’s computer directly via a connection. Direct data entry—A member of the provider’s staff manually enters claims into an application on the payer’s website. Transmission through a clearinghouse—Practices send their claims to clearinghouses to be edited and then sent to the payer; this is the method used by most providers. Learning Outcome: 10.6 Analyze the methods used to submit electronic claims. Teaching Notes: Have students debate the merits and drawbacks of the three methods of claim transmission. Which one do they think is best? Why? Which would they most like to employ in their future jobs? Why? * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.6 Methods of Claim Submission (Continued) 10-13 Companion guide—guide published by a payer that lists its own set of claim edits and formatting conventions Crossover claim—claim billed to Medicare and then submitted to Medicaid Learning Outcome: 10.6 Analyze the methods used to submit electronic claims. Teaching Notes: Discuss with students why each payer seems to have their own ways of dealing with claim edits and formatting. If everyone did things the same way, there would be no need for a companion guide; why is there so much inconsistency? Remind students that Medicaid is known as the “payer of last resort.” * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.7 Submitting Claims in Medisoft Network Professional 10-14 To submit electronic claims in MNP: Select Revenue Management > Revenue Management… on the Activities menu; the Revenue Management window opens. Select Claims on the Process menu. Select an EDI receiver. To perform an edit check, click Check Claims; when complete, the Edit Status column displays the status of each claim. To continue with ready-to-send claims, select Send, select Claims, and select the EDI receiver. Learning Outcome: 10.7 List the steps required to submit electronic claims. Teaching Notes: Explain to students that MNP has a number of built-in edit functions, such as ANSI, common, and user-defined edits. More options, like the CCI edits and Medicare policy edits, are available but require an annual subscription. Ask students if the annual fee is worth it to have those additional editing capabilities – why or why not? When walking through the steps to submit electronic claims, use the screenshots in the textbook to provide a visual for students (pages 512-515). * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.7 Submitting Claims in Medisoft Network Professional (Continued) 10-15 To submit electronic claims in MNP (continued): A claim file is created and a preview report is displayed. If any errors are identified, the claims must be edited before they can be transmitted. Click the Send button to send the claim files. Learning Outcome: 10.7 List the steps required to submit electronic claims. Teaching Notes: See notes on Slide 14. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.8 Sending Electronic Claim Attachments 10-16 Attachments that accompany electronically transmitted claims must be referred to in the claim. In MNP, the EDI Report Area within the Diagnosis tab of the Case dialog box is used to indicate that there is an attachment and how it will be transmitted. An attachment control number is required if the transmission code is anything other than AA. Learning Outcome: 10.8 Describe how to add attachments to electronic claims. Teaching Notes: Ask students why any attachments must be referenced in the claim itself. Give a pop quiz of the report type codes to reinforce them with students. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.9 Claim Adjudication 10-17 Adjudication—series of steps that determine whether a claim should be paid Initial processing—Data elements are checked by the payer’s front-end claims processing systems. Automated review—Payers’ computer systems apply edits that reflect their payment policies. Manual review—Claims with problems are set aside for further review. Determination—Payer makes a decision about how to handle a claim. Payment—If due, payment is sent to the provider. Learning Outcome: 10.9 Explain the claim determination process used by health plans. Teaching Notes: Discuss why there are so many steps taken before determination of claim payment. Explain that in the Automated Review step alone, there are TEN different facets that are evaluated (found on textbook pages 518-519). * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.9 Claim Adjudication (Continued) 10-18 Suspended—claim status when the payer is developing the claim Development—process of gathering information to adjudicate a claim Determination—payer’s decision about the benefits due for a claim Medical necessity denial—refusal by a plan to pay for a procedure that does not meet its medical necessity criteria Learning Outcome: 10.9 Explain the claim determination process used by health plans. Teaching Notes: See notes on Slide 17. Also provide examples of various claims and ask student groups to determine what status their assigned claim might have been given and why. Choose a variety of claims; if no actual sample claims are available, create some scenarios that involve each of the key terms listed here. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.10 Monitoring Claim Status 10-19 Practices closely track their accounts receivable using their PM/EHR. After claims have been accepted for processing by payers, their status is monitored using the PM/EHR. Monitoring claims during adjudication requires two types of information: The amount of time the payer is allowed to take to respond to the claim How long the claim has been in process Learning Outcome: 10.10 Discuss the use of the PM/EHR to monitor claims. Teaching Notes: Note that a practice IS allowed to send an electronic inquiry at any time to a payer. Direct students’ attention to Table 10.2 in their text, which outlines some Claim Status Codes that a practice might receive in reference to a query. Ask students what time frame they think might be fair for claim payment/turnaround. Compare their responses to actual wait times and use that as entry into a discussion on why payments tend to take a long period of time. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.10 Monitoring Claim Status (Continued) 10-20 Prompt payment laws—state laws that mandate a time period within which clean claims must be paid Claim turnaround time—time period in which a health plan must process a claim Aging—classification of accounts receivable by length of time Insurance aging report—report that lists how long a payer has taken to respond to insurance claims Learning Outcome: 10.10 Discuss the use of the PM/EHR to monitor claims. Teaching Notes: Most of the key terms on this slide and the following slide might have already been covered at the beginning of this PowerPoint. If so, refresh students’ memories and tie the terms into the section being discussed. If not, use this time to showcase and explain the terms using examples to strengthen understanding. Give students an assignment to research prompt payment laws – are they the same in every state? Are they similar? Are there any unique variations? Why do students think this is the case? * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 10.10 Monitoring Claim Status (Continued) 10-21 HIPAA X12 276/277 Health Care Claim Status Inquiry/Response—electronic format used to ask payers about claims Claim status category codes—used to report the status group for a claim Pending—claim status in which the payer is waiting for information before making a payment decision Claim status codes—used to provide a detailed answer to a claim status inquiry Learning Outcome: 10.10 Discuss the use of the PM/EHR to monitor claims. Teaching Notes: See notes on Slide 20. When discussing claim status codes, call out various codes and ask students what response they think a practice would have upon receiving that code. * CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 7 Office Visit: Examination and Coding * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 7.1 Discuss the methods of entering documentation in an EHR. 7.2 Compare the process of entering a progress note with and without using a template. 7.3 Explain why e-prescribing reduces some medical errors. 7.4 List the steps required to enter a new prescription. 7.5 Explain why ordering and receiving test results electronically is more efficient than using paper methods. 7.6 List the steps required to enter an electronic order. 7-2 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 7.7 Explain how orders are processed in an EHR. 7.8 Define medical coding. 7.9 Discuss the purpose of ICD-9-CM. 7.10 Discuss the purpose of the CPT/HCPCS code sets. 7.11 Demonstrate the process that is followed to select a correct evaluation and management code. 7.12 Compare coding in a paper-based office with coding in an office with an EHR. 7.13 Discuss the purpose of an electronic encounter form in an EHR. 7-3 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms Alphabetic Index Category I codes Category II codes Category III codes computer-assisted coding Current Procedural Terminology (CPT) dictation digital dictation electronic encounter form (EEF) 7-4 evaluation and management (E/M) codes formulary HCPCS ICD-9-CM ICD-9-CM Official Guidelines for Coding and Reporting ICD-10-CM key components medical coding Teaching Notes: Many of these terms deal with coding, which might be a new topic for many students. As much as possible, explain the terms and provide examples so students can make connections. OPTIONS: After you have gone over the basics of coding, have students/student groups research a set number of terms and present their findings to the class. Provide specific examples (of an instance of upcoding, for example) and see if students can match the examples to the correct terms. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms (Continued) primary diagnosis SOAP Tabular List template upcoding voice recognition software 7-5 Teaching Notes: See notes on Slide 4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.1 Methods of Entering Physician Documentation in an EHR 7-6 Dictation—process of recording spoken words that will later be transcribed into written form Traditional method of documenting patient encounters Digital dictation—process of dictating using a microphone, a headset connected to a computer, a smart phone, or a PDA Voice recognition software—software that recognizes spoken words Template—preformatted file that serves as a starting point for a new document Learning Outcome: 7.1 Discuss the methods of entering documentation in an EHR. Teaching Notes: Note that U.S. physicians create more than ONE BILLION clinical notes each year. Use this information to transition into a discussion of the benefits of an EHR. Direct students’ attention to Figures 7.1, 7.2, and 7.3 in the text, which compare various ways for dictating and transcribing information. Discuss the advantages and disadvantages of each method. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.2 Progress Notes in Medisoft Clinical Patient Records 7-7 Progress notes can be entered using dictation and transcription, voice recognition software, or templates, or with a combination of techniques SOAP—format used to enter progress notes; stands for subjective, objective, assessment, and plan Learning Outcome: 7.2 Compare the process of entering a progress note with and without using a template. Teaching Notes: Present a selection of patient encounters, and give students (either individually or in groups) the assignment of creating a brief SOAP note for their assigned encounter. Discuss the results as a class. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.2 Progress Notes in Medisoft Clinical Patient Records (Continued) 7-8 To create a progress note: A patient chart must be open. Click the Note button on the toolbar and enter the date and title. Then choose from one of the documentation entry methods. If using a template, it will be inserted in the note; the physician responds to its labels accordingly to complete the note. If not using a template, the information is typed freely by the physician. Learning Outcome: 7.2 Compare the process of entering a progress note with and without using a template. Teaching Notes: Ask students to brainstorm the reasons behind using or not using a template – why would one be better than the other? What does it depend upon? Are there any drawbacks to using a template? Us the figures from the text to show examples of what a progress note in MCPR looks like at various stages. Have students complete Exercises 7.1-7.8. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.3 E-Prescribing and Electronic Health Records 7-9 E-prescribing reduces some medical errors by: avoiding many of the mistakes that occur with handwritten prescriptions, providing a number of built-in safety checks, and checking to be sure the medication is in the formulary of a patient’s health plan. Formulary—list of a plan’s selected drugs and their proper dosages Learning Outcome: 7.3 Explain why e-prescribing reduces some medical errors. Teaching Notes: Ask students to think about how prescription safety checks and refilling were done before the days of e-prescribing. Use Figures 7.10 and 7.11 for assistance. What concerns are associated with the “old way”? Are there any benefits to doing safety checks without the benefit of technology? Ask: As a patient, would you rather your medicine be e-prescribed or checked and filled manually? Why? * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.4 Entering Prescriptions in Medisoft Clinical Patient Records 7-10 To enter a new prescription in MCPR: Start from the Rx/Medications folder in a chart, or click the Rx button; the Prescription dialog box will be displayed. Complete the fields in the Prescription dialog box. Review the ten check boxes in the dialog box. Click the OK button to save the current prescription. Learning Outcome: 7.4 List the steps required to enter a new prescription. Teaching Notes: Note that a PIN is needed to transmit prescriptions. Why? MCPR monitors ALL patient prescriptions – new, ineffective, and historical (review those terms with students). Point out the dose Calculator button, another Medisoft function that calculates doses based on patient weight and the 10 required check boxes that ensure prescription accuracy. Have students complete Exercise 7.9. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.5 Ordering Tests and Procedures in an EHR 7-11 Electronic order entry is more efficient than paper methods as it: reduces errors associated with handwritten and paper orders, provides numerous safety and cost-control benefits, allows the user to delay sending out orders until approval is received, and allows orders to be printed or transmitted electronically. In addition, MCPR is capable of checking orders against information specific to a patient. Learning Outcome: 7.5 Explain why ordering and receiving test results electronically is more efficient than using paper methods. Teaching Notes: Explain that some EHRs have built-in standard order sets for common procedures, and while many large practices have lab facilities on-site, most small practices must outsource all of their lab work. Thankfully, if the practice uses an EHR, the EHR can receive lab results electronically. Ask students to compare and contrast Figures 7.13 and 7.14. Which do they prefer? Why? * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.6 Order Entry in Medisoft Clinical Patient Records 7-12 In MCPR, physicians can enter orders for laboratory, radiology, pathology, and other diagnostic tests. To enter an electronic order in MCPR: Click on the Orders folder in the patient’s chart; the Orders dialog box is displayed. Click the New button to enter a new order; the Order dialog box will open. Complete the four sections of the Order dialog box. Click OK to record the orders. Learning Outcome: 7.6 List the steps required to enter an electronic order. Teaching Notes: Orders are automatically listed at the end of a progress note, if tests were ordered the same day a patient was seen. Have students discuss why the “panel” option is a nice function – user can order a whole panel rather than multiple single tests. Relate these panels to those in CPT, Lab and Path code section. Show students Figures 7.16 and 7.17 to point out the Order Tree. Have students complete Exercise 7.10. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.7 Order Processing in Medisoft Clinical Patient Records 7-13 To process an order: In MPCR, select Orders > Order Processing on the Task menu; the Order Processing Select screen appears, with the Select Orders dialog box on top. Use the filters in the Select Orders dialog box. The Order Processing Select dialog box will display the orders that meet the criteria selected. Click the Edit button to view an order before it is processed. To print an order for a patient, click the Forms button; then click the OK button on the Standard Orders Printing Select dialog box which appears. Learning Outcome: 7.7 Explain how orders are processed in an EHR. Teaching Notes: Walk students through the order processing process using the screenshots in the textbook for assistance and examples. Ask students why there appear to be so many steps to go through to process an order. When discussing the Order Processing Select dialog box, identify all pieces of information that are displayed: date and time of order entry, patient name and ID, order name and status, PVID, order set, facility, and whether or not the order is a repeat. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.7 Order Processing in Medisoft Clinical Patient Records (Continued) 7-14 To process an order (continued): To send an order electronically, right click the line that contains the order; a menu will appear. Select the appropriate options from the menu. Click the OK button to send the order. Once the order has been printed or sent electronically, its status will change from pending to sent. To view orders that have been sent, select Sent as the Order Status in the Select Orders dialog box. Learning Outcome: 7.7 Explain how orders are processed in an EHR. Teaching Notes: See notes on Slide 13. Have students complete Exercise 7.11. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.8 Medical Coding Basics 7-15 Medical coding—process of applying the HIPAA-mandated code sets to assign codes to diagnoses and procedures In the physician practice coding environment, the required code sets are: CPT (Current Procedural Terminology) HCPCS (Healthcare Common Procedure Coding System) ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) Learning Outcome: 7.8 Define medical coding. Teaching Notes: Have sample coding books available, and let students page through them while discussing coding basics. Have students debate the pros and cons of using medical codes to classify diagnoses and procedures. Ask why the code sets are divided between diagnoses and procedures. Discuss the fact that coding is directly tied to reimbursement. If possible, give examples of proper and improper coding and the results that come from each. Give examples of coding scenarios and have students guess if the claim was reimbursed or not. Ask them to justify their thoughts. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.9 Diagnostic Coding 7-16 Primary diagnosis—patient’s major illness or condition for an encounter ICD-9-CM—abberivated title of International Classification of Diseases, Ninth Revision, Clinical Modification, the source of the codes used for reporting diagnoses Used to code and classify morbidity data from patient medical records, physician offices, and national surveys Learning Outcome: 7.9 Discuss the purpose of ICD-9-CM. Teaching Notes: Explain to students that expertise in diagnostic coding requires knowledge of medical terminology, pathophysiology, and anatomy, as well as experience in applying coding guidelines. Ask students why a coder would need expertise in medical terms and pathologies in addition to coding knowledge. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.9 Diagnostic Coding (Continued) 7-17 The ICD-9-CM code set has three parts: Diseases and Injuries: Tabular List—Volume 1 Diseases and Injuries: Alphabetic Index—Volume 2 Procedures: Tabular List and Alphabetic Index—Volume 3 Tabular List—section of the ICD-9-CM listing diagnosis codes numerically Alphabetic Index—section of the ICD-9-CM alphabetically listing diseases and injuries with corresponding diagnosis codes Learning Outcome: 7.9 Discuss the purpose of ICD-9-CM. Teaching Notes: Explain to students which volumes (1 and 2) are for outpatient and which (3) is for inpatient coding. When might a coder use the tabular list versus the alphabetic list? Reference Figure 7.22 in the text, which is a flowchart of the diagnostic coding process. Discuss with the class the reasons for so many segmentations in use, type, and classification of ICD-9-CM codes. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.9 Diagnostic Coding (Continued) 7-18 ICD-9-CM Official Guidelines for Coding and Reporting—American Hospital Association publication that provides rules for selecting and sequencing diagnosis codes ICD-10-CM—abbreviate title of International Classification of Diseases, Tenth Revision, Clinical Modification, which will be used beginning in 2013 Provides many more categories for disease and other health-related conditions and much greater flexibility for adding new codes Learning Outcome: 7.9 Discuss the purpose of ICD-9-CM. Teaching Notes: Note that the WHO put out the ICD-10 code set in 1990, but the United States is only now beginning the transition. Ask students to debate why the delay might have occurred and whether or not it was a good idea to stay with the ICD-9 for so long. Ask students to put together a short research paper looking at the differences and challenges associated with ICD-9 and ICD-10; they should also look at the education/refreshers needed to aid in the transition. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.10 Procedural Coding 7-19 Procedure codes are used by physicians to report the medical, surgical, and diagnostic services they provide. Current Procedural Terminology (CPT)—standardized classification system for reporting medical procedures and services HCPCS—procedure codes for Medicare claims Learning Outcome: 7.10 Discuss the purpose of the CPT/HCPCS code sets. Teaching Notes: Explain that procedure codes are used to help implement best practices; researchers track the results of various treatment plans and report them to physicians. CPT = procedures and services HCPCS (hick picks) = supplies and equipment * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.10 Procedural Coding (Continued) 7-20 There are three categories of CPT codes: Category I codes—procedure codes found in the main body of CPT Category II codes—optional CPT codes that track performance measures Category III codes—temporary codes for emerging technology, services, and procedures Learning Outcome: 7.10 Discuss the purpose of the CPT/HCPCS code sets. Teaching Notes: Give a number of examples of things that would fall into each code category so students can make connections. Then, call out various issues and procedures and see if students can properly categorize them (reducing tobacco use = Category II code). NOTE: Explain that Category III codes may become permanent and part of the regular code set if the emerging service proves effective. As an optional in-class assignment, have students use the Internet to research some Category III codes that have been added to the regular code set. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.11 Evaluation and Management (E/M) Codes 7-21 Evaluation and management (E/M) codes—codes that cover physicians’ services performed to determine the optimum course for patient care To select the correct E/M code, eight steps are followed: Step 1: Determine the category and subcategory of service based on the place of service and the patient’s status. Step 2: Determine the extent of the history that is documented. Step 3: Determine the extent of the examination that is documented. Learning Outcome: 7.11 Demonstrate the process that is followed to select a correct evaluation and management code. Teaching Notes: Explain that E/M codes are a subset of CPT codes; they reflect a range of analysis and decision-making, from low to high. (Provide examples to students to enhance connections). Each range is tied to an increasingly higher payment level. Use the flowchart in the textbook (Figure 7.24) to illustrate the 8 steps of choosing an E/M code. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.11 Evaluation and Management (E/M) Codes (Continued) 7-22 Selecting the correct E/M code (continued): Step 4: Determine the complexity of medical decision making that is documented. Step 5: Analyze the requirements to report the service level. Step 6: Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination. Step 7: Verify that the documentation is complete. Step 8: Assign the code. Key component—factors documented for various levels of E/M services Learning Outcome: 7.11 Demonstrate the process that is followed to select a correct evaluation and management code. Teaching Notes: Provide sample scenarios to student groups, and have each group walk through the 8 steps of determining and assigning the codes. Discuss results as a whole class. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.12 Coding Methods 7-23 Coding in a paper-based office: Provider writes or dictates notes either during or after the examination. Written notes are filed in the patient’s chart; dictated notes must be transcribed and then reviewed for accuracy by the provider. Coder reviews the provider’s documentation and assigns codes for the patient’s diagnoses and for the services provided. Once codes are assigned, the encounter forms are forwarded to a billing department, where the staff manually enters the information into the PM system. Learning Outcome: 7.12 Compare coding in a paper-based office with coding in an office with an EHR. Teaching Notes: The typical coding/billing/reimbursement cycle takes anywhere from 3-14 days. It is estimated that some practices lose up to 10\% of revenue due to manual billing errors. Coding is done by a member of office’s coding staff. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.12 Coding Methods (Continued) 7-24 Coding in an office with an EHR: Provider documents the visit in the EHR. EHR assigns preliminary codes based on the documentation. Coder reviews the EHR-generated codes for the patient’s diagnosis and for the services provided and assigns a diagnosis code to each procedure code. Coder instructs the EHR to transmit the encounter information electronically to the PM system. Learning Outcome: 7.12 Compare coding in a paper-based office with coding in an office with an EHR. Teaching Notes: Normally, some part of the process is automated. Turnaround is much quicker since the computer system flags a lack of information for determining code sets. The user can search for codes by entering keywords and information into the system. Have students compare and contrast Figures 7.25 and 7.26. What differences do they see? Be sure to cover the warnings for coding in an EHR office – risk for committing fraud (ask students how this is so), inaccurate code submission. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.12 Coding Methods (Continued) 7-25 Computer-assisted coding—assigning preliminary diagnosis and procedure codes using computer software Upcoding—assigning a higher level code than is supported by documentation Learning Outcome: 7.12 Compare coding in a paper-based office with coding in an office with an EHR. Teaching Notes: Assign students a short paper discussing the pros and cons of a paper-based coding system versus computer/EHR coding. IMPORTANT: Stress the negative implications of upcoding, how it can be avoided, and whether or not it is always intentional. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 7.13 Coding in Medisoft Clinical Patient Records 7-26 Electronic encounter form (EEF)—electronic version of the form that lists procedures and charges for a patient’s visit It eliminates the need for paper encounter forms. It is automatically populated with preliminary codes derived from information in the progress note in the EHR. Its codes are reviewed by a coding specialist. Learning Outcome: 7.13 Discuss the purpose of an electronic encounter form in an EHR. Teaching Notes: Explain that MCPR’s coding function is employed after the EEF is completed and reviewed. Point out the Action Item tab in MCPR (reference Figure 7.29) and note that if there is an outstanding action item, a claim cannot be transmitted. Ask students: If electronic coding is supposed to reduce errors, aid in reimbursement, and streamline the coding process, why does a coding specialist need to review all codes? Doesn’t that seem counterintuitive? Have students complete Exercise 7.12. * CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 13 Accounts Receivable Follow-up and Collections * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 13.1 Explain why it is important to collect overdue balances from patients. 13.2 Describe the way in which financial policies help establish payment expectations. 13.3 Describe the procedures followed to identify overdue accounts. 13.4 Identify the major federal laws that govern the collection process. 13.5 Explain how letters are used in collecting overdue payments. 13-2 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 13.6 Explain payment plans. 13.7 Discuss the use of collection agencies to pursue patients who have not paid overdue bills. 13.8 Describe the procedures for clearing uncollectible balances and small balances from patients’ accounts receivable. 13-3 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms bankruptcy collection agency collection list collection tracer report Equal Credit Opportunity Act (ECOA) Fair Debt Collection Practices Act of 1977 (FDCPA) means test 13-4 patient refund payment plan small-balance account Telephone Consumer Protection Act of 1991 tickler Truth in Lending Act uncollectible account write-off Teaching Notes: There are a lot of key terms, but many of them might already be familiar to your students. Give a pop quiz of the terms to see how many students know. Grade the quiz in class and use the results to focus your lecture on terms that most or all students missed. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.1 The Importance of Collections from Patients 13-5 Receiving full payment for services is a critical factor in determining the financial success of a medical practice. Sums that are not collected must be subtracted from income, reducing working capital. If payments are not collected, the practice may have to borrow funds and pay interest on those amounts. The average patient is now responsible for paying nearly 35 percent of their medical bills. Learning Outcome: 13.1 Explain why it is important to collect overdue balances from patients. Teaching Notes: Since members of the practice’s staff may be asked to work with patients to aid in collections, have students role-play some customer scenarios in which they try to obtain payment from a past-due patient. Have students brainstorm some ways a practice could cut down on the number of collections they experience. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.2 The Financial Policy and Payment Expectations 13-6 The patient collection process begins with a clear financial policy. Clear financial policies: result in effective communications with patients about their financial responsibilities, help patients to understand the charges and the practice’s policies in advance, make collecting payments less problematic, enable practices to add finance charges on late accounts, when announced in advance. Learning Outcome: 13.2 Describe the way in which financial policies help establish payment expectations. Teaching Notes: Ask students how a clear financial policy will make collecting payments less problematic. Explain that it is acceptable for a practice’s financial policy to stipulate the addition of finance charges on past-due payments, as long as the finance charge penalty complies with state and federal law. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.3 Collection Procedures 13-7 Nonpayment of patient statements initiates the collection process. Patient aging reports are analyzed to determine which patients are overdue on their bills and to group them into categories for efficient collection efforts. Collection list—tool for tracking activities that need to be completed as part of the collection process Tickler—reminder to follow up on an account In MNP, selections for the Collection List feature are located on the Activities menu. Learning Outcome: 13.3 Describe the procedures followed to identify overdue accounts. Teaching Notes: Explain that many practices send an outstanding bill to collections after 90 days; the text mentions that some practices send to collections as soon as 30 days out. Why might this be the case? Is there an advantage to sending a bill to collections sooner? Later? Have students complete Exercises 13.1 and 13.2. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.4 Laws Governing Patient Collections 13-9 Collections from patients are classified as consumer collections and are regulated by federal and state laws. Fair Debt Collection Practices Act of 1977 (FDCPA)—federal law regulating collection practices Telephone Consumer Protection Act of 1991—federal law regulating collection practices Learning Outcome: 13.4 Identify the major federal laws that govern the collection process. Teaching Notes: Go through the best practices for contacting patients on page 647 of the textbook; elicit student feedback on the fairness and completeness of the points. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.5 Collection Letters 13-10 Collection letters are usually a patient’s first notice that their bill is past due. These letters: are brief and to the point, preserve a professional and courteous tone, remind the patient of the practice’s payment options, remind the patient of their responsibility to pay the debt. Collection tracer report—tool for keeping track of collection letters that were sent Learning Outcome: 13.5 Explain how letters are used in collecting overdue payments. Teaching Notes: Direct students’ attention to Figure 13.16 in the textbook to showcase an account which has been flagged. Have students draft a sample collection letter to a patient; use the letter as a springboard into discussion. Is it an advantage or a disadvantage to have MNP generate automatic collection letters? Why? Have students complete Exercises 13.3 and 13.4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.6 Payment Plans 13-11 Payment plan—agreement between a patient and a practice in which the patient agrees to make regular monthly payments over a specified time period Most practices have a number of different payment plan options. If a payment plan is assigned and followed by the patient, the patient will not be sent collection letters. Payment plans may be regulated by law. Learning Outcome: 13.6 Explain payment plans. Teaching Notes: Practices’ payment plans may be regulated by date, frequency of payment, or amount of payment. Usually, the amount of the debt plays a role in figuring out a payment plan. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.6 Payment Plans (Continued) 13-12 Equal Credit Opportunity Act (ECOA)—law that prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, or age, or because a person receives public assistance Truth in Lending Act—part of the federal Consumer Credit Protection Act that regulates collection practices related to finance charges and late fees Learning Outcome: 13.6 Explain payment plans. Teaching Notes: Ask students to discuss why it is important to have regulations surrounding payment plans and collections – if a person owes money to a practice, shouldn’t the practice be allowed to set its own policies? Discuss how discrimination might be shown to one of the classes protected under the ECOA. Have students complete Exercise 13.5. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.7 Collection Agencies 13-13 Collection agency—outside firm hired to collect on delinquent accounts Practices should select agencies that have a reputation for fair and ethical handling of collections. Collection agencies are often paid on the basis of the amount of money they collect. Office staff members no longer contact patients whose accounts have been referred to a collection agency. Learning Outcome: 13.7 Discuss the use of collection agencies to pursue patients who have not paid overdue bills. Teaching Notes: Ask students why an office staff member would no longer contact a patient whose accounts have been turned over to collections. Have students complete Exercise 13.6. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.8 Write-Offs and Refunds 13-14 Uncollectible account—account that does not respond to collection efforts and is written off the practice’s expected accounts receivable Means test—process of fairly determining a patient’s ability to pay Bankruptcy—declaration that a person is unable to pay his or her debts Write-off—balance that has been removed from a patient’s account Learning Outcome: 13.8 Describe the procedures for clearing uncollectible balances and small balances from patients’ accounts receivable. Teaching Notes: Discuss the impact an uncollectible account would have on the financial strength of a practice. Define each of the situations/terms on Slides 14-15 and provide examples of each; ask students to debate which situations could be most easily addressed or mitigated. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 13.8 Write-Offs and Refunds (Continued) 13-15 Small-balance account—overdue patient account in which the amount owed is less than the cost of pursuing payment Patient refund—money owed to the patient Uncollectible balances may be removed from patients’ accounts receivable using MNP’s Transaction Entry dialog box. Small balances may be removed using MNP’s Small Balance Write-off feature from the Activities menu. Learning Outcome: 13.8 Describe the procedures for clearing uncollectible balances and small balances from patients’ accounts receivable. Teaching Notes: See notes on Slide 14; have students complete Exercises 13.7, 13.8, and 13.9. * CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9 Checkout Procedures * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Learning Outcomes When you finish this chapter, you will be able to: 9.1 List the six steps in the charge capture process. 9.2 Explain the purpose of auditing diagnosis and procedure code assignment. 9.3 Discuss the effect of health plans’ rules on billing. 9.4 Describe the use of CPT/HCPCS modifiers to communicate billing information to health plans. 9.5 Discuss strategies to avoid common coding/billing errors. 9-2 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Learning Outcomes (Continued) When you finish this chapter, you will be able to: 9.6 Explain the difference between posting charges from a paper encounter form and posting charges from an electronic encounter from. 9.7 Identify the types of payments that may be collected following a patient’s visit. 9.8 Identify the steps needed to create walkout receipts. 9.9 Describe the use of a patient education feature in an electronic health record. 9-3 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Key Terms accept assignment addenda adjustments bundled code CCI column 1/column 2 code pair edits CCI edits CCI modifier indicator CCI mutually exclusive code (MEC) edits charge capture 9-4 charges claim scrubbing code linkage compliant billing Correct Coding Initiative (CCI) global period medically unlikely edits (MUEs) modifier MultiLink codes There are a lot of key terms. Following are some activities to help present them. Put students into small groups and assign each group a set of terms to define and learn. Follow up by having each group teach their set of terms to the rest of the class. Assign each student a set number of terms to define as a homework assignment. Follow up by discussing all of the terms as a group activity during class. Ask students whether any of the key terms are familiar to them already; use their responses to launch a discussion about the rest of the terms. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Key Terms (Continued) package payments place of service (POS) code query real-time claim adjudication (RTCA) self-pay patients unbundling walkout receipt 9-5 Teaching Notes: See notes on Slide 4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.1 Overview: Charge Capture Process 9-6 Charge capture—process of recording billable services The six steps of the charge capture process: Step 1: Access encounter data. Step 2: Audit coding compliance. Step 3: Review billing compliance. Step 4: Post charges. Step 5: Calculate, collect, and post time-of-service (TOS) payments. Step 6: Check out patient. Learning Outcome: 9.1 List the six steps in the charge capture process. Teaching Notes: Ask students why they believe the charge capture process needs to be done in the order shown; use responses as a springboard into discussion. Compare and contrast the electronic method of charge capture with the paper method. Discuss the pros and cons of each. As a group, complete “Thinking It Through” 9.1 to solidify concepts. If desired, assign students a second scenario similar to “Thinking It Through” 9.1 to complete on their own as reinforcement. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.1 Overview: Charge Capture Process (Continued) 9-7 Charges—amount a provider bills for performed health care services Payments—money paid by patients and health plans Adjustments—changes to a patient’s account Learning Outcome: 9.1 List the six steps in the charge capture process. Teaching Notes: These are key terms, so they may already have been defined/discussed. If so, see notes on Slide 6. If not, go through each term and relate it to the charge capture process steps. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.2 Coding Compliance 9-8 Physician practices audit medical coding to ensure maximum appropriate reimbursement Codes/claims must be current and accurate for reimbursement. Code linkage and medical necessity must be shown. Addenda—updates to ICD-9-CM Claim scrubber—software that checks claims to permit error correction Code linkage—clinically appropriate connection between a provided service and a patient’s condition or illness Learning Outcome: 9.2 Explain the purpose of auditing diagnosis and procedure code assignment. Teaching Notes: It is IMPORTANT TO NOTE that PHYSICIANS are ultimately responsible for coding compliance, even though they do not do the actual work. Discuss this with students – why is this the case? Is it fair? Why or why not? What could physicians do to protect themselves from non-compliance? When discussing the addenda to ICD-9, note that the code set is updated annually. What does this mean for billers/coders? Use the screenshots in the textbook to walk students through how payments, adjustments, and changes are handled through Medisoft Network Professional. Assign students Exercises 9.1 and 9.2. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.3 Billing Compliance 9-9 Health plans and government payers reimburse practices according to their own negotiated or government-mandated fee schedule. Health plans issue many billing rules that govern what will and will not be covered. Medical practices must comply to be reimbursed. Compliant billing—billing actions that satisfy official requirements Package—combination of services included in a single procedure code Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing. Teaching Notes: It is IMPORTANT to explain to students that noncompliant billing may be seen as FRAUD. Ask them why; discuss. Explain that noncompliant billing may lead to any or all of the following for a practice, physician (again, since they are ultimately responsible for compliance), or staff member: delays in claim processing/receiving payments, reduced payments, denied claims, fines/sanctions, loss of hospital privileges, exclusion from health plan programs, loss of licensing, prison. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.3 Billing Compliance (Continued) 9-10 Bundled code—two or more related procedure codes combined into one Global period—days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package Correct Coding Initiative (CCI)—computerized Medicare system that prevents overpayment CCI edits—CPT code combinations that are used by computers to check Medicare claims Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing. Teaching Notes: Focus on the CCI, which is updated every quarter; use Figure 9.12 in the text for reference. Stress the key terms associated with the CCI (on subsequent slides as well) and provide as many examples as possible to reinforce terms with students. The textbook has many figures and examples useful for facilitating discussion. If possible, have coding books/CCI addenda/etc. available in class for students to review. Consider a group activity or assignment that involves students’ checking sample coding scenarios for compliance. For example, you could present three procedures which have been coded individually when there is a bundled code for the entire process (“unbundling” is covered on Slide 11). * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.3 Billing Compliance (Continued) 9-11 Unbundling—incorrect billing practice of breaking a panel or package of services/procedures into component parts CCI column 1/column 2 code pair edits—Medicare code edit in which CPT codes in column 2 will not be paid if reported for same day of service, for the same patient, and by the same provider as the column 1 code Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing. Teaching Notes: See notes on Slide 10. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.3 Billing Compliance (Continued) 9-12 CCI mutually exclusive code (MEC) edits—edits for codes for services that could not have reasonably been done during one encounter Medically unlikely edits (MUEs)—units of service edits used to lower the Medicare fee-for-service paid claims error rate Learning Outcome: 9.3 Discuss the effect of health plans’ rules on billing. Teaching Notes: See notes on Slide 10. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.4 Modifiers 9-13 Modifier—number appended to a code to report particular facts Communicates special circumstances involved with procedures. Tells the health plan that the physician considers the procedure to have been altered in some way. There are both CPT and HCPCS modifiers. CCI modifier indicator—number showing whether the use of a modifier can bypass a CCI edit Learning Outcome: 9.4 Describe the use of CPT/HCPCS modifiers to communicate billing information to health plans. Teaching Notes: Use Tables 9.1 and 9.2 in the text as a reference and guide for this discussion. Explain that modifiers are mainly needed for situations like the following: a service/procedure was performed multiple times or by more than one physician; a service/procedure has been increased or reduced; only part of a procedure was done; unusual difficulties occurred during the procedure. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.5 Strategies to Avoid Common Coding/Billing Problems 9-14 Compliance errors can result from incorrect code selection or billing practices. Strategies for compliance include: carefully defining bundled codes and knowing global periods, using modifiers appropriately, and following the practice’s compliance plan, especially the guidelines about physician queries. Learning Outcome: 9.5 Discuss strategies to avoid common coding/billing errors. Teaching Notes: Have students discuss ways to avoid errors such as truncated codes, billing invalid/outdated codes, upcoding, or downcoding. Explain again that the coding process is usually the ONLY way health plans/insurance companies decide whether or not to reimburse. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.5 Strategies to Avoid Common Coding/Billing Problems (Continued) 9-15 Place of service (POS) code—designates location where medical services were provided Query—request for more information from a provider Learning Outcome: 9.5 Discuss strategies to avoid common coding/billing errors. Teaching Notes: See notes on Slide 14. If more coverage of these key terms is needed, provide examples for students; for instance, point out that a query might be needed when there is conflicting or ambiguous information. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.6 Posting Charges in Medisoft Network Professional 9-16 Process of posting charges differs when using a paper encounter form versus an EHR. Posting charges from a paper encounter form: Click the New button in the Transaction Entry dialog box. Complete the required fields. Apply the payment in the Charges Area of the Transaction Entry dialog box. Save the charges using the Save Transactions button. MultiLink codes—groups of procedure code entries that relate to a single activity Learning Outcome: 9.6 Explain the difference between posting charges from a paper encounter form and posting charges from an electronic encounter from. Teaching Notes: Explain what the “required fields” are when discussing posting charges; use textbook pages 456-460 as a guide. Discuss why the information is required rather than being optional. Be sure to explain the different color-coding references (partially paid claims are aqua, etc.) in the Transaction section. Have students complete Exercise 9.3. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.6 Posting Charges in Medisoft Network Professional (Continued) 9-17 Posting charges from an EHR: Transactions from an EHR do not need to be manually posted in the Transaction Entry dialog box. After electronic encounter form data is reviewed and edited (if necessary), it is posted and automatically appears in the Transaction Entry dialog box. Unprocessed transactions can be posted from the Unprocessed Charges dialog box or from the Unprocessed Transactions Edit dialog box. Learning Outcome: 9.6 Explain the difference between posting charges from a paper encounter form and posting charges from an electronic encounter from. Teaching Notes: Ask students why, if posting charges from an EHR is so much quicker, there is still a need to manually enter paper claims (because not every practice is using EHRs yet, etc.) Give student an assignment (either in groups or individually) to research reimbursement rates, fraud, or other transaction scenarios in terms of paper encounter forms versus EHR information. Ask them to write up a brief summary of their findings, with examples – did they notice anything in terms of the accuracy/reliability of EHR records versus paper records? Have students complete Exercises 9.4-9.7. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.7 Posting Patient Time-of-Service Payments 9-18 Practices routinely collect payment for the following types of charges at the time of service: Previous balances Copayments or coinsurance Noncovered or overlimit fees Charges of nonparticipating providers Charges for self-pay patients Deductibles for patients with consumer-driven health plans (CDHPs) Learning Outcome: 9.7 Identify the types of payments that may be collected following a patient’s visit. Teaching Notes: Ask students why these types of payments are collected at time of service; discuss what might happen if these payments are not collected at this time. If desired, integrate this section’s key terms (on next slide) into this discussion; terms might make more sense if they are discussed in context. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.7 Posting Patient Time-of-Service Payments (Continued) 9-19 Accept assignment—participating physician’s agreement to accept allowed charge as full payment Self-pay patients—patients with no medical insurance Real-time claim adjudication (RTCA)—process used to contact health plans electronically to determine visit charges Learning Outcome: 9.7 Identify the types of payments that may be collected following a patient’s visit. Teaching Notes: When discussing “accept assignment,” note that the procedure for collecting nonPAR payment is different: usually the patient needs to pay everything up front. Ask students why this is the case. Discuss the actual process for using RTCA (see textbook pages 471-472). Before assigning exercises, walk through the process of entering payment information in Medisoft Network Professional with students. Reinforce the color-coded payment key (gray, yellow, aqua). Ask students to complete Exercises 9.8 and 9.9. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.8 Creating Walkout Receipts 9-20 Walkout receipt—report that lists the diagnoses, services provided, fees, and payments received and due after an encounter To create a walkout receipt in MCPR: Click the Print Receipt button in the Transaction Entry dialog box; the Open Report window appears. Click the OK button; the Print Report Where? Dialog box is displayed. Make a selection, and click the Start button. Click the OK button to send the report to its destination. Learning Outcome: 9.8 Identify the steps needed to create walkout receipts. Teaching Notes: Ask students to brainstorm why walkout receipts are a good idea. In their experience, does every practice provide walkout receipts? Why or why not? Have students complete Exercises 9.10 and 9.11. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 9.9 Printing Patient Education Materials 9-21 It may be appropriate to give patients education materials during checkout in order to: help patients better understand their diagnoses and treatments, and provide instructions following an office procedure. The patient education feature of MCPR provides a built-in set of patient education articles that can be printed and given to patients. Learning Outcome: 9.9 Describe the use of a patient education feature in an electronic health record. Teaching Notes: Have students brainstorm what types of information might be given to patients (an article on blood pressure, information on reduced sodium diets, etc.). Have students discuss the benefits of providing this information to patients at the office, rather than saying “look it up when you get home,” or taking time during an appointment to explain everything. Highlight the usefulness of MCPR’s built-in database of materials – no need to look elsewhere! Note that the database contains sets of articles for pediatrics, adults, seniors, women, and behavioral health. MCPR can automatically select the proper module based on patient information and demographics if desired. Articles can be emailed or printed in-office (discuss benefits/drawbacks of each method). Have students complete Exercise 9.12. * CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 11 Posting Payments and Creating Statements * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 11.1 List the six steps for checking a remittance advice. 11.2 Describe the procedures for entering insurance payments. 11.3 Explain how to apply insurance payments to charges. 11.4 Explain how to enter capitation payments. 11.5 Discuss the purpose of appeals and postpayment audits. 11.6 Compare standard patient statements and remainder patient statements. 11-2 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 11.7 Explain the difference between once-a-month and cycle billing. 11.8 Explain the procedure for processing a nonsufficient funds payment. 11-3 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms appeal appellant autoposting capitation payments claim adjustment group code (CAGC) claim adjustment reason code (CARC) claimant claim control number cycle billing 11-4 electronic funds transfer (EFT) electronic remittance advice (ERA) explanation of benefits (EOB) nonsufficient funds (NSF) check once-a-month billing overpayment patient statement postpayment audit Teaching Notes: There are a lot of key terms, but many of them might already be familiar to your students. Give a pop quiz of the terms to see how many students know. Grade the quiz in class and use the results to focus your lecture on terms that most or all students missed. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms (Continued) Recovery Audit Contractor (RAC) remainder statements remittance advice (RA) remittance advice remark code (RARC) standard statements takeback X12 835 Electronic Remittance Advice (835) 11-5 Teaching Notes: See notes on Slide 4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.1 Working with the Remittance Advice (RA) 11-6 Remittance advice (RA)—document describing a payment resulting from a claim adjudication Six steps for checking a remittance advice: Check the patient’s name, claim control number, and date of service against the claim. Verify that all billed CPT codes are listed. Check the payment for each CPT code against the expected amount, which may be an allowed charge or a percentage of the usual fee. Analyze the payer’s adjustment codes to locate all unpaid, downcoded, or denied claims for closer review. Learning Outcome: 11.1 List the six steps for checking a remittance advice. Teaching Notes: Direct students’ attention to the sample RA, Figure 11.1, in the text (or better yet, provide handouts of it for quick reference during lecture). If possible, bring in sample RAs and have students/groups analyze them using the 6 steps for checking an RA. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.1 Working with the Remittance Advice (RA) (Continued) 11-7 Six steps for checking a remittance advice (continued): Pay special attention to RAs for claims submitted with modifiers. Decide whether there are any items on the RA that need clarification from the payer, and follow up as necessary. Electronic remittance advice (ERA)—electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier Learning Outcome: 11.1 List the six steps for checking a remittance advice. Teaching Notes: See notes on Slide 6; discuss what additional information/what benefits are available when using an electronic remittance advice. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.1 Working with the Remittance Advice (RA) (Continued) 11-8 X12 835 Electronic Remittance Advice (835)—electronic transaction for payment explanation Claim control number—unique number assigned to a claim by the sender Autoposting—software feature enabling automatic entry of payments from a remittance advice Learning Outcome: 11.1 List the six steps for checking a remittance advice. Teaching Notes: Here are some options for covering the key terms on this slide and Slide 9; complete as many as desired or as time allows: List the terms on the board or on a worksheet. Ask students to discuss where they have used or heard these terms before. Provide sample insurance documents and ask students (in a group activity, possibly) to identify the pieces of information found in the document. 3.Put students in groups and have them research the history of RAs, incorporating the terms from the slides; or, have them choose one of the terms themselves and research its origins, why it is used, etc. Students or groups can then report on their findings, if desired. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.1 Working with the Remittance Advice (RA) (Continued) 11-9 Claim adjustment group code (CAGC)—used on an RA/EOB to indicate the general type of reason code for an adjustment Also abbreviated GRP Claim adjustment reason code (CARC)—used on an RA/EOB to explain why a payment does not match the amount billed Remittance advice remark code (RARC)—code that explain a payer’s payment decision Learning Outcome: 11.1 List the six steps for checking a remittance advice. Teaching Notes: See notes on Slide 8. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.2 Entering Insurance Payments 11-10 Insurance payments are entered in the Deposit List dialog box of MNP To enter insurance payments: Select Enter Deposits/Payments on the Activities menu, or click the Enter Deposits and Apply Payments button; the Deposit List dialog box opens. Complete the fields in the Deposit List dialog box. Click the New button; the Deposit dialog box appears. Complete the fields in the Deposit dialog box. Click the Save button, and the deposit will be recorded. Learning Outcome: 11.2 Describe the procedures for entering insurance payments. Teaching Notes: Ask students to speculate about why, if patient payments are entered in the Transactions List dialog box, insurance payments must be entered in the Deposit List dialog box. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.2 Entering Insurance Payments (Continued) 11-11 Electronic funds transfer (EFT)—electronic routing of funds between banks Capitation payments—payments made to physicians on a regular basis for providing services to patients in a managed care plan Learning Outcome: 11.2 Describe the procedures for entering insurance payments. Teaching Notes: Contrast insurance payments and capitation payments. Have students complete Exercise 11.1. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.3 Applying Insurance Payments to Charges 11-12 To apply insurance payments to charges in MNP: Highlight the payment in the Deposit List dialog box. Click the Apply button; the Apply Payment/Adjustments to Charges dialog box opens. Enter the payment in the middle section of this dialog box. Click the Save Payments/Adjustments button to save an entry; click OK when an information dialog box is displayed. Repeat as needed, then use the Close button to exit. Learning Outcome: 11.3 Explain how to apply insurance payments to charges. Teaching Notes: Use Figure 11.9 in the textbook to walk through the dialog box students will use for this task; explain and provide examples as needed. Assign students Exercises 11.2, 11.3, and 11.4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.4 Entering Capitation Payments 11-13 To enter capitation payments in MNP: Open the Deposit List dialog box, then the Deposit Window. Select capitation from the Payor Type drop-down list in the Deposit window. Enter the appropriate deposit information. Enter a second deposit as an insurance payment with a zero amount and click Save; the deposit appears in the Deposit List window. Use the List Only Claims That Match dialog box to locate patients who have claims covered by the capitation payment. Learning Outcome: 11.4 Explain how to enter capitation payments. Teaching Notes: Explain that capitation payments are NOT applied to individual patient accounts/charges; rather, a health plan pays the practice a set fee to help cover insured patients. Ask students if they think it makes sense that a practice receives this payment regardless of the frequency of patient visits. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.4 Entering Capitation Payments (Continued) 11-14 To enter capitation payments in MNP (continued): Once patients have been identified, the Claim Management dialog box is closed and the Deposit List dialog box is opened. Apply the zero payment to the patient accounts using the Apply button. In the Apply Payment/Adjustments to Charges dialog box, enter an adjustment equal to the outstanding balance. Click the Save button to record the payments. Learning Outcome: 11.4 Explain how to enter capitation payments. Teaching Notes: Ask students to speculate why there appear to be so many more steps in applying capitation payments than applying insurance payments. Have students complete Exercises 11.5, 11.6, and 11.7. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.5 Appeals, Postpayment Audits, Overpayments, and Billing Secondary Payers 11-15 Appeal—request for reconsideration of a claim adjudication Used to challenge a payer’s decision to deny, reduce, or otherwise downcode a claim Claimant—person or entity exercising the right to receive benefits Appellant—person who appeals a claim decision Postpayment audit—review conducted after a claim is adjudicated Learning Outcome: 11.5 Discuss the purpose of appeals and postpayment audits. Teaching Notes: Walk students through the various postpayment processes, incorporating the key terms on Slides 15-16 as needed. Discuss again with students the importance of proper billing and coding up front to avoid situations like these. Note that most payers have a three-step escalating process of appeals, which must be started within a specific timeframe. The process usually involves steps such as the following: 1. Complaint; 2. Appeal; 3. Grievance. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.5 Appeals, Postpayment Audits, Overpayments, and Billing Secondary Payers (Continued) 11-16 Recovery Audit Contractor (RAC)—entity that audits Medicare claims to determine where there are opportunities to recover incorrect payments from previously paid but noncovered services, erroneous coding, and duplicate services Overpayment—improper or excessive amount received by provider from payer Takeback—balance that a provider owes a payer following a postpayment audit Learning Outcome: 11.5 Discuss the purpose of appeals and postpayment audits. Teaching Notes: See notes on Slide 15. Have students complete Exercise 11.8. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.6 Creating Statements 11-17 Patient statement—list of the amount of money a patient owes, the procedures performed, and the dates the procedures were performed Sent to patients to collect an account balance that is the patient’s responsibility Explanation of benefits (EOB)—document showing how the amount of a benefit was determined Learning Outcome: 11.6 Compare standard patient statements and remainder patient statements. Teaching Notes: Have students create a compare/contrast sheet of two of the four main types of patient statements. Have them (individually or in groups) complete this exercise in class, and then discuss the results as a large group. Provide examples to demonstrate when each type of statement is likely to be created and why. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.6 Creating Statements (Continued) 11-18 Standard statements—statements that show all charges regardless of whether the insurance carrier has paid on the transactions Remainder statements—statements that list only charges that are not paid in full after all insurance carrier payments have been received Learning Outcome: 11.6 Compare standard patient statements and remainder patient statements. Teaching Notes: See notes on Slide 17. Have students complete Exercises 11.9 and 11.10. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.7 Editing and Printing Statements 11-19 In MNP, the Edit button in the Statement Management dialog box is used to perform edits on account statements. Once-a-month billing—type of billing in which statements are mailed to all patients at the same time each month Cycle billing—type of billing in which statement printing and mailing is staggered throughout the month Learning Outcome: 11.7 Explain the difference between once-a-month and cycle billing. Teaching Notes: Explain that there are three tabs within the Statement Management dialog box: General, Transactions, and Comment. Provide examples of items/information that might go in each tab; ask students what types of comments might need to be entered about a statement. Have students complete Exercises 11.11, 11.12, and 11.13. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.8 Nonsufficient Funds (NSF) 11-20 Nonsufficient funds (NSF) check—check that is not honored by the bank because the account lacks funds to cover it When a practice receives an NSF notice from a bank, an adjustment is made in the patient’s account. The patient owes the practice the amount of the returned check. Most practices charge a fee for a returned check. Learning Outcome: 11.8 Explain the procedure for processing a nonsufficient funds payment. Teaching Notes: An NSF check is more commonly known as a “bounced” check. Ask students why most practices charge a fee for a returned check. Have students complete Exercise 11.14. * CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 8 Third-Party Payers * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Learning Outcomes When you finish this chapter, you will be able to: 8.1 Compare the major features of PPO, HMO, and POS health plans. 8.2 Identify the two parts of CDHPs. 8.3 Discuss the organization and regulation of employer- sponsored group health plans and self-insured plans. 8.4 Explain the purpose of Medicare Parts A, B, C, and D. 8.5 Describe the fee structures that are used to set charges. 8-2 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Learning Outcomes (Continued) When you finish this chapter, you will be able to: 8.6 Identify the three methods most payers use to pay physicians. 8.7 Maintain insurance carrier information in the PM/EHR. 8-3 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Key Terms allowed charge balance billing Blue Cross and Blue Shield Association (BCBS) capitation (cap) rate Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) consumer-driven (directed) health plan (CDHP) 8-4 disability compensation programs discounted fee-for-service dual-eligible Employment Retirement Income Security Act of 1974 (ERISA) Federal Employees Health Benefits (FEHB) fee schedule flexible savings account (FSA) Teaching Notes: There are a lot of key terms, so here are some options to help present them: Put students into small groups and assign each group a set of terms to define and learn. Then have each group teach their set of terms to the rest of the class. Assign each student a set number of terms to define as a homework assignment and then discuss the terms together during class. Ask students whether any of the key terms are familiar to them already; use their responses to launch a discussion of the rest of the terms. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Key Terms (Continued) group health plan (GHP) health maintenance organization (HMO) health reimbursement account (HRA) health savings account (HSA) high-deductible health plan (HDHP) individual health plan (IHP) Medicaid 8-5 Medicare Medicare Part A, Hospital Insurance (HI) Medicare Part B, Supplementary Medical Insurance (SMI) Medicare Part C, Medicare Advantage Medicare Part D Medicare Physician Fee Schedule (MPFS) Medigap Teaching Notes: See notes on Slide 4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Key Terms (Continued) Medi-Medi beneficiary Original Medicare Plan point-of-service (POS) plan preferred provider organization (PPO) primary care physician (PCP) relative value scale (RVS) resource-based relative value scale (RBRVS) 8-6 self-insured health plans third-party payer TRICARE usual, customary, and reasonable (UCR) usual fees workers’ compensation insurance write off Teaching Notes: See notes on Slide 4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.1 Types of Health Plans 8-7 Third-party payer—private or government organization that insures or pays for health care on behalf of beneficiaries Preferred provider organization (PPO)—managed care network of health care providers who agree to perform services for plan members at discounted rates The policyholder pays an annual premium and a yearly deductible. A PPO may offer either a low deductible with a higher premium or a high deductible with a lower premium. Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans. Teaching Notes: Slides 8-7 through 8-10 list the various types of health plans. Consider the following options for covering and discussing the plans: Draw a table on the board that lists the insurance types along the left side and various pieces of information (annual premium, needs referrals, copayments, etc.) along the top. Use this table to create a compare-contrast grid by checking the pieces of informational that fit each insurance type. Provide descriptions of each type of insurance and the names of each type; see if students can match each type to its description. Put students into groups and have each group research one type of insurance. Then have the group “teach” the type to the class. Cite the advantages and disadvantages of each type of plan, and note what might cause a patient to choose one type over another. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.1 Types of Health Plans (Continued) 8-8 PPO features (continued): Members typically pay a copayment at the time of service, and coinsurance may also be charged. Patients may see out-of-network doctors without a referral or preauthorization; the amount they have to pay will be higher. Health maintenance organization (HMO)—managed care system in which providers offer health care to members for fixed periodic payments This type of health plan has the most stringent guidelines and the narrowest choice of providers. Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans. Teaching Notes: See notes on Slide 7. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.1 Types of Health Plans (Continued) 8-9 HMO features (continued): A Primary care physician (PCP) is a physician in a managed care organization who directs all aspects of a patient’s care; members are assigned to a PCP. Members must use their HMO’s network except in emergencies or pay a penalty. HMOs are organized around one of three business models: the staff model, the group or network model, and the independent practice association model. Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans. Teaching Notes: See notes on Slide 7. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.1 Types of Health Plans (Continued) 8-10 Point-of-service (POS) plan—managed care plan that permits patients to receive medial services from nonnetwork providers A POS plan is a hybrid of HMO and PPO networks. Members may choose from a primary or secondary network. This kind of plan charges annual premiums and copayments for office visits. Indemnity or fee-for-service plans require premium, deductible, and coinsurance payments. Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans. Teaching Notes: See notes on Slide 7. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.2 Consumer-Driven Health Plans 8-11 Consumer-driven (directed) health plan (CDHP)—medical insurance that combines a high-deductible health plan with one or more tax-preferred savings accounts that the patient directs High-deductible health plan (HDHP)—health plan that combines high deductible insurance and a funding option to pay for patients’ out-of-pocket expenses up to the deductible First part of a CDHP Annual deductible over $1,000 Learning Outcome: 8.2 Identify the two parts of CDHPs. Teaching Notes: Explain the reasons for a high deductible; discuss what happens when a patient reaches the deductible limit. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.2 Consumer-Driven Health Plans (Continued) 8-12 The second part of a CDHP involves one of three types of funding options: Health reimbursement account (HRA)—CDHP funding option where an employer sets aside an annual amount for health care costs Health savings account (HSA)—CDHP funding option under which funds are set aside to pay for certain health care costs Flexible savings account (FSA)—CDHP funding option that has employer and employee contributions Learning Outcome: 8.2 Identify the two parts of CDHPs. Teaching Notes: Have students debate which of these three funding options is best; encourage them to look deeper than “HRA is best because an employer pays it.” * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.3 Private Insurance Payers and Blue Cross and Blue Shield 8-13 Group health plan (GHP)—plan of an employer or employee organization to provide health care to employees, former employees, and/or their families Human resource departments manage the health care benefits. Riders, or options, are often offered for vision and dental services. During open enrollment periods, employees choose the plans they prefer for the coming benefit period. This kind of health plan must follow federal and state laws. Learning Outcome: 8.3 Discuss the organization and regulation of employer-sponsored group health plans and self-insured plans. Teaching Notes: For slides 8-13 through 8-15, consider the following options for covering and discussing the various types of health plans. (NOTE: CHOSE AN OPTION THAT YOU DID NOT PICK FOR SLIDES 8-7 through 8-10): Draw a table on the board that lists the insurance types along the left side and various pieces of information (annual premium, needs referrals, copayments, etc.) along the top. Use this table to create a compare-contrast grid by checking the pieces of informational that fit each insurance type. Provide descriptions of each type of insurance and the names of each type; see if students can match each type to its description. Put students into groups and have each group research one type of insurance. Then have the group “teach” the type to the class. Cite the advantages and disadvantages of each type of plan, and note what might cause a patient to choose one type over another. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.3 Private Insurance Payers and Blue Cross and Blue Shield (Continued) 8-14 Federal Employees Health Benefits (FEHB)—health care program that covers federal employees Self-insured health plans—health insurance plans paid for directly by the organization, which sets up a fund from which to pay These do not pay premiums to insurance carriers or managed care organizations. These set up their own provider networks or lease the use of managed care organizations’ networks. Learning Outcome: 8.3 Discuss the organization and regulation of employer-sponsored group health plans and self-insured plans. Teaching Notes: See notes on Slide 13. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.3 Private Insurance Payers and Blue Cross and Blue Shield (Continued) 8-15 Employee Retirement Income Security Act of 1974 (ERISA)—law providing incentives and protection for companies with employee health and pension plans The law regulates self-insured health plans. Individual health plan (IHP)—medical insurance plan purchased by an individual Blue Cross and Blue Shield Association (BCBS)—licensing agency of Blue Cross and Blue Shield plans Learning Outcome: 8.3 Discuss the organization and regulation of employer-sponsored group health plans and self-insured plans. Teaching Notes: See notes on Slide 13. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.4 Government-Sponsored Insurance Programs, Workers’ Compensation, and Disability Plans 8-16 Medicare—federal health insurance program for people sixty-five or older and some people with disabilities Medicare Part A, Hospital Insurance (HI)—program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care Medicare Part B, Supplementary Medical Insurance (SMI)—program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D. Teaching Notes: For slides 8-16 through 8-20, consider the following options for covering and discussing the various types of health plans. (NOTE: CHOSE AN OPTION THAT YOU DID NOT PICK FOR SLIDES 8-7 through 8-10 and 8-13 through 8-15): Draw a table on the board that lists the insurance types along the left side and various pieces of information (annual premium, needs referrals, copayments, etc.) along the top. Use this table to create a compare-contrast grid by checking the pieces of informational that fit each insurance type. Provide descriptions of each type of insurance and the names of each type; see if students can match each type to its description. Put students into groups and have each group research one type of insurance. Then have the group “teach” the type to the class. Cite the advantages and disadvantages of each type of plan, and note what might cause a patient to choose one type over another. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.4 Government-Sponsored Insurance Programs, Workers’ Compensation, and Disability Plans (Continued) 8-17 Original Medicare Plan—Medicare fee-for-service plan Medigap—plan offered by a private insurance carrier to supplement Medicare coverage Medicare Part C, Medicare Advantage—managed care health plan under the Medicare program Medicare Part D—Medicare prescription drug reimbursement plans Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D. Teaching Notes: See notes on Slide 16. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.4 Government-Sponsored Insurance Programs, Workers’ Compensation, and Disability Plans (Continued) 8-18 Medicaid—federal and state assistance program that pays for health care services for people who cannot afford them Medi-Medi beneficiaries—people eligible for both Medicare and Medicaid Dual-eligible—Medicare-Medicaid beneficiary TRICARE—government health program serving dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D. Teaching Notes: See notes on Slide 16. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.4 Government-Sponsored Insurance Programs, Workers’ Compensation, and Disability Plans (Continued) 8-19 Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)—health care plan for families of veterans with 100 percent service-related disabilities and the surviving spouses and children of veterans who die from service-related disabilities Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D. Teaching Notes: See notes on Slide 16. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.4 Government-Sponsored Insurance Programs, Workers’ Compensation, and Disability Plans (Continued) 8-20 Workers’ compensation insurance—state or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment Disability compensation programs—programs that provide partial reimbursement for lost income when a disability prevents an individual from working Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D. Teaching Notes: See notes on Slide 16. Also, when discussing workers’ compensation insurance, do the following: Explain that workers’ compensation includes five types of payment: payment for medical treatments, payment for temporary disability (to replace lost wages), permanent disability payments, compensation for dependents of employees who are fatally injured, and payments in the form of vocational rehabilitation. Provide examples of current/recent workers’ compensation suits; have students debate whether workers’ compensation insurance is a help or hindrance. Ask them if they think employees abuse the insurance, and have them explain their reasoning. This could be done as a large or small group, or as an individual assignment. While this might be a touchy, potentially volatile subject, it is one worth discussing. Tie responses to class lecture and the text information. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.5 Setting Fees 8-21 Fee schedule—document that specifies the amount the provider bills for services Usual fees—normal fees charged by a provider Most payers use one of three methods to set the fees that their plan will pay physicians: Usual, customary, and reasonable (UCR)—fees set by comparing usual fees, customary fees, and reasonable fees Relative value scale (RVS)—system of assigning unit values to medical services based on their required skill and time Resource-based relative value scale (RBRVS)—relative value scale for establishing Medicare charges Learning Outcome: 8.5 Describe the fee structures that are used to set charges. Teaching Notes: Explain that billers are the ones that commonly hear questions from patients about fees; it is important for them to know the ins and outs of the payment plans. Important: Most practices set their fees slightly above those paid by the highest reimbursing plan in which they participate. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.5 Setting Fees (Continued) 8-22 Medicare Physician Fee Schedule (MPFS)—RBRVS-based allowed fees that are the basis for Medicare reimbursements Learning Outcome: 8.5 Describe the fee structures that are used to set charges. Teaching Notes: Ask students which of the three methods for determining payer fees seems to be the most fair? Most logical? Why? Explain that there are three parts to an RBRVS fee, which are updated every year: Nationally uniform relative value unit Geographic adjustment factor Nationally uniform conversion factor * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.6 Third-Party Payment Methods 8-23 Payers use one of three main methods of paying providers: Allowed charges Contracted fee schedules Capitation Allowed charge—maximum charge a plan pays for a service or procedure Balance billing—collecting the difference between a provider’s usual fee and a payer’s lower allowed charge Learning Outcome: 8.6 Identify the three methods most payers use to pay physicians. Teaching Notes: Use Table 8.2 in the text to enhance discussion; use the examples on pages 405-406 to illustrate the abstract concepts for students. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.6 Third-Party Payment Methods (Continued) 8-24 Write off—to deduct an amount from a patient’s account Discounted fee-for-service—payment schedule for services based on a reduced percentage of usual charges Capitation (cap) rate—periodic prepayment to a provider for specified services to each plan member Learning Outcome: 8.6 Identify the three methods most payers use to pay physicians. Teaching Notes: See notes on Slide 23. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.7 Maintaining Insurance Information in the PM/EHR 8-25 Setting up insurance carriers correctly in the PM/EHR is essential to getting claims paid in a timely manner. To maintain insurance carrier information in MCPR: Access the information by selecting Insurance on the Lists menu. Select Carriers (to enter, edit, or delete carriers) or Classes (for reporting) on the submenu that appears. Select the Carriers option; the Insurance Carrier List dialog box is displayed. Learning Outcome: 8.7 Maintain insurance carrier information in the PM/EHR. Teaching Notes: Note that insurance carriers for a practice must be set up in MCPR before they can be assigned to patients and/or maintained.; the Insurance Carrier dialog box for each carrier contains all pertinent information. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 8.7 Maintaining Insurance Information in the PM/EHR (Continued) 8-26 Maintaining carrier information (continued): Use the Edit, New, and Delete buttons to change, create, and delete insurance carriers. Use the Print Grid button to print the information. Close the dialog box using the Close button. Learning Outcome: 8.7 Maintain insurance carrier information in the PM/EHR. Teaching Notes: While walking through the steps required to maintain insurance information, use the screenshots in the text to aid understanding. Before assigning the exercises, ask students if they have any outstanding questions on the process of working with insurance information. Have students complete Exercises 8.1-8.6. * CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill 12 Financial and Clinical Reports * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 12.1 List the three types of financial reports available in Medisoft Network Professional (MNP). 12.2 Describe how to select data to be included in a MNP report. 12.3 Compare patient, procedure, and payment day sheets. 12.4 Discuss the purpose of a practice analysis report. 12.5 Explain how to create a production by provider report. 12.6 List the steps for creating a patient ledger report. 12-2 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 12.7 Describe how to create a standard patient list report. 12.8 Describe the use of Medisoft Reports to create a report. 12.9 Explain how aging reports are used in a medical practice. 12.10 Explain how to access MNP’s built-in custom reports. 12.11 Describe the process of editing reports in MNP’s Report Designer. 12-3 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 12.12 List the reasons for using reports for tracking specific clinical data. 12.13 Discuss the regulatory obligations for the retention of patient medical records. 12-4 * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms aging report day sheet insurance aging report patient aging report patient day sheet patient ledger patient registry payment day sheet performance measures practice analysis report 12-5 procedure day sheet production by provider report retention selection boxes Teaching Notes: If possible, pass around samples of each report/sheet in the key terms section and see if students can classify the form correctly. If forms are not available, prepare a matching activity where students match the forms and reports to what they represent. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.1 Types of Reports in Medisoft Network Professional 12-6 MNP offers several options for creating reports on its Reports menu, including: Standard reports Medisoft Reports… Design Custom Reports and Bills… Learning Outcome: 12.1 List the three types of financial reports available in Medisoft Network Professional (MNP). Teaching Notes: Showcase Figure 12.1 in the textbook and take some time to walk through each type of report listed and the category (Standard, Medisoft, Custom) under which each type of report falls. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.2 Selecting Data for a Report 12-7 To select data to be included in an MNP report: Once a selection is made in the Print Report Where? Dialog box, click the Start button; the Search dialog box is displayed. Selection boxes—fields within the Search dialog box that are used to select the data that will be included in a report Use the drop-down list or Lookup button for the selection boxes to input data. After the selections/inputs have been made, click the OK button to generate the report. Learning Outcome: 12.2 Describe how to select data to be included in an MNP report. Teaching Notes: Explain that the selection boxes make report creation easy and quick. Reference some of the selection boxes within the Search feature that you might use – date, provider, insurance carrier, etc. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.3 Day Sheets 12-8 Day sheet—report that provides information on practice activities for a twenty-four hour period Patient day sheet—summary of patient activity on a given day Procedure day sheet—report that lists all the procedures performed on a particular day, in numerical order Payment day sheet—report that lists all payments received on a particular day, organized by provider Learning Outcome: 12.3 Compare patient, procedure, and payment day sheets. Teaching Notes: Have students brainstorm what types of situations would warrant printing a patient, procedure, or payment day sheet. Use responses as a springboard for discussion. Have students complete Exercise 12.1. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.4 Analysis Reports 12-9 Practice analysis report—report that analyzes the revenue of a practice for a specified period of time Usually used to report on a month or a year Can be used to generate medical practice financial statements Can also be used for profit analysis Learning Outcome: 12.4 Discuss the purpose of a practice analysis report. Teaching Notes: Note that while practice analysis reports are the most common financial reports used in a practice, Medisoft Network Professional also prints reports that deal with, among other things, patients with outstanding co-payments, the average payment received for various procedure codes, and referring providers. Use Figure 12.16 in the text to show all of the available analysis reports. Ask students why the practice analysis is the most common. See if they can list a benefit for each type of report. This could be a group discussion or an individual assignment. Have students complete Exercise 12.2. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.5 Production Reports 12-10 Production by provider report—report that lists incoming revenue information for each provider in the practice To create a production by provider report in MNP: Click Production Reports from the Reports menu, then Production by Provider; the Print Report Where? Dialog box appears. Select the destination and click Start. Make the appropriate selections in the selection boxes. Click OK; the report will be sent to its destination. Learning Outcome: 12.5 Explain how to create a production by provider report. Teaching Notes: There are a number of other “production by…” reports available in MNP. (Figure 12.19 in the text shows all available reports.) Encourage students to think about the uses of different reports. Have students complete Exercise 12.3. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.6 Patient Ledger Reports 12-11 Patient ledger—report that lists the financial activity in each patient’s account To create a patient ledger report in MNP: Click Patient Ledger on the Reports menu; the Print Report Where? Dialog box is displayed. Select preview, print, or export; the Search dialog box is displayed. Make the appropriate selections. Click the OK button; the report is displayed. Learning Outcome: 12.6 List the steps for creating a patient ledger report. Teaching Notes: Note that the patient ledger report is another standard report in MNP, useful especially when there is a question about a patient’s account. Use this opportunity to again stress how important proper documentation and record keeping are! Have students complete Exercise 12.4. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.7 Standard Patient Lists 12-12 To create a standard patient list report in MNP: Click Standard Patient Lists from the Reports menu. Select either Patient by Diagnosis or Patient by Insurance Carrier. Make a selection in the Print Report Where? Dialog box. Make the appropriate data input selections and click the OK button; the report will be displayed. Learning Outcome: 12.7 Describe how to create a standard patient list report. Teaching Notes: Explain that there are two types of standard patient lists: patient by insurance carrier and patient by diagnosis. Ask students why it might be helpful to be able to sort patients by diagnosis. Have students complete Exercise 12.5. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.8 Navigating in Medisoft Reports 12-13 The Medisoft Reports feature offers the user access to over a hundred reports. Medisoft Reports contains these features that help in creating a report: The Medisoft Reports menus The Medisoft Reports toolbar The Medisoft Reports Find Report box and the Find Now button The Medisoft Reports help feature Learning Outcome: 12.8 Describe the use of Medisoft Reports to create a report. Teaching Notes: Note that the Medisoft Reports feature is a new addition to MNP; what benefits does it offer (especially since many of the reports can be accessed through other report functions)? Point out Figure 12.25 in the textbook, which shows the Medisoft Reports menu. Ask students to skim through it and discuss what they notice about it and its organization. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.9 Aging Reports 12-14 Aging reports—report that lists the amount of money owed to the practice, organized by the amount of time the money has been owed Used by medical practices to determine which accounts require follow-up to collect past-due balances Patient aging report—report that lists a patient’s balance by age, date and amount of the last payment, and telephone number Insurance aging report—report that lists how long a payer has taken to respond to insurance claims Learning Outcome: 12.9 Explain how aging reports are used in a medical practice. Teaching Notes: Discuss the importance of aging reports – timely and proper payment/reimbursement is critical for a practice and is one of the areas that needs to be monitored most closely. Have students complete Exercise 12.6. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.10 Custom Reports 12-15 MNP has a number of built-in custom reports To access MNP’s built-in custom reports: Click the Custom Report List option on the Reports menu; the Open Report dialog box is displayed. Make the appropriate selections in the series of data input dialog boxes. Make the appropriate selection in the Preview Report window and click OK; the report will be displayed. When a new custom report is created, it is added to the list of custom reports displayed on the screen. Learning Outcome: 12.10 Explain how to access MNP’s built-in custom reports. Teaching Notes: List some of the custom reports available: patient walkout receipts, EDI receivers, referring providers, etc. Figure 12.34 in the textbook showcases the Open Report dialog box, which shows all possible custom reports…..notice the “Birthday Card” option. Have students complete Exercises 12.7 and 12.8. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.11 Using Report Designer 12-16 MNP’s Report Designer allows the user to modify existing reports or create new reports. To edit reports using MNP’s Report Designer: Click Design Custom Reports and Bills on the Reports menu; the Report Designer will be displayed. Click Open Report on the File menu to select a report. Double click in the list to make edits. Click the OK button to make the changes. Click Preview Report on the File menu to save the file as a new report; key in the new report name. Click the OK button, make the appropriate selections, and click the OK button again; the report is shown. Learning Outcome: 12.11 Describe the process of editing reports in MNP’s Report Designer. Teaching Notes: Explain to students that each practice is able to create its own custom reports using this feature; new reports can be saved to the Custom Reports list. While the details of actual report creation are beyond the scope of this text, referencing it for students can be helpful. Have students complete Exercise 12.9. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.12 Preparing Clinical Reports 12-17 MNP’s reports can be used to capture the required items for performance measure reporting and for meaningful use. Performance measure—processes, experience, and/or outcomes of patient care, observations, or treatment that relate to one or more quality aims for health care, such as effective, safe, efficient, patient-centered, equitable, and timely care Learning Outcome: 12.12 List the reasons for using reports for tracking specific clinical data. Teaching Notes: Ask students how MNP’s reports can be used to prove compliance with various HIPAA, HITECH, and government incentive acts. Ask students what “meaningful use” means. Discuss meaningful use’s implications for the healthcare field. Provide specific examples of performance measures: therapeutic interventions such as physical therapy, preventative measures such as mammograms, and other interventions such as counseling. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.12 Preparing Clinical Reports (Continued) 12-18 Patient registry—method of reporting clinical data to payers using an online service rather than claims-based reporting Learning Outcome: 12.12 List the reasons for using reports for tracking specific clinical data. Teaching Notes: Explain that if a practice chooses not to use a patient registry, it will most likely use a clearinghouse to report pertinent information. * © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 12.13 Record Retention 12-19 Retention—preservation of information on patients’ medical conditions for continuity of care Retention is performed: According to the practice’s retention schedule To protect both the provider and the patient In accordance with federal business records retention requirements, and any state requirements that apply Under HIPAA, covered entities must keep records of HIPAA compliance for six years. Learning Outcome: 12.13 Discuss the regulatory obligations for the retention of patient medical records. Teaching Notes: After discussing record retention, discuss with students what must/should happen when it is time to dispose of records. Ask them how the advent of electronic records influences the disposal of records and information. Is it better or worse than before? Why? * HAS-6197 Health Information System and Electronic Health Record: Week 5 Administrative and Structural Analysis of an Electronic Health Claim Management: Chapters 9 &10 Objective: In this assignment you are request to you will describe, analyze and apply process of creating claims, locating specific claim, methods used to submit electronic claims, and the claim determination process used by health plans. ASSIGNMENT GUIDELINES (10\%): Students will judgmentally evaluate the readings from Chapter 9 and 10 on your textbook and from the article assigned for week 5. The Purpose of this Administrative and Structural Analysis of an Electronic Health Claim Management is to describes the potential benefits of EHRs that include clinical outcomes (eg, improved quality, reduced medical errors), organizational outcomes (eg, financial and operational benefits), and societal outcomes (eg, improved ability to conduct research, improved population health, reduced costs). Despite these benefits, studies in the literature highlight drawbacks associated with EHRs, which include the high upfront acquisition costs, ongoing maintenance costs, and disruptions to workflows that contribute to temporary losses in productivity that are the result of learning a new system. Moreover, EHRs are associated with potential perceived privacy concerns among patients, which are further addressed legislatively in the HITECH Act. Overall, experts and policymakers believe that significant benefits to patients and society can be realized when EHRs are widely adopted and used in a “meaningful” way. You need to develop a 4-5-page paper long including title page and references page reproducing your understanding and capability to relate the readings to claim management. Each paper must be typewritten with 12-point font and double-spaced with standard margins. Follow APA style 7th format when referring to the selected articles and include a reference page. EACH PAPER SHOULD INCLUDE THE FOLLOWING: 1. Introduction (25\%) Provide a brief synopsis of the meaning (not a description) of each Chapter and articles you read, in your own words. 2. Your Strategies (50\%) a. Briefly compare the CMS-1500 paper claim and the 837 electronic. b. Discussion the information contained in the claim management dialog box c. Analyze the method used to submit electronic claims. d. Discuss the use of the PM/HER to monitor claims. 3. Conclusion (15\%) Briefly summarize your thoughts & conclusion to this assignment and your appraisal of the Chapter you read. How did these articles and Chapters impact your thoughts about Claim Management? How this Administrative Analysis help you in relation to Claim management in Medisoft. Evaluation will be based on how clearly you respond to the above, in particular: a) The clarity with which you present and analyzed the strategies; b) The depth, scope, and organization of your Administrative Analysis paper; and, c) Your conclusions, including a description of the impact of these articles and Chapters on any Healthcare Organization. ASSIGNMENT RUBRICS Assignments Guidelines 1 Points 10\% Introduction 2.5 Points 25\% Your Strategies 5 Points 50\% Conclusion 1.5 Points 15\% Total 10 points 100\% HSA-6197 Health Information System and Electronic Health Records Week 6 Financial Report in Medisoft Network Professional (MNP): Chapters 11 & 12 Objective: To critically reflect your understanding of the readings and your ability to apply them to your Health care Setting. ASSIGNMENT GUIDELINES (10\%): Financial Report in Medisoft Network Professional (MNP). For this assignment, you will critically evaluate, create and generated a Medisoft Report and apply a specific financial report available in MNP within a Health Care Setting, for a specific patient, describe and select data to be include in a MNP report, create a patient ledger report, and create a standard patient list report. You are invigorated to choose a specific Health Care Facility as a reference to do this assignment You need to read the article (in the additional weekly reading resources localize in the Syllabus and also in the Lectures link) assigned for week 6 and develop a 4-6-page paper reflecting your understanding and ability to apply the readings to your Health Care Setting. Each paper must be typewritten with 12-point font and double-spaced with standard margins. Follow APA 7th edition format when referring to the selected articles and include a reference page. EACH PAPER SHOULD INCLUDE THE FOLLOWING: 1. Introduction (25\%) Provide a short-lived outline of the three types of financial reports available in MNP (not a description) of each Chapter and articles you read, in your own words. I’m 2. Medisoft Financial Report (50\%): Create a Medisoft Report with the following information: Select data to be include in a MNP. Create three day Sheets: Patient Day Sheet, Procedures Day Sheet, and Payment Day Sheet. Analysis Report 3. Conclusion (15\%) Briefly summarize your thoughts & conclusion to your critique of the articles and Chapter you read. How did these articles and Chapters impact your thoughts on Financial and clinical reports. Evaluation will be based on how clearly you respond to the above, in particular: a) The clarity with which you critique the articles; b) The depth, scope, and organization of your paper; and, c) Your conclusions, including a description of the impact of these articles and Chapters on any Health Care Setting. ASSIGNMENT RUBRICS Assignments Guidelines 10 Points 10\% Introduction 25 Points 25\% Your Critique 50 Points 50\% Conclusion 15 Points 15\% Total 100 points 100\% HSA-6197 Health Information System And Electronic Health Record Final Project Final Project: Implementation Assessment of Electronic Health Record. Objective: For this assignment, you will create the assessment to implement the new HER in a Health care setting. The assessment phase is foundational to all other EHR implementation steps, and involves determining if the practice is ready to make the change from paper records to electronic (EHRs), or to upgrade their current system to a new certified version. You will be encourage to choose a Community Health Center or a Doctor’s Office. The Assessment is designed because our world has been radically transformed by digital technology – smart phones, tablets, and web-enabled devices have transformed our daily lives and the way we communicate. Medicine is an information-rich enterprise. A greater and more seamless flow of information within a digital health care infrastructure, created by electronic health records (EHRs), encompasses and leverages digital progress and can transform the way care is delivered and compensated. With EHRs, information is available whenever and wherever it is needed. The Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act of 2009, represents the Nation’s first substantial commitment of Federal resources to support the widespread adoption of EHRs. As of August 2012, 54 percent of the Medicare- and Medicaid-eligible professionals had registered for the meaningful use incentive program. The paper will be 8-10 pages long. More information and due date will provide in the assignments link. ASSIGNMENT GUIDELINES (10\%): The assessment should look at the current state of the practice: · Are administrative processes organized, efficient, and well documented? · Are clinical workflows efficient, clearly mapped out, and understood by all staff? · Are data collection and reporting processes well established and documented? · Are staff members computer literate and comfortable with information technology? · Does the practice have access to high-speed internet connectivity? · Does the practice have access to the financial capital required to purchase new or additional hardware? · Are there clinical priorities or needs that should be addressed? · Does the practice have specialty specific requirements? Through the Regional Extension Centers (RECs), we’ve learned that these questions and assessment tools provide a good understanding of the current state of the practice and can help identify key goals for improvement. Often, these goals relate to patient quality, patient satisfaction, practice productivity and efficiency, improved quality of work environment, and most important to the overall goal – improved health care. EACH PAPER SHOULD INCLUDE THE FOLLOWING: 1. Introduction (25\%) Offer an abstract that provide a brief outlook of the proposal and explaining in your own words what is meant by a Electronic Health Record for a Health care Facility. 2. Your Implementation Assessment of Electronic Health Record. Plan (50\%) a. Presentation Page: PROJECT NAME ORGANIZATION NAME BUSINESS ADDRESS CITY, ST, ZIP TELEPHONE NUMBER FACSIMILE NUMBER WEBSITE ADDRESS EMAIL ADDRESS b. Envision the Future The next EHR implementation step is to envision the future state of the practice. What would the practice leadership like to see different in the future? More specifically: · What will be different for the patients? · What will be different for the providers? · What will be different for the staff? c. Set Goals Goals and needs should be documented to help guide decision-making throughout the implementation process. And they may need to be re-assessed throughout the EHR implementation steps to ensure a smooth transition for the practice and all staff. We recommend that you set goals in areas that are important and meaningful to your practice. These may be clinical goals, revenue goals, or goals around work environment. Goals in all three areas will help assure balanced processes after the implementation. Goals that are important to you will help you and your staff through the change process. We recommend you follow the “SMART” goals process. This process includes setting objectives and goals that meet the following criteria: · Specific – Achieving the goal would make a difference for our patients and our practice · Measureable – We can quantify the current level and the target goal · Attainable – Although the goal may be a stretch, we can achieve it · Relevant – This is worth the effort · Time bound – There are deadlines and opportunities to celebrate success! These goals become the guide posts for an EHR implementation project, and achieving these goals will motivate providers and practice staff to make necessary changes and attain new skills. d. Plan Your Approach Clarify and Prioritize Building an EHR implementation plan becomes critical for identifying the right tasks to perform, the order of those tasks, and clear communication of tasks to the entire team involved with the change process. One effective first step in the planning process is for the team to segment tasks into three categories: · What new work tasks/process are we going to start doing? · What work tasks/process are we going to stop doing? · What work tasks/process are we going to sustain? The start/stop/sustain exercise helps clarify what the new work environment will be like after the change and help the team prioritize tasks in the overall EHR implementation plan. Steps in the Planning Phase Here are some tactical steps that typically occur during the EHR implementation planning phase. You may collaborate and use tools provided by your Regional Extension Center (REC), IT vendor, and/or EHR vendor (if you already have an existing EHR product) to complete these activities. 1. Analyze and map out the practice’s current workflow and processes of how the practice currently gets work done (the current state). 2. Map out how EHRs will enable desired workflows and processes, creating new workflow patterns to improve inefficiency or duplicative processes (the future state). 3. Create a contingency plan – or back-up plan – to combat issues that may arise throughout the implementation process. 4. Create a project plan for transitioning from paper to EHRs, and appoint someone to manage the project plan. 5. Establish a chart abstraction plan, a means to convert or transform, information from paper charts to electronic charts. Identify specific data elements that will need to be entered into the new EHR and if there are items that will be scanned. 6. Understand what data elements may be migrated from your old system to your new one, such as patient demographics or provider schedule information. Sometimes, being selective with which data or how much data you want to migrate can influence the ease of transition. 7. Identify concerns and obstacles regarding privacy and security and create a plan to address them. It is essential to emphasize the importance of privacy and security when transitioning to EHRs. e. Achieve Meaningful Use The Medicare and Medicaid EHR Incentive Programs provide a financial incentive for achieving meaningful use, which is the use of certified EHR technology to achieve health and efficiency goals. This section provides an overview of the Stage 1 and Stage 2 EHR meaningful use core and menu objectives for eligible professionals (EPs) as outlined by CMS – which are intended to set a baseline for electronic data capture and information sharing. The meaningful use objectives are grouped into five patient-driven domains that relate to health outcomes policy priorities. As depicted in the dashboards below, each core and menu objective is aligned to one of the following domains: · Improve Quality, Safety, Efficiency · Engage Patients & Families · Improve Care Coordination · Improve Public and Population Health · Ensure Privacy and Security for Personal Health Information 3. Conclusion ( 15\%) Briefly recapitulate your thoughts & conclusion to Your Implementation Assessment of Electronic Health Record. Plan. How did this plan impact your thoughts on Health Care Administrator and Health Information System? Evaluation will be based on how clearly you respond to the above, in particular: a) The clarity with which you associate, relates, stablish and apply your knowledge to generate the Implementation Assessment of Electronic Health Record Plan. b) The Complexity, depth, scope, Profundity and organization of your paper; and, c) Your conclusions, including a description of the impact of the Electronic Health Record on any Health Care Setting. HSA-6197 Health Information System and Electronic Health Records Week 4 Critical Reflection Paper: Chapters 7 & 8 · Objective: To judgmentally reflect your understanding of the readings and your skill to apply them to your Health care Setting. ASSIGNMENT GUIDELINES (10\%): Students will censoriously scrutinize the readings from Chapter 7and 8 in your textbook. This project is planned to help your assessment, analysis, and apply the readings to your Health Care Organization as well as become the foundation for all your outstanding jobs. You need to read the chapters assigned for week 4 and develop a 2-3-page paper reproducing your understanding and ability to apply the readings to your Health Care Organization. Each paper must be typewritten with 12-point font and double-spaced with standard margins. Follow APA style 7th edition format when referring to the selected articles and include a reference page. EACH PAPER SHOULD INCLUDE THE FOLLOWING: 1. Introduction (25\%) Deliver a short-lived synopsis of the meaning (not a description) of each Chapter and articles you read, in your own words. 2. Your Critique (50\%) What is your reaction to the content of the articles? What did you learn about Medical Coding and the Purpose of ICD-9-CM? What did you learn about PPO, HMO and POS Health Plans? Did these Chapter and articles change your thoughts about Third-Party Payers? If so, how? If not, what remained the same? 3. Conclusion (15\%) Briefly summarize your thoughts & conclusion to your critique of the articles and Chapter you read. How did these articles and Chapters impact your thoughts on the purpose of an electronic encounter form in an EHR. Evaluation will be based on how clearly you respond to the above, in particular: a) The clarity with which you critique the chapters. b) The depth, scope, and organization of your paper; and, c) Your conclusions, including a description of the impact of these articles and Chapters on any Health Care Setting. ASSIGNMENT RUBRICS Assignments Guidelines 10 Points 10\% Introduction 25 Points 25\% Your Critique 50 Points 50\% Conclusion 15 Points 15\% Total 100 points 100\%