A new patient (NP) has not received any services from the provider (or another provider of the same specialty who is a member of the same practice) within the past three years. An established patient (EP) has seen the provider (or another provider in the practice who has the same specialty) within the past three years.
During preregistration, basic information about the patient is gathered to check that the patient’s health care requirements are appropriate for the medical practice, to schedule an appointment of the correct length, and to determine whether the physician participates in the caller’s health plan in order to establish responsibility for payment. When a patient arrives for an appointment, a medical history form is completed for the physician’s use. The patient information form is completed to gather demographic information such as personal, biographical, and employment information; insurance coverage; and emergency contact and related information. Patient information forms are reviewed annually by established patients to confirm the information. The insurance card is scanned or photocopied; all information is double-checked against the patient information form.
An assignment of benefits statement may also be signed by a patient or policyholder. This form authorizes the provider to receive payments for medical services directly from payers.
Every patient must be given the office’s Notice of Privacy Practices once and must be asked to sign an Acknowledgment of Receipt of Notice of Privacy Practices. This process is followed and documented to show that the office has made a good-faith effort to inform patients of the privacy practices.
Medical insurance specialists contact payers to verify patients’ plan enrollment and eligibility for benefits. If done electronically, the HIPAA Eligibility for a Health Plan transaction is used. Patients’ insurance cards are scanned or photocopied, and their patient information or update forms are checked against the cards. Covered services, restrictions to benefits, various copayment requirements, and/or deductible status may also be checked. Referrals and authorizations for services are handled electronically with the HIPAA Referral Certification and Authorization transaction.
Primary insurance coverage is determined when more than one policy is in effect. This determination is based on coordination of benefits rules. The HIPAA Coordination of Benefits transaction may be used to transmit data to payers.
Encounter forms are lists of the medical practice’s most commonly performed services and procedures and often of frequent diagnoses. The provider checks off the services and procedures a patient received. The encounter form is then used for billing.
Patients may be responsible for copayments, excluded services, overlimit usage, and coinsurance. Patients often must meet deductibles before receiving benefits, and some offices collect this, too.
After a patient encounter, the medical insurance specialist uses the completed encounter form and the patient medical record to code or verify assigned codes and to analyze the billable services. The charges for these services are calculated; copayments and other fees are collected from patients according to practice policy; and patients’ accounts are updated. Walkout receipts are given for any payments patients make.
Throughout the billing and reimbursement cycle, communication skills are critical to keeping patients satisfied. Equally important are good relationships with third-party payer representatives who can help smooth the payment process. Medical insurance specialists also communicate important changes in payers’ policies to providers and work with the health care team to answer patients’ billing questions.
