Term
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Definition
Car accident victims
Federal Black Lung
Aged covered under LGHP
ESRD- during 30 day coordination period
Spouse covered under a LGHP
Disabled Person
Liability Claims- Auto and W/C |
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Term
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Definition
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Term
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Definition
Admitting and registration
First department to have contact with patients |
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Term
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Definition
| Gathering patient information and take care of any items possible when it is known in advance |
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Term
| Advantages of pre-admissions |
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Definition
Patient demographics can be gathered beforehand
Saves time day of appointment
Patient under less stress |
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Term
Reasons for sound Financial Program
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Definition
Accurate demographics
Initiation of a medical record number
Orientation to patients surrounding
Identify uninsured patients
Provide financial counseling
Request deposits or deductibles
Screen for repeat bad debt
Explain collection policy and payment options
Initiating pre-authorization if needed |
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Term
Collection times
5 points during the revue a person can be asked to pay |
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Definition
Prior to service
Admission
Discharge
After discharge
During admission |
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Term
| When a patient is an emergent direct admit and has a pending balance you should? |
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Definition
| Make admission- discuss pending balance at a later time |
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Term
| When a patient is an urgent direct admit and has a pending balance you should? |
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Definition
| Contact physician to see if patient admission can be rescheduled |
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Term
| When a patient is an elective direct admit and has a pending balance you should? |
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Definition
| Cancel admission and reschedule after payment arrangements of prior balances have been made |
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Term
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Definition
Patient admitted to a bed
Require the highest level of care
ALOS - generally more than a day
Incur daily room/bed charge |
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Term
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Definition
Outpatient in a bed
Monitor acute condition
ALOS 23 hrs - MCR 48 hrs |
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Term
Patient types
Emergency Room |
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Definition
Outpatient in ER
Receives medical screening or treatment |
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Term
Patient types
Outpatient Clinic |
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Definition
Urgent care offices
IV therapy
Pain management
Wound care
Drug rehab |
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Term
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Definition
| Acute care for extended stay more than 25 days |
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Term
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Definition
Coordinated palliative care for terminally ill patients at home or facility
Must have MCR A and physician certified condition expected to cause death within 6 months |
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Term
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Definition
| Care of a patient by someone other than original caregiver |
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Term
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Definition
Care provided at a practitioner place of business
Various type of locations- Dr., Dentist, Psychologist and physical therapist
Billed on 1500 |
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Term
Patient types
Home Health |
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Definition
| Skilled nursing or therapeutic services |
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Term
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Definition
| Collaborative approach to providing and coordinating health care services |
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Term
Case Management Functions
List functions:
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Definition
Prevent unnecessary service or treatment
Evaluate an individual ability to live at home
Obtain appropriate medical care
Secure necessary medical supplies
Obtain assistance for custodial care
Obtain persons grooming services
Coordinate healthcare delivery of services
Arrange transportation to Dr. appointments
Obtain assistance with errands |
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Term
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Definition
| Patients permission to render services |
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Term
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Definition
Permission is given in writing ATOS
Information may contain:
Consent to bill insurance
Assignment of insurance
Agreement to pay
Agreement to release medical records to insurance |
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Term
Types of consent
Informed |
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Definition
| Patient made aware of risk and benefit of service received |
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Term
Types of consent
Implied consent |
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Definition
Consent is inferred from certain actions or by inaction
Failure to object treatment by a patient who is aware
If unaware of treatment; provider protected by Good Samaritan Law |
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Term
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Definition
Advance Beneficiary Notice
States services that are not billable by MCR |
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Term
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Definition
Prior to service is provided
Software using CPT and diagnosis codes generate ABNs when required |
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Term
| What are the key elements of an ABN? |
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Definition
Description of service
Diagnosis that caused denials
Statement that MCR is not likely to pay and why
Statement that patient is responsible for charges
Patient's name and date of service
Signature
Medicare number
Estimate charge amount |
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Term
| Effective collection policy at time of service ensures |
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Definition
cash flow improvements
AR days reduced
Patient statement cost reduced
Bad debt reduced
Follow-up time reduced
Patient satisfaction increased |
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Term
How often is an MSP required for a
recurring patients |
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Definition
| MSP must be redone every 90 days |
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Term
| Laws governing Medicare as a secondary payer are? |
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Definition
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Term
Coordination of Benefit
Who goes first when there are two commercial payers? |
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Definition
A persons own coverage is primary
Patient is married with children, birthday rule applies; parent DOB first in a calendar year is primary |
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Term
Coordination of Benefit
Who goes first when there is a divorce decree or support agreement? |
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Definition
| Divorced with children; custodial parent is usually primary |
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Term
| Purpose of a Compliance Plan |
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Definition
Prevent fraud
Identify fraud
Remedy instances of fraud |
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Term
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Definition
Skill nursing care of resident due to injury or illness
Can be separate wing, nursing home or freestanding |
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Term
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Definition
Protected health information
Registration must be in a private area
PHI must be shredded
Password should not be shared |
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Term
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Definition
Joint Commission agency that protects and improve quality and safety of care
CMS allows JCAHO accredit hospitals |
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Term
What is EMTALA and components?
AKA Patient Dumping Act |
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Definition
Emergency Medical Treatment and Active Labor Act
Response to uninsured patients not being treated.
Medical screening must be performed regardless of ability to pay
Transfer hospital must be notified of uninsured status prior to transfer |
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Term
| What is an Advance Directives? |
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Definition
| Written instruction that explain what type of medical care a person desires |
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Term
| List types of Advance Directives: |
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Definition
Living Will
Health care Power of Attorney
DNR |
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Term
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Definition
| Omnibus Budget Reconciliation Act 1986,1989 |
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Term
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Definition
| Specifies type of treatment wanted or not while the person is living |
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Term
| What is a Healthcare Power of Attorney? |
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Definition
| Designated Proxy makes decisions on patient's behalf |
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Term
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Definition
| Do Not Resuscitate- In the event of emergency patient does Not want CPR or similar interventions |
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Term
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Definition
| Used to determine if Medicare is primary or secondary to other insurance or liability claims |
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Term
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Definition
# of Patient Days / #discharges = ALOS
Divided the total number of patients day by the number of discharges |
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Term
What is Percent of Occupancy?
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Definition
| Sum of Census/ #available beds |
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Term
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Definition
| # Available bed * % occupancy |
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Term
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Definition
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Term
| What should not be included in Daily IP census? |
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Definition
| Same day surgeries , OP visits, ER visits or canceled admissions |
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Term
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Definition
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Term
What are collection types of patient payment?
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Definition
Pre-admission
Admission In-house
Discharge
Post-discharge
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Term
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Definition
Deficit Equity and Reduction Act 1984
Applicable to groups with 20 or more employee
Employees age 65 or over may enroll in the same coverage as younger employees |
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Term
| A facility's admission policy impacts what? |
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Definition
Hospital public image
Attending physician
Business office
Hospital staff |
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Term
Who must approve a facility's admission's policy? |
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Definition
Governing Board
Implemented by administration, CFO and Patient accounts director/manager |
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Term
| A facility Admission Manual includes policies and procedures to address admission variable. What is covered? |
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Definition
Eligibility of admitting physician
Admission criteria t assess eligibility for admission based on type
Circumstances that would cause an elective admission to be postponed or canceled |
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Term
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Definition
Emergency
Urgent
Elective
Newborn
Trauma |
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Term
| When experiencing delays in the Admission Process the completeness of pre-admissions is an area to investigate. List 5 areas to investigate. |
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Definition
Staffing
Bed availability
Employee efficiency and effectiveness
Scheduling
Housekeeping
Operational status of computer, printer, etc |
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Term
| Advantages of collecting at time of service? |
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Definition
Cash flow improvements
Reduced AR Days
Cost of patient statement reduced
Bad debt reduced
Follow-up time reduced
Patient satisfaction increased |
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Term
| List advantages of accepting credit cards payment? |
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Definition
Immediate confirmation of payment
Patient convenience of credit card installment payments
Payment can be made over the phone
Patient may agree to pay amount due prior to insurance payment
Prior authorization can be obtained to charge pending balances |
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Term
| List 5 general responsibilities of Patient Access? |
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Definition
Acting as liaison with CM
Hospital patient relations
Good communication
Recognition of financial risks
Strengthening of collection efforts and procedures
Evaluation of financial danger signs |
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Term
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Definition
A health insurance program or health care financing system designed to provide health services to a defined population within a specific budget
Used to control cost and decrease unnecessary care |
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Term
How often does JCAHO audit a hospital for their Joint Commission Surveys?
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Definition
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Term
| What three questions determine informed consent? |
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Definition
Did you speak to a doctor?
Did they explain the procedure?
Do you understand the procedure? |
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Term
| What is the definition of a guarantor? |
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Definition
| An individual who assumes responsibility for the cost of a patient's care |
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Term
| What is the period of Gratification? |
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Definition
| An estimate portion a patients pays before or at the time of admission, after which insurance adjudicates and pays provider |
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Term
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Definition
| Health Insurance Portability and Accountability Act 1996 |
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Term
| List 5 or more laws that govern MSP |
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Definition
BBA-Balance Budget Act 1997
TEFRA -Tax Equity and Fiscal Responsibility Act 1982
COBRA-Consolidated Omnibus Budget Reconciliation Act 1982
DEFRA- Deficit Equity and Reduction Act 1984
OBRA- Omnibus Budget Reconciliation Act 1986,1989
HIPAA-Health Insurance Portability and Accountability Act 1996
Black Lung Benefits Act
Federal Coal Miners Health and Safety Act
Title XIII |
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Term
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Definition
Tax Equity and Fiscal Responsibility Act 1982
Requires the employer's group health plan to be primary payer and MCR secondary for the working aged 65-69 |
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Term
| List procedures in a HCF admissions program |
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Definition
1. Obtain Patients Demographics
2. Obtain insurance
3. Identify ability to pay
4. Verify insurance
5. Complete all paperwork
6. Make necessary payment arrangements |
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Term
| Advantages for pre-admitting patients |
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Definition
1. Familiarized admission process
2. Completed paperwork
3. Admission process reduced
4. Completed diagnostic and clinical procedures
5. Obtained pre-certification and authorization
6. Collection of co-insurance and deductible
7. Verified insurance
8. Anticipated room requirement |
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Term
| Disadvantages of NOT pre-admitting |
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Definition
1. Admission date unknown
2. Incomplete consent forms
3. Unknown insurance
4. Authorization and pre-certification not obtained
5. Illegible patient handwriting
6. Unaware of insurance changes |
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Term
| Medicare Patient accepts medically unnecessary admission as per UR. What steps are required? |
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Definition
Complete ABN
Obtain Insurance info
Bill as 110 bill type
Include OC 32 |
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Term
| What are MCR -Exempted units in hospital? |
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Definition
Are not paid by DRG
Rate - reasonable cost reimbursement system |
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Term
| State types of exempted units |
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Definition
Psychiatric units
Rehab
Children's Hospitals
Cancer Hospitals |
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Term
| Implications of exempted units |
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Definition
ALOS can not be predicted
Difficult to discuss patients co-pay
Difficult pre-certifying inpatient admit without known LOS |
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Term
| Advantages of Centralized Registration |
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Definition
All staff trained in all jobs
Easier to re-appropriate staff
Able to perform complete registration
Consistency in collection policy
Centralized files |
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Term
| Disadvantages of Centralized Registration |
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Definition
Longer patient wait times
Multiple areas of care
Limited time to complete task
Increase need for cashiers
Multiple training |
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Term
| Advantages of Decentralized Registration |
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Definition
Employee specialized jobs
More time to complete tasks
Easier statistical tracking
Reduction of admission time
Patient are managed at location of service |
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Term
| Disadvantages of Decentralized Registration |
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Definition
Difficulty in covering absent employees
Require training in separate groups
May experience delays in care
Inconsistent usage of system policies
Patient inconvenience due to multiple registrations |
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Term
| Financial procedure key components for admission and house patients |
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Definition
Appropriate identification
Issuance of medical record number
Identification of self-pays
Obtain required info for claim processing
Gather accurate demographics and billing information
Identify potential charity care patients
Provide financial counseling at time of registration
Meet with patient in room
Qualify patient for government programs
Request deposits for deductibles
Screen for repeat bad debt |
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Term
Define Patient type
Recurring |
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Definition
| Outpatient - repetitive type no treatment |
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Term
| MCR is secondary in which cases? |
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Definition
W/C
Auto accidents
Black Lung
Third party liability
Services payable by VA
Clinical research
Employee primary coverage |
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Term
| MCR is primary in which cases? |
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Definition
Patient and spouse is 65 or older
Employer has 20 or more employees
Employed patient under 65 with an employer having 100 or more employees
ESRD within a 30 month coordination period |
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Term
| List payers of last resort |
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Definition
Medicaid
TRICARE
All payer are secondary to liability claims |
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Term
| Importance of determining the ALOS |
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Definition
Determine performance related DRG payments
Opportunities for improvement in discharge planning
Indicate a higher than average severity of illness |
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Term
| Define Percent of Occupancy |
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Definition
Summing the census for a given period of time and dividing that total number of beds available
Can be performed daily, monthly or yearly |
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Term
| % of Occupancy may indicate? |
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Definition
Low percent of occupancy indicates inefficiency
A percentage too high means difficulty finding available beds, long holding times in the ER
Ambulance diversions |
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Term
| Daily inpatient census should include? |
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Definition
The number of inpatients at the census taking time each day plus any inpatients who were both admitted and discharged after the census taking time of the previous day
Midnight is the preferred time to take census |
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Term
| Disadvantages of accepting credit cards |
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Definition
Credit card company payments have discounted rates, representing an additional cost for using card
Electronic response is an additional cost of collections
May create more paperwork
Additional deposit slips
Patient may object to pay interest charges on medical bills
May not accept all credit cards due to expense |
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Term
| Advantages of collecting deposits |
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Definition
Increased hospital cash collections
Reduced amount due at discharge
Reduced overall accounts receivable
Reduced bad debt |
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Term
| What law governs patients confidentiality? |
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Definition
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Term
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Definition
| Whichever parent's birthday occurs first in the calender year is the primary carrier |
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Term
| List 5 different Outpatients types |
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Definition
Same day surgery
Private
Ambulatory
Clinical
Emergency |
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Term
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Definition
| Patient receives surgical services on an outpatient basis not requiring admission |
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Term
| Define Private outpatient type |
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Definition
| Referred by and attending physician for diagnosis or treatment by the hospital on an ambulatory basis and will return to physician for further care and disposition |
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Term
| Define Ambulatory outpatient type |
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Definition
| Patient receiving medical and surgical services that tend to involve a broader, less specialized range of care |
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Term
| Define Clinic outpatient type |
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Definition
| Patient entering for diagnosis or treatment in a medical or surgical specialty unit of the hospital responsibility for continuing care and disposition |
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Term
| Define Emergency outpatient type |
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Definition
| Patient entering for immediate diagnosis and treatment on an unscheduled basis in the emergency facility of the hospital and are not admitted for inpatient services |
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Term
| List types of healthcare providers |
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Definition
Hospitals
LTC facility
Ambulatory care agencies
Home Healthcare agencies
Outpatient treatment centers
Renal dialysis centers
Family planning centers
Community Health centers
Freestanding ER
Family planning centers |
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Term
|
Definition
| Governs patient confidentiality in all aspects of hospital or clinic service areas and requires confidentiality of information collection during registration |
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Term
| Define Patient Protection Bill |
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Definition
| Proposed legislature to provide certain protection for patients in managed care plans |
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Term
| Define Patient Bill of Rights |
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Definition
| Developed by AMA, guarantees basic rights every patient should have when accessing healthcare services |
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Term
| Patient Basic Rights should include |
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Definition
Receive courteous, considerate, respectful treatment/safe environment
Appropriate healthcare
Continuity of care
Confidentiality
Information about healthcare
Privacy
Refuse care
Participation in planning care
Review itemized bill an explanation of all charges
Review medical records and copy for reasonable fee |
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Term
| Define collection control point pre -admission |
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Definition
Obtain all critical information via phone
Verify insurance and pre auth information
Determine patients portion
Determine patients patients options
Finalize payment arrangements
Prioritize financial counseling to patients with previous balances |
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Term
| Define collection control point Admission |
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Definition
Validate all previous information obtained
Obtain necessary signatures and insurance forms
Collect all deposits, copays, co-insurances etc |
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Term
| Define collection control point In-House |
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Definition
Monitor patient's financial situation based on insurance eligibility and coverage limitations
Visit room for third party coverage and payment arrangements |
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Term
| Define collection control point Discharge |
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Definition
Collect the patient's portion and make final arrangements.
Verify mailing and billing address
Obtain all signatures |
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Term
| Define collection control point Post-Discharge |
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Definition
| Pursue collection activities include follow-up on over due accounts from patient and payer using letters and phone calls |
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Term
|
Definition
Employment Retirement Insurance Security Act 1974
Require plans to provide participants with plan information, fiduciary responsibility, established grievance and appeals
Gives participant the right to sue for breach of fiduciary duty |
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Term
|
Definition
Consolidated Omnibus Budget Reconciliation Act 1982
Law that makes employers let you remain covered under the employers group health plan for a period of time after death of spouse, loss of a job, work hour reduction pr divorce |
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Term
|
Definition
Omnibus Budget Reconciliation Act 1986
Legislature to make large group health plans primary for active employees
Set limits of MAAC- maximum actual allowable charge amount |
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Term
|
Definition
Omnibus Budget Reconciliation Act 1989
Provides for RBRVS- Resource Based Relative Value Scale as a payment reform provision
Require hospital with emergency to post signs which specifies rights of women who are in labor and individuals with emergency medical conditions |
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Term
| Define elective admission |
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Definition
| A patient's condition patients condition permits adequate time to schedule the availability of suitable accommodations and financial arrangements |
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Term
|
Definition
| Admission required in the next 2-4 days |
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Term
| Define emergent admission |
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Definition
| Patient entering for immediate diagnosis and treatment on an unscheduled basis in the emergency facility of the hospital and are not admitted for inpatient service |
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Term
Define Medicare Spell of Illness
AKA Benefit period |
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Definition
Benefit period begins when the beneficiary enters hospital or from a skilled nursing facility
Can be readmitted into hospital or SNF without limit s due to the same spell of illness
If admitted patient must pay a new inpatient hospital deductible for each new spell of illness |
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Term
| Define Non-Available Statement |
|
Definition
A statement issued by a military treatment facility when medical care in not available at their institution and the patient must use civilian health care
Must be issued by the Commander
Valid for 30 days |
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