University of Mississippi Medical Center. Access Management. Patient Access Specialists II

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1 Financial Terminology in Access Management University of Mississippi Medical Center Access Management Patient Access Specialists II

2 As a Patient Access Specialist You are the FIRST STAGE in the Revenue Cycle. Your job is to collect ACCURATE patient information during registration. In order to do this successfully, you ll need an understanding of key financial terms related to healthcare.

3 What to Expect This module will help you prepare to be an effective and efficient Patient Access Specialist I. THIRTY-EIGHT FINANCIAL TERMS are presented. You will need to know each of them as you register patients. A quiz at the end will measure what you learned.

4 NOTE: Understanding the first three terms are crucial to comprehending the other thirty-five. Before proceeding, make sure you know the difference between the Payer, Beneficiary, and Provider. These terms are used throughout the entire module.

5 Payer- broad term describing any organization that pays medical expenses on behalf of patients. For example: Blue Cross Blue Shield, Aetna, Medicaid, Medicare, etc. Beneficiary- the person or persons entitled to medical benefits. This usually refers to the patient. Provider a doctor hospital or medical Provider- a doctor, hospital, or medical clinic that delivers healthcare.

6 Managed Care Organization- A concept under which an organization delivers health care to enrolled members and controls costs by closely supervising and reviewing the delivery of health care.

7 Administrative Costs- any cost associated with creating and submitting a bill for services. For example: registration, utilization review, coding, billing, and collection of expenses. These are the non-medical costs of collecting money for services rendered. Admissions i Authorization ti process where Payer accepts or rejects coverage for Beneficiary in urgent/emergent care situations. This usually takes hours.

8 Ambulatory Payment Classification (APC)- a method used to calculate payment for outpatient services. It is made up of a system of averaging and bundling common services and procedures using Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPC), and revenue codes submitted for payment.

9 Annual Maximum Benefit Amount Deductible - The maximum dollar amount set by Managed Care Organizations (MCO) that LIMITS the total amount the plan must pay for a subscriber in a year. It s the maximum amount an insurance company will pay for a patient in one year. Out-of-pocket maximums This occurs in extreme cases of chronic illness where large amounts of out-of-pocket expenses add up. MCO s set a limit to the amount of out-ofpocket expenses a member pays in a single year.

10 Deductible - the dollar amount per year the patient must pay before Insurance pays a dime. The maximum amount a patient will pay for medical services in a year, considering they don t exceed the insurance company s Annual Maximum. Assignment of Benefits- Patient gives written approval for their insurance company to pay Provider directly on their behalf. The form is usually signed at the time of registration.

11 Average Daily Census- the average number of inpatients maintained in the hospital each day for a specific length of time. Average Length of Stay- the average number of days of service rendered to each patient during a specific time. Appeal-a a complaint made when Beneficiaries or Providers disagree with decisions about health care services. This typically relates to payment issues.

12 Balance Billing- the practice of billing a patient for the fee amount remaining after the Insurer payment and Patient co-payment have been made. Example: Total Bill is $100 and insurance pays $80 while patient pays a $10 Co-Pay. Remaining balance to bill patient is $10. Claim- an itemized statement of the costs incurred during treatment. It is normally sent by the Provider to the Payer to initiate reimbursement. The itemized i bill sent to the insurance company.

13 Clinical Data Repository (CDR)- the process of receiving, reviewing, adjudicating, and processing claims. Also known as the Revenue Cycle. Fee for Service- the traditional healthcare Fee for Service the traditional healthcare payment system, where Providers receive a payment for each unit of service delivered.

14 Benefit Period the time period in which Medicare covers inpatient care in hospitals and Skilled Nursing Facilities(SNF) under one deductible. The Benefit Period begins the first day of a patient s stay and ends sixty days after discharge IF the sixty days is not interrupted by another stay in a hospital or SNF. Patient gets as much treatment as needed with one deductible within 60 days of initial discharge. Once patient is out of facility for 60 days, their deductible starts over.

15 Deposit - the amount of money a Provider requires prior to rendering service. This amount is typically a percentage of the patient s estimated total bill. Diagnosis Related Group (DRG)- classification system for over 490 diagnoses based on patterns of resource consumption and length of stay. Used in many prospective payment plans including Medicare.

16 Co-insurance a cost sharing arrangement of many MCOs where the Payer and Patient share a percentage of medical charges. Example: 80/20 where Payer is responsible for paying 80% and the Patient 20%. Bad Debt- when a patient s outstanding balance is regarded as uncollectible and is charged as a credit loss. This occurs when collections has been unable to collect the debt from patient and hospital has given up hope of receiving it.

17 Financial Terminology In Healthcare Co-pay- a cost sharing arrangement where the patient/guarantor is responsible for a defined payment amount for a specific type of service, usually paid at the time of treatment. Claimant - the person, patient, or entity submitting the claim for reimbursement.

18 HCFA the standard form used to submit claims for air ambulance, communicative disorders, Medicare Part B services, and physician clinics. Eligible Expenses- the agreed upon fee for health services and supplies covered under a health plan. This ensures reasonable and fair prices. For example, if a doctor charges $100 for a flu shot, and Blue Cross deems $75 to be the reasonable rate, Blue Cross will only reimburse $75.

19 Fee Schedule- a listing of accepted fees or established allowances for specific medical procedures. As used in medical care plans, it usually represents the maximum amount the Insurance company will pay for services such as lab and radiology. The Fee Schedule lists Eligible Expenses. Per Diem- a negotiated daily payment for delivery of hospital services provided. This usually refers to room and board charges. meals, routine nursing care, housekeeping, etc.

20 Premium- a patient s regularly scheduled payment for insurance coverage to Medicare, an insurance company, or health plan. Out-of-Pocket- non-reimbursable expenses patients are responsible to pay for services received from Provider. This is NOT part of the Deductible. Example is a Co-Pay.

21 Reimbursement - the amount of cash paid to the Provider by Patients and Payers for healthcare services. Revenue Cycle -all administrative i i and clinical i l functions that contribute to the collection of payment for services provided to the patient. Self-pay - the portion of bill to be paid in part or full by the Patient/Guarantor from their own resources. This refers to uninsured patients or procedures.

22 Tertiary Payer the insurer or entity with third priority of payment for a bill, after the primary and secondary payers. Uniform Billing Code - a federal directive requiring hospitals to follow specific billing procedures such as providing itemization of all services billed for on each invoice.

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