- NES: Education for Healthcare Management Professionals
-
- Series 1: Medical Billing as a Business
Introduction: The Business Basics
A. How to Choose the Right Name for Your Business B. How to Choose the Most Advantageous Structure for
Your Business
1. The Sole Proprietorship a. Advantages of the Sole Proprietorship b. Disadvantages of the Sole Proprietorship
2. The Partnership
a. Characteristics That Distinguish a Partnership b. Types of Partners c. Advantages of the Partnership
3. The Corporation
a. Advantages of the Corporation b. Disadvantages of Forming a Corporation
C. The Legal Implications and Responsibilities of a Medical
Billing Business
1. Confidentiality 2. Assignment of Benefits / Release Information 3. Setting Up the Best Accounting Method for Your Business
a. The Cash Method b. The Accrual Method
4. The Difference Between Personal and Business Expenses
5. The Basic Rules of Business Expenses
a. Car Expenses b. Home Expenses c. Travel and Entertainment d. Personal Use e. Start-up Costs
6. Taxes
7. Tax Concerns for the Self-employed
a. How to Survive Paying Taxes
8. Choosing a Tax Advisor
a. Experience b. Services c. Price d. References e. Calendar Year vs. Fiscal Year
9. Insuring Your Business
a. Physical Liability b. Errors and Omissions c. Business Equipment d. Health Insurance e. Business Interruption f. Disability Insurance
D. Your Responsibilities as an Employer
1. Employees
a. Behavioral Control b. Financial Control c. Relationship of the Parties
2. Your Legal Responsibilities 3. Responsibilities to Independent Contractors 4. Keeping Thorough Records
E. Business Management Skills
1. Developing an Effective Business Plan 2. Developing an Effective Marketing Plan
a. Who Your Market Is b. The Steps You Will Take to Reach Your Market
3. Pricing Your Services
a. Per Claim Fee b. Flat Fee c. Percentage
4. The Basics of Contracts 5. Setting Goals and Determining Projections 6. Personal and Professional Growth 7. Effective Client Relations
a. Personal Image
8. Keeping Your Existing Clients
a. The Problem Client
F. Your Physical Office
1. Choosing Your Office Location 2. Furniture
a. Desk b. Ergonomic Chair c. File Cabinet d. Shelving
3. Equipment
a. Computer b. Modem c. Fax Machine d. Laser Printer or Inkjet Printer
4. Optional Equipment 5. Telephones and Communications
Appendix A: Essential Resources
1. Associations and Trade Groups for Medical Billers 2. Business Information on the Web 3. Business Reference Books and Periodicals 4. Medical Billing Books 5. HSP Review 6. HSP Review Key
COURSE 2 HOW HEALTH INSURANCE WORKS
A. Definitions of Health Insurance, Premiums, Benefits, and Policies
1. Health Insurance 2. Premiums 3. Benefits 4. Policy
B. Individual vs. Group Plans
1. Individual Plans 2. Group Plans
C. Various Types of Health Insurance
1. Basic / Major Medical Insurance 2. Major Medical 3. Comprehensive Medical 4. Comparison of Basic/Major Medical vs. Comprehensive Payouts 5. Specialized Types of Health Insurance
a. Surgical b. Disability c. Dental Care d. Vision Care e. Senior Citizen f. Special Class g. Special Risk
6. Self-Funded Insurance Plans
7. Auto Insurance
D. Consolidated Omnibus Budget Reconciliation Act (C.O.B.R.A.)
1. Definition of C.O.B.R.A.
2. Guidelines for Continuing Coverage Under C.O.B.R.A.
a. When a Covered Employee Dies b. When Covered Employees Become Eligible for Medicare c. When a Covered Employee is Divorced d. When a Covered Employee Becomes Unemployed e. When Dependent Children Exceed Age Limit on Family Contracts f. When Retiree's Company Undergoes Chapter 11 Bankruptcy Reorganization
3. Pros and Cons of C.O.B.R.A. 4. Guidelines for Conversion From C.O.B.R.A.
Continuing Coverage to a Non-group Plan
a. Double Coverage
E. Coordination of Benefits
1. Why Benefits Coordination is Necessary
2. Determining the Primary vs. Secondary Carrier
a. Birthday Rule b. Gender Rule c. Other Determinations
F. Health Insurance Carriers G. Blue Cross / Blue Shield H. Medicare
1. Medicare Part A Coverage
a. Additional Part A Benefits b. Skilled Nursing Facilities (SNF) c. Home Health Services d. Hospice Care e. Psychiatric f. Christian Science Monitor Sanitarium g. Prospective Payments System (PPS)
2. UB-92
3. Care Outside the United States 4. Medicare Part B Coverage 5. How Medicare Part B Claims are Paid
a. Participating vs. Non-participating Physicians
6. Medigap and Supplemental Insurance 7. Medicare and Managed Care
I. Medicaid
1. Prior Approval Procedure 2. Services Requiring Approval for Medicaid Payment
J. Other Government Carriers
1. CHAMPUS 2. CHAMPVA 3. Worker’s Compensation
a. Medical Care b. Disability Benefits
4. Self-Insurance 5. Federal Employee Compensation Act (FECA) 6. Crime Victims Division Benefits 7. Federal Employees’ Health Benefits Program (FEHB)
K. Fraud and Abuse Under the Medicare Program
1. Penalties for Fraud 2. Civil Monetary Penalty Law 3. Kickbacks
L. Managed Care: Prepaid Health Care Organizations M. Health Maintenance Organizations (HMOs) N. Preferred Provider Organizations (PPOs) O. Medical Fees and Schedules P. The 25 Major DRG Diagnostic Categories
COURSE 3 ICD-9 CODING
A. Overview and History
1. Annual ICD-9-CM Update
2. Briefing on ICD-10 International Classification of Diseases
B. Introduction to Coding
1. Coding Guidelines for Physicians 2. Characteristics of ICM-9-CM 3. Volume 1 (Tabular - Numeric) 4. Routine Diagnosis Codes 5. Non-Covered Diagnosis Codes 6. Volume 2 (Alphabetic-Index) 7. Volume 3 (Tabular and Alphabetic)
a. Field 67 = Primary Diagnosis Codes b. Field 68-75 = Other Diagnosis Codes c. Field 76 = Admitting Diagnosis d. Field 77 = External Cause of Injury
8. Conventions Used in ICD-9-CM
9. Coding Notes 10. Neoplasm Coding Tips 11. VXXX Codes Associated With Neoplasms 12. Diabetes 13. Coding Burns
C. Medicare Claim Filing Rules and Regulations
1. Why ICD-9? 2. Procedures with Specific Diagnosis Requirements 3. ICD-9-CM Valid Three-Digit Codes 4. Valid Three-Digit Codes
COURSE 4 MEDICARE: GUIDE TO PROCEDURAL CODING
A. How HCPCS Is Organized
1. HCPCS Overview
2. Level 2 HCPCS Codes
3. Using CPT / HCPCS Codes
a. How CPT is Used
b. Format of the Terminology
c. Unlisted Procedure or Service
d. Alphabetical Reference Index
B. Modifiers
1. Pricing and Non-Pricing Modifiers
2. HCPCS Alpha and Alphanumeric Modifiers
a. Statistical Modifiers
3. Using Modifiers
a. Multiple Endoscopic Procedures
b. Certain Dermatological Services
4. American Medical Association Copyright Information
5. Purchasing HCPCS / CPT Code Books
C. Documentation Guidelines for Evaluation and Management Services
1. What Is Documentation, and Why is it Important?
2. What Payers Want and Why
3. General Principles of Medical Record Documentation
a. Documentation of E/M Services
b. Documentation of History
c. Chief Complaint
d. History of Present Illness
e. Review of System (ROS)
f. Past Family and/or Social History
g. Documentation of Examination
h. Documentation of the Complexity of Medical Decision Making
i. Number of Diagnoses or Management Options
j. Amount and/or Complexity of Data to be Reviewed
k. Risk of Significant Complications, Morbidity and / or Mortality
l. Documentation of an Encounter Dominated by Counseling or Coordination of Care
m. Counseling
n. Established Patient
o. New Patient
4. E/M Service Codes
5. The HCFA-1500 Claim Form: An Overview
a. Place of Service (POS) Codes
b. Place of Service Codes for E/M Visits
D. Medicare: Guide to Procedural Coding: HSP Review
COURSE 5 Medicare: Billing Guide
A. What’s New With Medicare?
1. National Provider Identifier (NPI)
2. Millennium Changes
3. Clinical Laboratory Improvement Act (CLIA)
4. New Panel Codes
5. Medicare General Enrollment Applications
B. Medical Record Documentation
1. What is Documentation, and Why is it Important?
2. What do Payers Want and Why?
3. Documentation Tips
4. Administrative Costs for Documentation Retrieval
C. Use of Diagnostic Codes
1. Coding
2. Coding is a Three-Step Process
D. Codes are to be Used at Their Highest Level of Specificity
E. Preparing the HCFA-1500 Claim Form
F. Limitation of Liability
1. Advance Beneficiary Notice
2. Billing Requirement
G. Correct Coding Initiative
1. Background
2. Coding Based on Standards of Medical / Surgical
3. Principles of General Coding
4. Medical / Surgical Review
5. CPT Procedure Code Definition
6. Coding Services Supplemental to a Principal Procedure (Add-On Codes)
7. CPT Coding Manual Instruction / Guidelines
a. Separate Procedures
b. Most Extensive Procedures
c. Not Otherwise Classified (NOC) Codes
8. Mutually Exclusive Procedures
9. Modifiers
H. "Rejected" Claims
1. Resubmission of Rejected Codes
a. Box 19 Billing Requirements
I. Reject Remittance Codes
J. Reject Remark Codes
K. The Appeals Process
L. Partied to an Appeal
M. Why Use EMC?
COURSE 6 1998 E&M GUIDELINES
A. Introduction
1. What is Documentation, and Why is it Important?
2. What Do Payers Want and Why?
B. General Principles of Medical Record Documentation
C. Documentation of E/M Services
D. Documentation of History
1. Chief Complaint (CC)
2. History of Present Illness (HPI)
3. Review of Systems (ROS)
4. Past, Family, and/or Social History (PFSH)
E. Documentation of Examination
1. General Multi-System Examinations
2. Single Organ System Examinations
3. Content and documentation Requirements
a. General Multi-System Examination
b. Cardiovascular Examination
c. Ear, Nose, and Throat Examination
d. Eye Examination
e. Genitourinary Examination
f. Hematologic/Lymphatic/Immunologic Examination
g. Musculoskeletal Examination
h. Neurological Examination
i. Psychiatric Examination
j. Respiratory Examination
k. Skin Examination
F. Documentation of the Complexity of Medical Decision Making
1. Number of Diagnoses or Management Options
2. Amount and/or Complexity of Data to be Reviewed
3. Risk of Significant Complications, Morbidity, and/or Mor- tality
4. Table of Risk
G. Documentation of an Encounter Dominated by Counseling or Coordination of Care
COURSE 7 COLLECTING MEDICAL CLAIMS INFORMATION
A. The Patient Information (PI) Sheet
1. Patient Demographics
2. Medical History
3. Insurance Information
4. Assignment and Release Statement
5. Office Use Only
6. Additional PI Form Entries
7. Changing Information on a PI Form
B. Other Pertinent Patient Forms
1. Waiver of Medicare Assignment of Elective Surgery
2. Medicare Waiver of Liability for Medically Unnecessary Procedures
C. Medical Services Documentation
1. Source-Oriented Records (SOR)
2. Problem-Oriented Records (POR)
3. Service Documentation Specifics
D. Documentation Pitfalls
1. Time of Service
2. Length and/or Size of Wounds or Lesions
3. Layers
4. Wound Debridement
5. Cosmetic Surgery
6. Complications
7. Consultative Services
8. Operative Reports
9. Medical Record Maintenance
10. Record Retention
E. Obtaining Claims Data From Physicians
1. Day Sheets
2. Superbills and Charge Tickets
3. Standard Full Page Charge Ticket
4. Peg Board System
5. Computer-generated Charge Tickets
6. Routing Sheets
7. Designing Customized Charge Tickets
8. Practice Information
9. Patient Information
10. Procedures
11. Diagnosis
12. Linking Diagnoses to Procedures
13. Other Information
F. Essential Claims Processing Information
1. Visit Information
2. Patient Information
3. Cover Notes (When Appropriate)
4. What to Do About Missing Data
5. Design Your Own "Request for Information" Form
G. Maintaining Confidentiality
H. Working Within Insurance Carriers’ Requirements
1. Payers’ Guidelines
2. Request Guidelines Directly From Payers
3. Devise a Filing System for Payers' Guidelines
4. Pre-authorization and Predetermination
COURSE 8 PROCESSING CLAIMS MANUALLY
A. Preparing Paper Medical Claims for Submission
1. Overview of the HCFA-1500 Form
2. General use of the HCFA-1500 Form
3. Completing the Form
4. Patient and Insured Information: Blocks 1-8
5. Railroad Retirees
6. Medigap Insurance: Blocks 9-9d
7. Blocks 10a-10c
8. Other Insurance Primary to Medicare: Blocks 11-11d
9. Signatures: Blocks 12-13
10. Dates of Illness/Injury: Blocks 14-16
11. Referring and Ordering Physician: Blocks 17-17a
12. Surrogate UPINs
13. Blocks 18-19
14. Outside Lab and Purchased Tests: Block 20
15. Diagnosis: Block 21
16. Highest Level of Specificity
17. Nonphysician Specialties
18. Blocks 22-23
19. Detail of Services, Items Rendered: Blocks 24a-24k
20. Place of Service Billing Tips
21. Place of Service Codes and Definitions
22. Anesthesia
23. Quantity Billed and Procedure Code Descriptions
24. Physician and Supplier Billing Information: Blocks 25-33
a. Laboratory Services
b. Tips for Submitting Claims
25. Reporting Same-Day Services
26. Other Tips
27. Signature Requirements
28. Signature of Medicare Patients
29. Incapable Beneficiaries
30. Deceased Beneficiaries
31. Signature on File
32. Authorization Statement and Claim Submission Require- ments
33. Hospitals and Other Facilities
34. Additional Requirements
35. Signature for Supplemental Insurance Information
36. Signature of Provider
37. Claim Form Requirements
a. Definitions
38. Incomplete or Invalid Claims
39. Conditional Data Element Requirements
40. Claim Specific Requirements
a. Anesthesiology Claims
b. Chiropractic Claims
c. Certified Registered Nurse Anesthetist (CRNA) and Anesthesia Assistant (AA) Claims
d. Erythropoietin (EPO) Claims
e. End Stage Renal Disease (ESRD) Claims
f. Foot Care Claims
g. Laboratory Services
h. Independent Laboratory Services to a Patient at Home or in an Institution
i. Mammography Claims
j. Physician Assistant, Nurse Practitioner, and Clinical Nurse
k. Physician Claims
l. Physician Claims for Hospice Services
m. Portable X-ray Service
n. Physician Claims
o. Physician Claims for Hospice Services
p. Portable X-ray Service
q. Radiology and Pathology Services to Hospital Inpa- tients
r. Claims for Assistant at Surgery Services in Teaching Hospitals
B. Preparing Standard Dental Claim Forms for Submission
1. Dentist's Pretreatment Estimate or Statement of Actual Services
2. Carrier Name and Address
C. Submitting Paper Claims
1. The Life of a Paper Claim
2. The Insurer’s Explanation of Benefits
3. Logging and Monitoring Claims Submissions
a. Suspension File System
b. Log Sheet System
c. Computer Database System
D. Tips for Obtaining Better and Faster Reimbursement
1. Eliminate Down-Coding by Eliminating Descriptions
2. Rank Procedures by Order of Importance
3. Use Modifiers Appropriately
4. Don't Send Documentation Unless It's Asked For
5. Submit Claims Promptly and Frequently
6. File Claims by FAX
7. Additional Tips
E. Following Up on Problem Claims
1. Common Reasons Why Claims Are Rejected
2. Troubleshooting Problem Claims
3. Claims Problem Troubleshooter
4. Making Inquiries and Submitting Corrections
5. Appeals and Hearings
6. Appeals
a. What to Include in an Appeal
b. Medical Necessity
c. Preexisting Conditions
d. Sample Appeal Letter
8. Insurance Department Complaints
a. FTC and Health Insurance
9. Hearings
a. Hearing on Record
b. Telephone Hearing
c. Personal Hearing
10. Administrative Law Judge Hearings
F. Cutting Claims Submission Costs
1. Using the Insurance Carrier’s Dollars
a. Free Phone Calls
b. Free Mailing Envelopes
c. Free Training and Seminars
d. Free User Guides
COURSE 9 PROCESSING CLAIMS ELECTRONICALLY
A. The Advantages of Electronic Claims Processing
B. How Electronic Claims Processing Works
1. Directly to Insurance Companies
2. Clearinghouse
C. Selecting Software and a Clearinghouse
1. Selecting Software
a. Format/Platform
b. Claims Only vs. Practice Management
c. Basic Functions of Practice Management Software
2. Selecting a Clearinghouse
a. Finding Clearinghouses From Which to Choose
b. Determining Which Clearinghouse is Best for You
D. Operation, Organization, and Filing of Electronic Claims
1. Organization of a Client’s Information
2. Pickup/Receipt of Information
3. Daily Operations
4. Filing Information
5. Weekly Operations
6. Monthly Operations
COURSE 10 CREDIT POLICIES, BILLING PROCEDURES, AND MAKING COLLECTIONS
A. Establishing Sound Credit Policies
B. Patient Billing Procedures
1. Patient Billing Statements
2. Determining Where to Send the Bill
3. Coding and Itemizing
4. Determining the Time and Frequency of Billing
C. Making Collection
1. Setting Collection Objectives and Measuring Results
2. Collection Ratio
a. Figuring the Collection Ratio
3. Accounts Receivable Ratio
b. Figuring the Accounts Receivable Ratio
D. Accounts Receivable Aging Analysis
E. Collection Methods
1. Reminder Notes
2. Reminder Letters
3. Telephone Collection Techniques
a. Some Telephone "Don'ts"
b. Typical Telephone Reactions and How to Respond to Them
4. Collection Letters
F. Special Collection Problems
1. Tracing "Skips"
a. Ways of Finding "Skips"
2. Claims Against Estates
COURSE 11 ANCILLARY SERVICES
A. Ancillary Services
B. Coding Analysis
C. Office Policy and Procedure Manuals
D. Making Recommendations Regarding Managed Care Plans
E. Preparing Financial Reports
F. Performing Bookkeeping Functions
G. Fee Schedule Review
H. Marketing of the Practice
I. Chart Documentation
J. Tracking Allowables
K. Analyzing a Practice's Financial Health
L. Insurance Verification
M. Tracking Referrals
N. Transcription
COURSE 12 GLOSSARY
COURSE 13 APPENDIX
A. Abbreviations
B. Acronyms
C. Addresses
D. Automobile Medical or No-Fault Insurance
E. Black Lung Benefits
F. Books & Educational Tools
G. Combining Forms: Prefixes & Suffixes
H. Disability
I. How To Handle People Who Seem to Like You But Sign Up With Someone Else
J. Liability Insurance
K. Managed Care
L. Medicare & Hospice Care
M. National Association of Insurance Commissioners
N. Secondary Payer
O. Veterans Administration
P. Worker’s Compensation
Q. Working Aged
R. Women’s Resources
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