...reviews medical records is to make sure that the standards are met in the hospital. They also make sure everything that was done is in compliance. HIM is involved in the medical record documentation and billing process. 3. The billing process is important so the hospital can maintain its financial stability. If they don’t get the payment from the patient then they might not be able to afford the equipment they need. Only physician under contract can bill a patient for professional services. 4. The cms-1500 form is used for submitting claims for health care service providers. It is used by non-institutional providers. The cms-1450 (UB-04) is used by institutional providers such as hospitals. 1. Ferenc, D. (2014). Patient accounts and data flow. In Understanding hospital billing and coding (3rd ed., pp. 102-132). St Louis, Missouri: Elsevier Saunders 2. Ferenc, D. (2014). Hospital regulatory environment. In Understanding hospital billing and coding (3rd ed., pp. 53-54). St Louis, Missouri: Elsevier Saunders. 3. Ferenc, D. (2014). Hospital regulatory environment. In Understanding hospital billing and coding (3rd ed., p. 54). St Louis, Missouri: Elsevier Saunders. 4. Ferenc, D. (2014). Hospital billing process. In Understanding hospital billing and coding...
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...CODER INTERVIEW Kathryn L. Elican Grand Canyon University: HCA-530 April 3, 2013 CODER INTERVIEW Like a regular business entity, healthcare facilities need continuous inflow of funds to continue existing. However, billing complexity in the health care industry is unlike all other industries. The biggest difference of healthcare from other businesses is the source of payment for services rendered: the majority of which is from a third party with pre-determined rates and strict prerequisites. Foundational to these prerequisites is the accuracy of medical coding. An interview with a coder provided fresh understanding of the coding profession. And a look into the private and government payers and insurers’ roles brings better understanding of their impact on reimbursement. MEDICAL CODING Medical Coding is the process of using standard codes in identifying medical services and procedure. This is used for billing and reimbursement from payers for services rendered. Medical code is foundational and standardized with industry-wide language. The use of the Healthcare Common Procedure Coding System (HCPCS) is mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), (Medial Billing and Coding). THE INTERVIEW I interviewed an outpatient coder of Pennsylvania Hospital. Her job includes coding for hospital out-patients and Physicians’ in-patients and out-patients. She explained medical coding is quite complex and a coder needs proper schooling...
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...new74598_ch01_001-024.indd Page 1 24/09/12 1:18 PM user-f502 /202/MH01799/new74598_disk1of1/0073374598/new74598_pagefiles FROM PATIENT TO PAYMENT: UNDERSTANDING MEDICAL INSURANCE KEY TERMS Step 1 S te St ep 10 Follow up payments and collections Preregister patients p2 Establish financial responsibility St ep 3 S te p 9 Generate patient statements Check in patients Monitor payer adjudication Review coding compliance St ep 8 S te Check out patients Review billing compliance p7 St ep 5 S tep 6 Learning Outcomes After studying this chapter, you should be able to: 1.1 Explain how healthy practice finances depend on correctly accomplishing administrative tasks in the medical office. 1.2 Compare coinsurance and copayment requirements for health Copyright © 2014 The McGraw-Hill Companies plan benefits. 1.3 Identify the key steps in the medical billing cycle. 1.4 Discuss the impact of electronic health records on clinical and billing workflow. 1.5 Evaluate the importance of professional certification and of medical liability insurance for career advancement. S te p4 Medical Billing Cycle Prepare and transmit claims 1 accounts payable (AP) accounts receivable (AR) benefits cash flow certification coding coinsurance copayment covered services deductible diagnosis documentation electronic claim (e-claim) electronic health record (EHR) ...
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...Running head: Evaluating Compliance Strategies Assignment: Evaluating Compliance Strategies Name Axia College of University of Phoenix HCR 220 Date “Guidelines established by the healthcare staff and laws established by HIPAA are what make up the compliance process. These laws and guidelines were established to protect the patients, physicians, and staff members” (U.S. Dept. of Health and Human Services, n.d.). Errors in the office can be avoided by having a compliance process in effect. Using updated billing and coding software will help reduce errors made in the billing process. I agree with having a guide consisting of codes to aid in the billing process. I do regard this as cheating rather, to be used as a guide. Many offices currently have sheets that are located on the front of the patients’ file with the diagnosis and the code next to the diagnosis which the physician fills out. This eliminates an unnecessary step in the billing process and is a quicker, easier, and more accurate way to avoid errors. “In order to avoid rejection of the claim, it is important that the diagnoses and procedures are correctly linked” (AAFP, 1999). This also ensures that the claim is paid for the correct procedure performed by the physician. If an incorrect procedure was billed this could result in a loss of money by the physician for the type of procedure that was performed. The claim will have to be adjusted and resubmitted...
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...the accounts that finance health care and are the data that "flows." Charge capture is the process of capturing all charges, [though it is often susceptible to "charge capture leakage" - an undercharge for services. Charge capture leakage can be minimized by constructing predictive models for charge capture leakage, and comparing these models to the current state of data flow on patient accounts. In sum, patient accounts, data flow, and charge leakage are the process of healthcare finances. Patient accounts are the elements, data flow is the process, and charge capture is the outcome. The relationship between patient accounts, data flow and charge capture is as follows: in order to provide competent medical billing and collections services in a timely and cost effective manner that will maximize the reimbursement revenue at a competitive market price. This guarantees that 98% of claims are paid on first submission and electronic claims are paid within 5 to 14 days, and payments are recovered on aged claims within 30 days . List two reasons why the HIM Department reviews patient medical records. To make sure the information is complete and accurate and ensures all the necessary forms are complete and signed - sort of a quality assurance function. The HIM department may also review patient records for other reasons such as audits, to determine trends, to respond to or resolve billing or legal issues. Research and education is another reason for medical record review. This...
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...|Information Technology (22-28%) |Information Systems and Communication (15-19%) | |Area V |Planning and Measurement (22-28%) |Strategic Planning (10-14%) | |Area VI |N/A |Operations Management (12-16%) | Controls over Business Processes • segregation of duties: for each transaction cycle, the functions of authorization, approval, execution (custody of assets) and recordkeeping should be segregated (manual- different individuals performing functions, technology-based- controlling access and passwords) Sales & Collections Business Process |Risk |Nature of Process |Examples Controls | |Inaccurate or incomplete sales data and lack |Sales orders inputted manually |• Password control over terminals to assure that sales are | |of security over sales order information | |authorized by sales...
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...many of the terms and the processing of insurance, I felt more comfortable discussing issues with customers who had questions. However, I still noticed that I struggled with insurance rejections and how to fix them in the Lewis system. I decided that learning the ropes of insurance rejections is something that comes with experience and practice. Although many of concepts of third party billing are taught during pharmacy school, it seems like they are only addressed in quick lectures that don’t require much critical thinking. An option to improve this deficit would be to address the information early and often. Repetition is one of the best ways for me to commit knowledge to long-term memory. I vaguely remember one or two labs in pharmacy practice where we practiced filling a prescription and billing it through a fake third party. If this lab was repeated more often with different kinds of rejections that are common in a community pharmacy, I think that would greatly help improve comprehension. Moving forward, I hope that with more practice I will gain a greater understanding of third party billing. I plan to discuss with my preceptor or fellow coworkers any questions that arise during my rotations and throughout my...
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...Healthcare Information That Helps to Reinforce Career Experience Jennifer A. Dresen Lakeland College Healthcare Information That Helps to Reinforce Career Experience There are a lot of different aspects to look at in the healthcare industry, which can make it feel a little overwhelming at times. The more that I continue to learn, the more comfortable I feel working within this ever changing industry. I currently work for Rehab Management Solutions, which is a practice management company for multiple physical therapy clinics across the United States. In our office we provide services such as; Managed Care, Preliminary Systems, Billing & AR Management, Marketing, and Clinical Growth & Development. A lot of the topics that we have discussed in the course so far I have heard of, but I did not have extensive knowledge of many of them. Below are a few of the topics that I found most interesting and beneficial to my current position and daily activities. Regulation in the healthcare industry There is very heavy regulation for entry into all areas of the healthcare industry. States have set requirements on the licensure of healthcare facilities as well as providers. These mandatory licensures have been set to try and protect the public’s safety, welfare, and health. The provider licensing procedures were put in place to create the minimum accepted standards to be able to practice. Providers such as nurses, doctors, physical therapists, and dentists;...
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...what was learned from the both cases. I will provide the appropriate citing that will present the reason or reasons as to why I drew my conclusion. In addition, my citing will establish counterarguments that will support my conclusion. Lessons Learned In reference to the Clinic and Resort cases they both had disconnected systems within their organizations; however both organizations can increase their costs of operation by implementing an innovative and a highly recognized business data system. Although popular and highly recognized business data systems are not considered to be the best solutions for businesses by their leadership, they are possible solutions. The inefficiency of services and the lack of continuity in business process were because of the disconnected systems, which made it more costly for both organizations because both, the clinic and the resort were losing customers/ guests and their prestige. Citing Appropriate Sources In the resort case, the disconnected system that was implemented lead the resort to less optimal services in the planning and enjoyment of their guest’s vacations. In the case of the Marshfield clinic, the...
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...Folder according to the Course Schedule. The stages build upon each other and consist of the following assignments: (Only do stage 1 to 3) Text Book- (Systems Analysis and Design 10th edition by Harry J. Resenblatt. 2014. Shelly Cashman Series. Course Technology) Stage 1: Using the case provided, develop a Requirements Document that provides a high-level description of the current information system and a proposed replacement system, process diagrams for each, a Functional Decomposition Diagram (FDD), and a Systems Requirement Checklist for the new system. Analysis will be presented in 3-5 page paper, plus diagrams, using Microsoft Word. Stage 2: Using the case provided and the process identified in the assignment, model the data and processes by developing a Context Diagram and a Diagram 0 for the new system. Deliverable is the two diagrams, properly labeled, using Microsoft Word or PowerPoint (or a drawing tool that can be viewed without specialized software other than Microsoft Office). Stage 3: Using the case provided and the process identified in the assignment, develop a Decision Table and a Decision Tree, relevant to the new system. Deliverable is the two illustrations, properly labeled, using Microsoft Word or PowerPoint (or a drawing tool that can be viewed without specialized software other than Microsoft Office). Case Study Document IFSM 461: Systems Analysis and Design Udo, Marian, & Uduak Corporation (UMUC) Case Study Page 1 of 6 Udo, Marian, & Uduak...
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... | | | Career Objective: To take a challenging post for understanding business change needs, assessing the impact of those changes, capturing, analyzing and documenting requirements and then supporting the communication and delivery of those requirements with relevant parties. Professional summary: ✓ 2.8 years of experience in the field of IT on as Functional Consultant Oracle Applications ERP and Business Analyst for Bespoke Applications. ✓ Extensive experience in Requirement gathering, Analysis and understanding of AS-IS and TO-BE models, Documentation (like BRD’s, Wireframes, Use cases, Test cases, and Test Plans) and High Level Design. ✓ Experience in preparing Functional requirement document, High Level Design and Test Cases. ✓ Exposure to Backend system with working knowledge of PL/SQL. ✓ Extensively worked on Oracle Applications Project Costing and Billing Module. ✓ Good knowledge on Order to Cash Process. ✓ A highly motivated, energetic individual and a team player with excellent communication and...
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...right product in the right place at the right time for the right price. There are four basic revenue cycle business activities that are sales order entry, shipping, billing and account receivables also cash collection. Sales order entry process entails three steps that are taking the customer’s order, checking and approving the customer credit and checking inventory control. The second basic activity in the revenue cycle is by filling the customer orders and shipping the desired merchandise. It is entail two step that is picking and packing the order also shipping the order. The third basic activity in the revenue cycle involves billing customers and updating the account receivables. The last step in revenue cycle is cash collections in which involve handling the customer remittance and depositing remittance in the bank. Basically, this case is about an audit process made to our client in term of its process of sales and cash receipts document as well as in shipping and billing system. Based on this case, we had made an audit process on the sales order entry, cash receipt, shipping and billing of the client transaction of business. We had discovered the weaknesses of its internal control system revealed from the client’s procedures on documenting of sales and cash receipt also omission from shipping and billing system. PART I: SALES AND CASH RECEIPT SYSTEM SALE DEPARMENT | Mail Clerk | Sales...
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...assist in identifying the readiness of an organization to successfully starting an EHR, the readiness for the staff to accept, and productively by using the EHR. The results will help assess what the current state of technology is, what is needed to make a change, what the potential barriers are, the user needs, time-sensitive factors and appropriate steps to take action. The readiness and the needs assessment should involve everyone who will be using the EHR or whose job could be affected by the EHR. This could include personnel such as clerical, and office staff, administration, scheduling, or billing staff, physicians, nurses and computer support staff (Ginsberg, n.d.). A vision for what the EHR means to the organization should be included in the needs assessment. It should also include an assessment of the current processes, the workflow, and data collection, reporting, and billing needs. An assessment should be made of what the Internet capabilities are, the financial abilities, clinical priorities, and any other special requirements. Special considerations need to be made to assess the computer abilities of staff members, along with their knowledge and attitudes towards a new system (Amatayakul, 2005). The American Medicine Association has developed a needs assessment checklist that has included the integration with the processes being used, the workflow features, interfaces,...
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...Solving Team Challenges at DocSystems Billing, Inc. The case study is based on an insurance billing company called DocSystems Billing, Inc. It is a call centre that has an onsite and an outsourced center. The onsite call centre has forty employees, 10 Senior Insurance Consultants (SIC) and 30 Medical Insurance Specialists (MIS) divided into two teams. The outsourced company has 100 employees called Billing Specialists who perform the initial billing work and data entries. The issue is mainly on the onsite center where the recent reshuffle of the team members and combining of MIS (15 members) and SIC (5 members) on each team headed by Dana and Alex as the managers. Jim is the senior director whom the managers report to. The case revolves around the situation where Jim wants to redesign the teams because the second team structure does not seem to be productive and efficient. Jim, thus, appoints Dave, an OD consultant over a meeting to discuss about the possible bottlenecks and solutions to enable them create a productive and efficient team. The problems that exist in the organization are internal problems which arise from conflicts between team members and teams, ego issues, insecurity, poor leadership and lack of mutual cooperation and interaction. Due to this, there is inefficiency in productivity causing delay in job completion and ultimately poor customer satisfaction. The delay is caused by the ego issues that the team members have with the senior team instead of trying...
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...Access Control, Time Log, and Billing Application Executive Summary The need to maximize the economic performance in business organizations remains a key objective for many companies. Since firms lack an effective way to monitor the activities of the workforce, most of the business organizations needs to acquire access control systems, time log, and the billing application. The system assists companies in determining the productivity of the enterprise. Development of well-functioning application that would suit the needs of the ultimate users is often a challenge to the IT engineers. The main issue with the incomplete application is caused by inadequate communication between the developer and the program developers. There have been many research reports that suggest the appropriate procedures in the development of programs to avoid development of uncompetitive programs. Another issue with the development of faulty programs includes failures of the sponsors to provide the adequate requirements for the application. A research on this matter indicates that many firms continue experiencing reduced quality systems. Some organizations spend enormous amount of finances in hope to acquire adequate systems that would satisfy their intended needs. It is unfortunate that some of the developed systems end failing to deliver as expected by the sponsors. Such issues emerge from inadequate communication between the users and developers. In some cases, they might manifest after implementation...
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