University of Phoenix Material

Accurate Registration Worksheet

In 50 to 100 words, explain each step of the medical billing cycle, using Figure 6.7 of Integrated Electronic Health Records as a reference. Your explanations must be in your own words.

Step Explanation
1 Pre-registration confirms the patient’s information and helps to identity the patient to ensure the patient safety. This is an important step especial for reoccurring patients... This step also helps with verifying a patients insurance. Pre-registration gives the office ample time to answer questions before they are asked by looking into the EHR. Pre-registration also allows you to see procedures that may require prior authorization (pre-cert).
2 Establish financial responsibility- Establishing financial responsibility is knowing who owes what for a certain doctor’s visits. Once the clinic gathers the pertinent information from the patient, then the biller can then determine which services are covered and allowed under the patient’s insurance plan. Insurance coverage can differ hugely between companies, individual, and plans, The biller needs to make sure each patient’s coverage in order to create the bill correctly. This also goes for prescriptions, some insurance companies do not allow for certain types or prefer generics.
3 Check in patients- Patient check-in and check-out are pretty much straight-at the desk task. When the comes in, First time patients will be asked to fill out paper forms or confirm the information the doctor has on file. The patient should be asked to verify ID and provide an insureance card. Some providers will receive a copy of the check in.
4 Check out Patient- When the patient is checked out, the medical report from that patient’s visit is sent to the medical coder, who will decode and translate the information into a report. This report, which also includes the patient’s demographic information and past medical history to create what’s called the “Superbill. The superbill has all of the imortant information about medical service hat was provided. This information will include the name of the provider, the name of the physician, the name of the patient, the procedures that were performed, the codes for the diagnosis and procedure, and other pertinent medical information. This information is vital in the creation of the claim.
5 Review coding compliance- Coding has sensitive and confidential information that medical coders have to process, it is vital that coders are compliant with state and federal regulations. Medical coders must follow the guidelines listed in the Internal Classification for Diseases, Clinical Modification (ICD-9-CM) for coding and reporting issued by the Center for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS). Compliance also needs to be reviewed under the HIPPA Act.
6 Check Billing Compliance- Many medical billing companies coordinate with the provider-clients and will establish the compliance responsibilities. The billing company will need to send a copy of compliance program to all of their provider clients. The company will also work together with their provider clients to help with training programs, audit plans and policies for investigating misconduct with billing. Because of different billing services, different policies are important for having effective medical billing compliance. Companies code the bills for their provider clients but other companies only process the bills that have been coded by the provider.

7 Prepare and Transmit Claims- Because of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all health and entities that are covered by HIPAA required to submit the claims electronically, except under some circumstances. Most providers, clearinghouses, and payers are covered by HIPAA. HIPAA does not require physicians to be there for all transactions electronically. Only those standard transactions listed under HIPAA guidelines must be completed electronically. Claims are a one standard transaction. In the case of high-volume third-party payers, like Medicare or Medicaid, billers can submit the claim directly to the payer. If the biller is not submitting a claim directly to these large payers, they will most likely go through a clearinghouse.
8 Monitor payer adjunction- When the claim gets to a payer, it goes through adjudication. With adjudication, a payer will evaluate the claim and decides if the claim is valid and compliant if the claim is valid the payer will need to know, how much of the claim the payer needs to reimburse the provider for. This is the stage where the claim is valid or not acceptable. Accepted claims does not mean that the payer will pay the whole bill.
9 Generate patient statements- Once the biller has got the report from the payer, the patient will sometimes receive a statement. The statement makes the bill for the patients visit and procedure. Once the payer pays the provider for a portion of the services on the claim, the remaining amount is passed to the patient also known as a co pay.
10 Follow up payments and collections- The last step of the billing cycle is ensuring the bills get paid. Billers are required to send out bills in a timely manner, and then following up with patients whose bills are past due. When the bill is paid it is confirmed in the patient’s file. If the patient is past due in their payment, or if they do not pay the full amount, it is the responsibility of the biller to make sure that the provider is properly reimbursed for their services.

Using the following tables, choose two steps from the medical billing cycle. Then, in 100 to 200 words, explain the consequences of missing these steps.

Step Missed in the Billing Cycle Consequences of Missing This Step
Pre-registration During pre-registration every action is entered into the patient's medical record and mistakes can happen. Entry errors create confusion, and tests that are not done correctly. Getting an insurance company authorization for treatment is a common area of costly mistakes... It’s important to check for mistakes because the clinic or hospital must accurately learn and understand all of the requirements of the patient's insurance company. And the insurance company must have full documentation that the treatment is medically necessary. This can cause problems with billers and can have dire consequences such as insurance fraud. Penalties and suites, wrongful billing can occur. If the insurance is not verified during pre-registration it can not only cost the provider, it can also cost the patient.

Step Missed in the Billing Cycle Consequences of Missing This Step
Billing Compliance Missing this step may causes violations of the Business Code or Compliance Plan. The Compliance Plan gives many methods available to the staff for reporting potential violations and/or to express concerns. It is the clinics duty to ensure we are protecting confidentiality of those staff members making known or sharing their concerns with the compliance department, where appropriate. The compliance department wants billing to report potential violations when it is believed a potential abuse of the system is occurring. This can be costly with penalties and removal from the job. Clinics can be sanctioned, and patients’ rights may be violated.