CHAA Examination
Preparation
Encounter - Session II
Pages 81-95
University of Mississippi Medical Center
What to Expect…
• This module covers various aspects of
Patient Access knowledge found in pages 8195 of the ENCOUNTER section of the 2010
CHAA Study Guide.
• A quiz at the end will measure your
understanding of the content covered.
Medicare
• Medicare is the nation’s largest health
insurance program which covers nearly 40
million Americans.
• This is health insurance for:
– People age 65 or older
– Certain disabled persons under age 65
– Patients with End-Stage Renal Disease
(permanent kidney failure treated with dialysis
or a transplant)
Medicare Part A, B, and D
• PART A:
– typically pays for INPATIENT HOSPITAL expenses
• PART B:
- typically covers OUTPATIENT HEALTH CARE
EXPENSES including doctor’s fees
• PART D:
– any beneficiary with Part A/B can obtain
PRESCRIPTION drug coverage
Medicare Eligibility
Requirements
Generally, patients are eligible for Medicare if:
• The patient or their spouse worked for at
least 10 years in Medicare-covered
employment
• They are 65 years or older
• They are a citizen or permanent resident of
the United States
Admitting Medicare Patients
• ALL MEDICARE PATIENTS are required to
complete a MEDICARE SECONDARY PAYER
(MSP) QUESTIONNAIRE.
• The MSP Questionnaire determines if
Medicare is the primary payer for the
medical services or if another third-party
payer is primary.
Coordination of Benefits
• The private insurance industry uses the term
COORDINATION OF BENEFITS to determine
the order for primary and secondary
payment.
• The MSP Questionnaire should be completed
based on the information provided by the
patient or their representative for each
claim.
Medicare Secondary Payer
Questionnaire
The MSPQ is designed to draw out:
• If the illness/injury is work related
• If the patient is covered by a Large Group Health
Plan
• If they’re covered by their spouse’s insurance
• If they qualify due to disability
• If they qualify due to ESRD
• If they are eligible due to Federal Black Lung,
Veteran’s Administration, or a Government
Research Grant
MSPQ - Coordination of Benefits
Medicare Hospice Insurance
• Beneficiaries entitled to hospital insurance
(Part A) who have a terminal illness and a
life expectancy of six months or less have
the option of receiving HOSPICE INSTEAD OF
STANDARD INPATIENT TREATMENT.
Medicare Advantage Plans
• This is also known as Part C, MA Plans, or Medicare
HMO.
• They are approved by Medicare but are operated by
PRIVATE COMPANIES.
• This coverage REPLACES traditional Medicare and is
NOT SUPPLEMENTAL INSURANCE.
• Most MA Plans are similar to HMOs/PPOs in that
they have networks of doctors and hospitals. The
one exception is Private Fee For Service Plans.
Unique Medicare Advantage
Plans
• PRIVATE FEE FOR SERVICE PLANS - This MA
Plan allows the patient to go to any doctor
who agrees to accept the plan’s terms of
payment before treatment.
• MEDICARE SPECIAL NEEDS PLANS – serves
certain people with Medicare who are
chronically ill, live in institutions like nursing
homes, or who have special needs.
Medicaid
• Medicaid is available to CERTAIN LOW INCOME
individuals and families who fit into an
eligibility group recognized by STATE and LAW.
• Patients may or may not have to pay a small copayment for some medical services.
• Medicaid is a state administered program and
EACH STATE sets its own GUIDELINES regarding
eligibility and services.
Medicaid Requirements
Medicaid Requirements MAY INCLUDE:
• Patient’s age
• Medical condition (pregnant, disabled, blind,
or aged)
• Income and resources (bank accounts, real
property, assets, etc.)
• Patient’s status as a U.S. Citizen or lawfully
admitted immigrant
Medicare Eligibility
Requirements
• Medicare eligibility is TRICKY because it varies from
state to state.
• Except in emergency services for certain persons,
Medicaid does not provide health care services,
even for very poor persons, unless they meet
specific eligibility requirements.
• Low income is ONLY ONE TEST for Medicaid
eligibility; assets and resources are tested against
established thresholds.
Medicaid Coverage Beginning and
Ending
• Coverage may start RETROACTIVE to any or
all of the THREE MONTHS PRIOR to
application if the individual would have been
eligible during that period.
• Coverage stops at the END OF THE MONTH in
which a person’s circumstances change.
Managed Care
• Managed care is defined as any system that manages
healthcare delivery WITH THE AIM OF CONTROLLING
COSTS.
• HMOs/PPOs are examples of Managed Care plans.
• They typically rely on a PRIMARY CARE PHYSICIAN to
serve as a gatekeeper to health services.
• Managed Care REIMBURSEMENT is tied to “utilization
management” where services are only paid for if the
managed care organization deems the services as
MEDICALLY NECESSARY.
Physician Orders
• A PHYSICIAN ORDER is a written document
that includes:
–
–
–
–
Patient Name
Procedure
Diagnosis
Ordering Physician’s name and signature
• An ICD-9 and/or CPT code may be required
as well
Medicare Medical Necessity
• The Centers for Medicare and Medicaid Services (CMS)
is required by the Social Security Act to reimburse
payment ONLY for services that are REASONABLE and
NECESSARY.
• There must be EVIDENCE of MEDIAL NECESSITY before
Medicare will pay.
• Procedures are medically justified for specific
diagnosis as established by a LOCAL MEDICAL REVIEW
POLICY (LMRP).
– Many facilities are installing software to check medical
necessity versus checking manually.
Advanced Beneficiary Notice
(ABN)
• The ABN is a WRITTEN NOTICE given to beneficiaries
informing them that Medicare IS NOT LIKELY to
provide coverage for certain procedures and that
they may be liable for payment.
• The ABN must be VERBALLY REVIEWED and must be
delivered far enough in advance for patients to
consider other options.
ABNs ARE NEVER REQUIRED IN EMERGENCY OR URGENT
SITUATIONS!!!!!!!!!!!!!!
Advanced Beneficiary Notice
(ABN)
• Patients can NOT BE BILLED for uncovered
services if the ABN is NOT SIGNED.
• The ABN must be SPECIFIC to the SERVICES
being provided and the COST of services not
covered.
Medical Terminology
• Patient Access Employees need to understand
and accurately spell medical terms.
• They should also understand the
CLASSIFICATION SYSTEMS used to translate
diagnosis and procedural information into
alphanumeric codes used to process insurance
claims. The Classification Systems are:
» ICD-9-CM
» HCPCS
Medical Terminology
• International Classification of Diseases, Ninth
Revision (ICD-9-CM) – this includes classification
systems for diseases, injuries, and procedures.
• Healthcare Common Procedure Coding
Systems (HCPCS) – this is used to classify items
and services provided in the delivery of
healthcare.
– Level I – codes dealing with physician services.
– Level 2 - codes dealing with non-physician services.
Wayfinding
Effective Wayfinding alleviates anxiety among
patients and reduces strain on staff who are
less likely to have to provide directions.
Wayfinding refers to:
– Directions and alternate means of transportation
to the facility
– Location of parking and patient drop-off point in
relation to the location of the service area
– Campus maps
– Visual cues such as color coding and repetitive
designs
Wayfinding
• Digital signage is becoming more popular as
the use of electronic kiosks and flat panel
screens that display information are
increasing.
• Access Management is crucial to the
improvement of wayfinding efforts by
providing feedback from patients and visitors
regarding current wayfinding tools.
Patient Tracking
• Because patient safety is compromised when
there is high occupancy and overcrowding, the
Joint Commission includes the management of
patient tracking and patient flow as part of
their accreditation requirements.
• Documenting the arrival and departure times
allows caregivers to know where a patient is
at any point of service during the encounter.
Patient Tracking
• The Joint Commission requires hospitals to
have a patient flow committee, gather
patient tracking data, and use that data to
make changes.
• Radio Frequency Identification (RFID)
technology assists patient tracking by
transmitting the identity and location of any
object or person wirelessly using radio
waves.
Census Management
• Census Management has become more important
due to the fact that hospitals are increasingly
required to do more with fewer resources.
• Manually generating a paper nightly census no
longer meets the needs of most hospitals.
• Electronic census management systems allows
information to interface with other clinical or
housekeeping systems which facilitates
communication.
Customer Information
• Maintaining patient confidentiality is one of
the most important duties of any health care
organization.
• There are certain instances when limited
information may be relayed to others
without the patient’s EXPRESS permission.
Medical Record Release
• Protected Health Information (PHI) – is any
information that may be used to identify the
patient.
• Before releasing any information, there should be
specific evidence that the requestor has a
legitimate right to the information on a “need to
know” basis.
• Patients have a right to know who has accessed
their PHI.
Medical Record Release
• Except for limited circumstances, the patient
should provide written consent for the release of
any PHI.
• Protecting PHI is one of the main goals of HIPAA.
• The Provider OWNS the medical records but patients
have the right to INSPECT, OBTAIN A COPY OF, and
RESTRICT RELEASE of their medical records at
anytime.
Opting out of the Facility
Directory
• Patients can restrict access of their
Protected Health Information when being
treated at a facility by “opting out” of their
directory.
• When they do so, a confidentiality flag is
placed by the patient’s name in the MPI,
alerting staff that no information is to be
disclosed to callers, visitors, florists, or
clergy.
Opting out of the Facility
Directory
• Patient Access Employees are REQUIRED to ask if
the patient wishes to “opt out” of the directory.
• They SHOULD EDUCATE THE PATIENT on the
implications of their choice.
• Incarcerated and Psychiatric patients are usually
deemed confidential automatically and facilities
restrict all information except those required by
law.