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- 3. Physician’s Office Or Emergency Room Physician writes an order To admit patient To observe patient For tests, procedures, lab, radiology, etc For surgery SDS Inpatient surgery
- 4. Scheduling Referrals Authorizations Pre-cert or pre-auth must be obtained from insurance prior to treatment Pre-cert or pre-auth number must be included on claim Notifications Some insurances do not require authorization. Some insurance request to be notified.
- 5. Pre-Registration Verify Insurance Coverage Verify Authorization Verify Patient Demographics Determine Patient Responsibility Co-pays, deductibles Co-insurance Obtain Patient Responsibility up front Collect deposits
- 6. Financial Counseling Meet with patients to review their financial obligations Scheduling / Pre-registration process Registration Prior to discharge – inpatients During discharge process – in and out patients Once they are out the door the chances of collecting diminish dramatically
- 7. Registration’s Turn Verify any missing data Verify Identity Scan Insurance Cards and documentation Obtain co-pays & patient responsibility $$$ Patient Signs required documents Permission to treat, guaranty of payment, assignment of benefits Other consent forms
- 8. And More …… Advance Directives Notice of Financial Responsibility MSP Questionnaire Rights as a Medicare patient ABNs HIPAA – Privacy Notice Red Flag Regulations Etc.
- 9. Bed Management Bed Accommodation Private Semiprivate Verified at Midnight Charged at Midnight Patients holding in ED for a bed
- 10. Case Management See every observation or inpatient Case management monitors inpatient and observation patients’ care to ensure admission meets admission criteria Interqual Milliman Care Standards - used by insurances Works with physicians to discharge the patient in the appropriate amount of time or ensure patient still meets inpatient criteria. Monitors and works on delays to recovery. Review patients status: Medicare and Medicaid – every 3 days All others - daily
- 11. Discharge Planning Performed by case management. Begins when patient is admitted. Goal is to only keep patient in house as long as is medically necessary to provide excellent quality of care while maximizing reimbursement. Discharge to appropriate community resource May arrange transfer to SNF, Home Health, contact family, etc. Work with physician and family Consider what insurance will pay for
- 12. Charges are Entered Charges are maintained in the charge master (CDM) A unique charge code identifies each service and test performed or supply provided Many charges have CPT-4 or HCPCS codes attached, required for billing Charges connect to Revenue Codes, required for billing Charges are billed on UB04 and HCFA 1500 claim forms
- 13. Services are Documented Documentation must exist in the Medical Record to support all procedures performed and supplies used. Physician and Clinical staff signatures are critical Verbal orders must be signed Documentation must be complete and legible
- 14. Electronic Medical Record Automate as much of the medical record as possible. Eliminates filing issues Allows for instantaneous access to medical record Reduces storage space Much of our medical record is electronic
- 15. Patient is Discharged Financial Counseling Outstanding balances, co-pays, co-insurance, deductibles, bad debt, non-covered services Discharge Planning Discharge disposition – can affect reimbursement Another facility SNF Home Home health
- 16. Medical Records – “HIM” Manages the medical record Scans and files loose documentation Verifies electronic records Ensure physician, nurses and clinical staff have signed where necessary Monitors, reports and obtains chart deficiencies Coding and abstracting DNFB management
- 17. Medical Records Coding Medical records chart reviewed by certified coder Physician, nursing and ancillary documentation is critical ICD- 9 codes: diagnoses, procedures CPT-4 codes: procedures performed Greatly impacts reimbursement Heavily regulated
- 18. Insurance Processes Claim Pays claim Denies claim Immediately After processing Line item denials Pends claim Doesn’t notify hospital Timely filing
- 19. Contact Us Futuristic Gigatech 46/4, Novel Tech Park, Garvebhavi Palya , Kudlu Gate, Hosur Main Road, Bangalore, Karnataka – 56 00 68. E-mail : info@futuristicgigatech.com India Office: 0091 80 4093 4093 India Mobile: 0091 903 500 4530
- 20. QUESTIONS ???