21. BACK AND FRONT OFFICE
Typical medical office has two main areas:
Back office
Front office
Back office
Also known as “clinical” area
Where all examinations, diagnostic testing, and
medical procedures conducted
22. BACK AND FRONT OFFICE
Back office (cont’d)
Typical personnel:
Health care professionals
e.g., doctors, nurses, physicians assistants, medical
assistants,
X-ray technicians
Even though primary focus is patient care, work
closely with those in front office
Sometimes sharing responsibilities
23. FRONT OFFICE
Front office
Also known as
administrative area
Hub of medical facility
Staff play key role in
proper management of
medical office
e.g., administrative
medical assistants,
medical transcriptionists,
medical insurance billers,
office managers
24. APPOINTMENT SCHEDULING PRINCIPLES
Front office staff usually have first contact with
patients when they request appointments
Partial patient information collected over phone
25. THE PROCESS
Patient registration
Registration information/form
Encounter form
Clinical assessment and treatment
Physician/Provider visit
Patient departure
Scheduling and billing
27. PATIENT REGISTRATION FORM
Demographic information
Insurance information
Authorization/Assignment of benefits
Electronic or paper format
28. PATIENT REGISTRATION
Electronic health (medical) record
New patient
Create patient database
Enter registration information
Scan insurance card
Established patient
Update database
29. ENCOUNTER FORM
Also called charge slip, routing form, or superbill
Type of visit
Lab tests and treatments
Diagnoses
Charges, payment, and balance due
Patient signature/authorization
30. CLINICAL ASSESSMENT AND TREATMENT
Physician/Provider
Examines patient
Orders lab tests and
treatments
Completes clinical sections
on encounter form
31. DEPARTURE PROCEDURES
Schedule another appointment
If necessary
Compute charges for services
Collect copayment
Post charges and payments
32. POSTING CHARGES AND PAYMENTS
Charges:
Encounter forms are “source documents”
Payments:
Checks, receipts, and insurance statements
are “source documents”
Charges and Payments posted to
patient account ledger and day sheet
33. POSTING CHARGES AND PAYMENTS
Electronic billing
Charges and payments entered into patient database
Billing Specialist
generates:
Statements
Receipts
Claim forms
Transaction journals b
34. DIAGNOSTIC AND PROCEDURE CODES
Remember Source Documents are
Encounter form
Medical record
Medical coder
Reviews encounter form and medical record
Assigns codes
Enters codes into database
35. INSURANCE CLAIM FORM
CMS-1500
Patient and insurance information
CMS-1500 blocks 1-13
Treatment and provider information
CMS-1500 blocks 14-33
Charges
CMS-1500 blocks 24F, 28, 29, and 30
36. INSURANCE CLAIM FORM
Billing specialist
Submits claim
Paper
Completes claim form using source documents
Electronic
Generates claim form using patient database
38. DENIED CLAIMS
Technical (data entry) errors
Missing or incorrect information
Transposed numbers
Incomplete codes
Coverage
Service not covered by health insurance
Patient not covered by policy at time of service
40. OTHER CLAIMS PROBLEMS
Delinquent or pending
Payment from insurance carrier overdue
Claim lost or misplaced
Billing specialist
Contacts insurance company
Phone, e-mail, or written inquiry
May resubmit claim
41. STATE INSURANCE COMMISSION
Responsibilities
Monitor financial strength of insurance companies
Protect interest of insured and policyholders
Maintain complaint records
Resolve insurance conflicts
42. STATE INSURANCE COMMISSION
Referrals
Pattern of problems with payment for services
Unresolved primary payer status conflicts
Provider or patient may submit complaint
Billing specialist may assist patient
Notas del editor
Welcome to Medical Receptionist and Insurance Billing Class.
I would like to begin by asking each of you “What do you see when you look at this picture?” Let some people answer…“You see everyone’s perception is different; the way you see something the first time can also be very different the next time you get to look at it…and this is why learning and meeting standards in the medical field is very important…everyone needs to be on the same page, looking at things the same way, and practicing to meet the same standards of care.”
Have you ever felt as if you were on a road to nowhere?Not knowing exactly what to do or where to go?
Lets take a moment to look at all of the different positions within a medical office.As you can see at the very top of the pyramid is the Physician and then the Nurse and then possibly the Therapist..these positions are considered the Clinical Staff of the office..these individuals provide the “hands on” with the patients.Now lets look at the positions called Support Staff…the office manager, Insurance billing Specialist, Medical coder, Medical secretary, Unit coordinator, receptionist, transcriptionist, medical record clerk, and file clerk…depending upon the size of the office or department or clinic or hospital you may find that you will be doing more than one position duties and then again there may be whole departments comprised of duties related just for medical record keeping.
When you look at this iceberg…two thirds of it is not even visible below the water, what stands out of the water is beautiful and gets most of the recognition …just like the pyramid before, doctors, nurses, and therapists standout the most in the publics eye; but below the surface and behind the scenes are the core components of people and duties that can make an office or department shine like this iceberg.
You will become a very important piece of the puzzle!But first..let’s talk about the necessary traits and qualities that you must possess and develop to the highest standard to be able to work in the medical field.
You must be detailed oriented!Why do you think…
You must be able to read, write, and speak…in different languages!When you learn a new language you must learn vocabulary…Medical vocabulary as it relates to disease processBusiness vocabulary as it relates to accounting and office management, telephone and office etiquetteComputer literacy as it relates to electronic medical health records, scheduling, mailings,Excel spreadsheets or power point presentations and typing speed and accuracy.
You must be honest and ethical…the rules and procedures regarding confidential information, the reason why malpractice and fraud occur; you need to keenly aware of
You need to be adaptable..because things are always changing.
You may have to put fires out
You will need to be aggressively patient with yourself…otherwise you will find that you will frustrated and discouraged.
You will need to learn how to not take things personally
And soon enough…you will find yourself doing things that you thought were impossible.
You will find people following your lead…because you are a leader.
Are you scared?
Or just terrified.
As we begin this process of learning you will find your way.
Because there is always a way…even if at first you can quite see it…you journey will take you over a bridge that was not visible and lead you on a path to your future.
Let’s talk about logistics..How is a medical office set up..
You may not know this, but the front and back office willingly need to work together as a team.
Lets start to discuss the front office…
“First contact” is the key to a successful office!
The work flow process..
Two of your projects are related to completing the Sims Claims forms that are provided with your book.
For every professionally licensed practice there are public agencies that oversee the process and procedures.