Case Study: Zero Charge Fee

For established patients receiving evaluation and management, providers may bill for these services using the CPT codes 99212, 99214. Choosing the correct code depends on the patient’s history, examination findings, and decision-making complexity. If complexity is found to be straightforward taking the provider less than 10 minutes, the billing code will be 99212 (Engle, 2014). If the history and examination findings result in moderate decision-making complexity, requiring more time from the practitioner and more diagnostic procedures the billing code will be 99214 (Engle, 2014). While, Ms. Trinidad does not encounter established patients in the emergency department, within my clinical hours, Ms. Rossow encountered several established patients of various levels of complexity. The billing code 99212 is appropriate to use for patients with low complexity, such as one of Ms. Rossow’s patients whose visit was due to elbow pain after a fall a week ago. Mrs. Rossow also managed the care of patients with a higher level of complexity such as a middle-aged male with a history of recent prostate cancer and a chief complaint of abdominal pain and fever.

If the patient's presenting problem required hospitalization, the patient would receive a minimum of two separate bills, one from their physician for medical consultation during the hospital stay and one from the hospital for the use of hospital services. If the presenting problem required additional diagnostic procedures or multiple therapeutic interventions, the patient would receive a bill from each consulting physician as well as charges for all ancillary services used, such as pathology laboratory, radiology, etc. Each time the patient sees a different physician or other provider, he or she has to re-tell the story of the presenting problem. From the provider standpoint, he or she has to follow-up on each additional

The policy states that if a patient has a copay or any other payment that needs to be made then he/she should do so at the time of their visit. This is usually done at the end of the visit encase the doctor orders any tests or lab work that might cost the patient more money. Patient’s should be informed of all or any charges and given an estimated cost.

It is believed that NPs can overcome challenges with billing and coding, as well as Medicaid and Medicare, third party payers, commercial managed care companies’ reimbursements through appropriate coaching and remaining up to date on regulations. As mentioned earlier, implementing compliant electronic systems, staying well-informed of billing regulations, evaluating weekly reports, and consulting with compliance experts can aid in accurate reimbursement for NPs in primary care.

Legally and ethically under Informed consent a patient has the right to refuse specialty treatment or referral but needs to be informed about the risks involved with delay or lack of the specific treatment recommended. Mostly, if the patient does agree to visit the specialist then, the specialist is responsible for the informed consent for the specific treatment. But is has been contested and help in courts that the primary care physician still is responsible for the patients welfare in all phases of treatment. For a provider in a busy practice it is difficult to keep track of all the referrals and at times, the specialist’s office has a different outlook on the matter.

will have a higher premium. These patients must pay the adjustment plus the standard premium

13). The clinical services department within the hospital is responsible for the accurate charting of any procedure or service that was provided to the patient. This process begins with patient registration and verification. The healthcare provider then will perform their job as necessary and will indicate what billable tasks were performed which can later be processed. The patient accounts department is responsible for going through the patient’s chart and recording the patient’s bill by use of the hospital’s chargemaster to send the bill to the payer by the health information department. In this department the initial coding of the patient’s medical record is done. Once overviewed for the sake of accuracy, the final coding is done and sent to the payer. Any inaccuracies by any of these departments could directly impact the hospitals reimbursement process through a slowing for the process or simply by failing to bill for a procedure performed, ultimately hurting the hospital’s financial stability. The patient financial services (PFS) department is responsible for ensuring compliance within the billing and coding policies through training and with quality assurance checks and regular audits. This ensures that the revenue and reimbursement cycle continues without any inaccuracies in patient charges. It is especially important to have quality management within this department, as it has the potential to affect the entire organization, reflective of the institutes financial situation. Poor PFS management can lead to a loss in revenue and can lead to a loss in budget if the hospital is losing too much as a result. Ensuring compliance with medical coding and billing guidelines and policies ensures a more accurate representation of the hospitals financial and budgetary situations, while

Based upon service rates above, it is more cost effective for the physicians to see the patients.

review the SFL audit report and here is the numbers of patient accounts that we can't bill out to the SFL program b/c the patient don't qualify or never complete the SFL application. Please review my founding and let me know How do you want me handle all this claims. My suggestion is if the patient is active with Title X we can adjusted off under the Title X program and just bill the patient for the Title X copay fee and the lab fee if the patient is scale level is B,C,D,E & F. I will be waiting for the final decision that you and Sara will like to make.

I agree with the statement that the patient could be wrongly charged. The insurance company is also likely to deny

Criteria: setting evaluation, contact was it direct or indirect, is patient a child or infant, service provided, is the patient established/new. Service level consist of three components, which is the history, exam, and decision made at the time of visit. Patient that has seen the doctor for three year is established. One that has not seen the doctor is new. There are four levels of making a decision. HPI factors relate to the issue the patients is dealing with. ROS factors relates to the sign of illness. PFSH factors deals with the history of the patient and history of the

The key elements to a healthy and successful medical practice are a reliable and properly trained staff and a sound revenue cycle that produces satisfactory reimbursement. Revenue cycle management starts at the front-end with pre-registration of the patient. Complete and accurate recording of patient insurance and billing information is imperative. Insurance verification plays a major role in the assurance of reimbursement. The front desk should counsel and confirm financial responsibility with the patient during the registration process. Patient encounter is equally as important. Correct coding of patient diagnosis and procedures minimizes the likelihood of claim rejection. The next step in the revenue cycle is claim submission. The claims process begins with the provider treating the patient then sending a bill to the designated payer. Before the bill is sent, a certified coding specialist or medical billing specialist prepares and reviews the claim for any inaccuracies. There are a few ways the claim is submitted, either manually or electronically. Once the claim is submitted, follow-up with third party payers is a necessary step in the

A lot of complaints were received regarding the EC billings, especially yellow patients. It was suggested that billing structure be reviewed and that patients are billed according to their exit billing code and not to triage colour. YH suggested that examples of accounts must be presented to AN. Cost around nursing input needs to be determined.

→→ Most patients do, they are usually never admitted for only one thing. However, you check 0 if they only have one medical diagnosis and 15 for more

The cycle time is the time from the initial visit to Follow-up.  Medical licensing barriers: The limited access of physicians to practice in a particular state can be relieved with Team Edition. Any Specialist form any area can login and check for the patient’s NEGATIVES  PCP Reference to a particular specialist may not be available there by choosing different specialist who PCP may not have worked or dealt with  The Revenue for local Specialist may reduce due to breach in medical licensing barriers.