Physician-Based Claim: A Case Study

The information that should be obtained from the patient at the time of scheduling the appointment is the reason for the visit, name, DOB, phone number, and insurance information.

Other patient information you may find is documentation for any allergies the patient may have. Insurance information will be noted if the patient is covered were you will find the provider, the billing address, and the patient’s policy number. There will be many different forms in this system that are used to document things such as the patient’s family history, diagnostic results, immunization records, past and present medications taken and the effectiveness of them, and of course there will be doctors notes for any office visits and hospitalizations. In the doctors notes and hospitalization notes you will find documentation for medical conditions or diseases the patient may have had in the past or has presently. Last but certainly not least there will be the common release and authorization forms, there may be advanced directives or living wills on file if the patient has completed them and other relevant information that staff and medical facilities may need to provide quality care for the patient. (Whatis.com, 2008).

Step 1- Register Patients/ Check In - You can do this either when patient calls to set initial appointment and ask for their insurance information via phone to confirm prior to appointment. You can also at this time ask them to fill out paperwork prior if it is available via email or company web page. When patient comes in ask for insurance card for your records, along with any documentation that is needed. Example Referral or Prior Health Records.

Patient Check-In and Check-Out - If this is the patient's first visit, forms are required to be filled out, a copy of photo I.D. and verification of insurance card is accessed.

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

The very first stage of a patient's appointment should include the notation of the patient's demographic information as well as information about his/her insurance, such as the insurance payer and policy number. Any information that will be useful and/or necessary in a claim situation should be detailed at patient check-in.

First, I verify the patient was active under their insurance for the date of service. I do this by going on the insurance companies website or I can call to confirm eligibility. Then, I confirm the patient’s identification and group number is correct. I do this by reviewing the patient’s insurance card and what is entered onto the claim. Next, I

• Pre-Registration - When the Patient either comes into the office or calls over the phone for the inital appoitment. If they are new Patients you will need all their insurance information prior to appoitment to confirm they infact take that insurance, co-pays, and active insurance. You then will need to know what the patient is being seen for.

The second process happens when you arrive at the doctor’s office and check in with the receptionists. This process should involve you giving your ID and insurance card to that person. Twice a year you may be required to update this information to their office. The reason is because at the beginning the year patient’s insurance change and to double check later if that coverage is active. This step is crucial because medical coding is done with the type of insurance you have.

The Centers for Medicare & Medicaid Services (CMS) 1500 health insurance claim form replaces what was previously known as the Health Care Financing Administration (HCFA) 1500. The CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Medicare Parts A/B and Durable Medical Equipment Medicare Administrative Contractors (A/B MACs and DME MACs). This form is the official claim form used to report medical services to all government insurance plans and private insurance plans. CMS-1500 form has 33 spaces of information about the patient, insurance, services, and provider to be entered. Photocopies are not acceptable; you can only submit the original claim. Superbills cannot replace

· Confirm Financial Responsibility: When financial responsibility is confirmed the person will owe for that particular doctor’s visit. This is where a biller can determine which services are

This is usually done privately so that family members are unable to prompt the patient. Assessment of the patient’s behavior and interactions with staff in the office can also be helpful.

The administrative life cycle of a physician based claim consist of the preclinical interview and check in . In this section it is important to establish an appointment schedule by identifying the patient by get preliminary data name address phone number date of birth. You would also need to verify insurance information. By filling out the registration form it allows you to open up the patient medical account. All patients with insurance must sign an authorization release of medical information. A photo copy of the Id must be made, establishing a new patient chart and enter patient demographics into the practice s patient data base.

The very First step is to make an appointment (maybe by calling the facility or by walk in to the facility). Once the appointment is made, that means you have a date and time to come see the doctor,and the facility has some information about you like you name and insurance so the medical assistant can call and verify your coverage information.. when you come to the appointment, you receive some document that you have to fill out. Between these documents you have appointment sheet, that collects all information about you,your medical history and your insurance information. The practice also request for you to sign an acknowledgment form prior the delivery if care to help secure appropriate payment and for procedure and services.

The third step in the process is the healthcare provider examining the patient and recording the patient symptoms and treatment. This is recorded and the medical coder or billing