What are Patient encounters?

An interaction between a health care provider and a patient can be described as a patient encounter. The length, time, and detail of a patient encounter depend on the local procedure. The most common patient encounters are inpatient stay, telephone consultation, outpatient visit, and general practitioner visit.

Steps to be taken before and during patient encounters

Initially, the health care provider must set a fee or a fee schedule for patients. This fee must be set based on the local patient population. A manual that states the work routine and procedure of the health care provider must also be set to have smoother encounters. A proper process can be set by the health care provider for making appointments. This enables a smoother flow of patients in the clinic. Insurance information can be collected while an appointment is being scheduled. The possible out-of-pocket costs in the absence of a health plan can also be discussed before the appointment. The health care providers can use medical portals or software for verifying insurance information before the appointment.

CC BY 2.0 ǀ Image Credits: https://commons.wikimedia.org | Michael Havens

During the encounter, a set of information must be collected directly from the patient. This can be done through a patient registration form or encounter form. Information such as patient demography and health plan is collected. This collected information can be used in billing later on in the process. This billing information is also extremely crucial for the patient while submitting claims.

Billing information

Billing for the patient begins when they schedule an appointment. To begin the collection of billing information, information regarding patient registration and schedule is used. Accurate clinical information collected during the patient encounter is also crucial for medical billing. Information cannot legally be used for billing if it is not properly documented during the encounter. Health care providers will be committing fraud if they charge the payer for services that are not documented. Additionally, in case of conflicts, the clinical documentation must be used to justify the reimbursement to a patient or a payer.

CC BY-SA 4.0 ǀ Image Credits: https://commons.wikimedia.org/ | Yasmine.shal

When a patient gets checked in, staff from financial services ensures to collect patient information. This information covers the home address of the patient and their current insurance coverage. These staffs are also responsible for verifying the patient’s financial responsibility.

Medical billers and financial staff must also verify continuously if the services offered to the patient are covered by their insurance or not. The authorization for the same must be submitted as the services take place. When a patient is about to check out, the medical billers use patient information to prepare the superbill. Superbill is used by health care providers to create insurance claims. The superbill contains provider’s name, provider’s location, provider’s signature, the national provider identifier, list of attending physicians, patient’s name, patient’s date of birth, patient’s insurance information, the first symptom of patient, date of services, time, and authorized information. In some cases, the provider adds comments and notes to the superbill to justify certain medical care. Once the patient checks out from the hospital/clinic, the healthcare provider generally submits the superbill for claims on behalf of the patient. Once the insurance company processes the claim and pays for the portion of the bill, the remaining must be paid by the patient or the payer. Certain health care plans have a network of hospitals and doctors that will only get insurance coverage. In case the patient gets medical care out-of-network, the patient will be responsible for the payment as the bill is not covered by insurance.

Billing is extremely important as it affects the revenue cycle of the health care industry. Billing information also impacts the reimbursement to the payer for the health care services obtained. Therefore, it is necessary for the service providers to fully understand the fundamentals of billing to have a smoother revenue cycle while providing proper reimbursement to patients.

Challenges faced during the billing

  • While technology has advanced, certain procedures such as payment claims are still manual in several countries. According to the Council of Affordable Quality Healthcare (CAQH), if all payment claims are made electronically, 9.5 billion dollars could be saved every year.
  • Certain health care and health plan providers neglect to inform payers of their financial responsibility which results in inefficient billing. Over one-third of providers do not inform patients about financial responsibility resulting in higher costs and burdens for patients.
  • There is very little transparency when it comes to price quotations. The patients and payers fear the price that comes with medical assistance especially in the case of emergencies. The U.S. government has been pushing transparency policies to make the payment process smoother for patients.

Key terms

According to chapter 3 of the Medicare claims processing manual, the following are the key terms and their meaning under the concept of patient encounter and billing information,

  • Insured: The individual obtaining health insurance is called the insured. The insured is also referred to as a policyholder or subscriber. Insured when faced with medical expenses does not have to bear the whole cost as insurance providers will cover it partly or fully.
  • Self-pay: Self-pay refers to when the patient does not have or does not use insurance and bears the entire medical expense by themselves. Such uninsured patients need to have greater financial responsibility and funds readily available for emergencies.
  • Co-pay: Co-pay refers to when the insured individuals bear a part of the payment while the rest is covered by the insurance provider. The bill amount covered by the insured individual can be pre-determined, i.e., a fixed percentage of the bill or a fixed amount.
  • Referral number: The number provided by the insurer when the primary care provider refers the patient to another doctor or specialist. Without proper referral details, the insurer may not cover the medical expenses incurred.
  • Non-PAR provider: If the health care provider is nonparticipating or is out-of-network, the provider is considered a non-PAR provider. If a non-PAR provider is visited by the insured, a higher co-pay may be involved.
  • Authorization number: The certification number provided to the patient during admission or procedure. The authorization number indicates that the insured authorizes payment for services before receiving them.
  • Encounter form: The encounter form is a document that is used to collect information on diagnosis along with procedure codes. Encounter form is later used for billing information.

Context and Applications

The aspiring students can pursue further specialization in this field into the following streams:

  • Masters in Business Administration (Insurance Management)
  • Bachelors in Insurance and Risk Management
  • Masters in Business Administration (Finance)

Practice Problems

Question 1: Which document is prepared by the provider upon collecting and authorizing all the information?

    1. Medicare bill
    2. Superbill
    3. Insurance bill
    4. Encounter form

Answer: Option b

Explanation: The superbill is the final document prepared by the provider containing all the patient and provider information. It is later used for the payment of claims.

Question 2: When is the billing information collected by the provider from the patient?

    1. While scheduling appointment
    2. During patient encounter
    3. After patient encounter
    4. All of the above

Answer: Option d

Explanation: Billing information collection begins while the patient makes an appointment. Registration forms may be given to the patient before and during the encounter to collect more information. After the encounter, information on the procedure and services is collected. Therefore, the answer is all of the above.

Question 3: What is the term used if a patient makes the entire payment for medical services obtained by themselves without a health plan?

    1. Self-pay
    2. Co-pay
    3. Patient billing
    4. None of the above

Answer: Option a

Explanation: As the name indicates, the patient pays by themselves. This generally occurs if the payer does not have a health plan or if the service is obtained out-of-network.

Question 4: Which of the following is a patient encounter?

    1. Face-to-face consultation
    2. Telephone consultation
    3. Inpatient stay
    4. All of the above

Answer: Option d

Explanation: Patient encounters refer to an interaction between a patient and a health care provider. This interaction could be in any form including but not limited to telephone consultation, face-to-face consultation, and inpatient stay.

Question 5: Which of the following numbers is provided by the insurer when a primary care provider refers the patient to a specialist?

    1. Specialist number
    2. Referral number
    3. Authorization number
    4. Insurance number

Answer: Option b

Explanation: As the name indicates, a referral number is provided when the patient is referred to another doctor. Generally, a referral is given if the patient needs medical assistance from a specialist.

Common mistakes

It is incorrect to assume that medical billing alone is crucial in managing the revenue cycle of the health care industry. Medical coding also plays an important role in the revenue cycle. Medical coding refers to converting medical reports produced by a person involved in medical practice into medical codes. These converted codes make billing easier. It is also easier for insurers to read medical information. Therefore, medical coding procedure is just as important as medical billing.

While studying the patient encounters and billing information, it is important to read the following topics to get a better knowledge:

  • Medical coding
  • Health care plans
  • Life Insurance policy

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