1. Introduction
(25%) Deliver a short-lived synopsis of the meaning (not a description)
of each Chapter and articles you read, in your own words.
2. Your Critique
(50%)
What is your reaction
to the content of the articles?
What did you learn
about Medical Coding and the Purpose of ICD-9-CM?
What did you learn
about PPO, HMO and POS Health Plans?
Did these Chapter and
articles change your thoughts about Third-Party Payers? If so, how? If not,
what remained the same?
3. Conclusion
(15%)
Briefly summarize
your thoughts & conclusion to your critique of the articles and Chapter you
read. How did these articles and
Chapters impact your thoughts on the purpose of an electronic encounter form in
an EHR.
Evaluation will be based on how clearly you respond to the
above, in particular:
a) The clarity with which you critique the articles;
b) The depth, scope, and organization of your paper; and,
c) Your conclusions, including a description of the impact
of these articles and Chapters on any Health Care Setting.
http://www.library.armstrong.edu/eres/docs/eres/MHSA8630-1_CROSBY/863001croThird.pdf
chapter08.ppt
chapter07.ppt
Unformatted Attachment Preview
CHAPTER
8
Third-Party Payers
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-2
Learning Outcomes
When you finish this chapter, you will be able to:
8.1
8.2
8.3
8.4
8.5
Compare the major features of PPO, HMO, and
POS health plans.
Identify the two parts of CDHPs.
Discuss the organization and regulation of employersponsored group health plans and self-insured
plans.
Explain the purpose of Medicare Parts A, B, C, and
D.
Describe the fee structures that are used to set
charges.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-3
Learning Outcomes (Continued)
When you finish this chapter, you will be able to:
8.6
Identify the three methods most payers use to pay
physicians.
8.7
Maintain insurance carrier information in the
PM/EHR.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-4
Key Terms
• allowed charge
• balance billing
• Blue Cross and Blue
Shield Association
(BCBS)
• capitation (cap) rate
• Civilian Health and
Medical Program of the
Department of Veterans
Affairs (CHAMPVA)
• consumer-driven
(directed) health plan
(CDHP)
McGraw-Hill
• disability compensation
programs
• discounted fee-forservice
• dual-eligible
• Employment Retirement
Income Security Act of
1974 (ERISA)
• Federal Employees
Health Benefits (FEHB)
• fee schedule
• flexible savings account
(FSA)
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-5
Key Terms (Continued)
• group health plan (GHP)
• health maintenance
organization (HMO)
• health reimbursement
account (HRA)
• health savings account
(HSA)
• high-deductible health
plan (HDHP)
• individual health plan
(IHP)
• Medicaid
McGraw-Hill
• Medicare
• Medicare Part A,
Hospital Insurance (HI)
• Medicare Part B,
Supplementary Medical
Insurance (SMI)
• Medicare Part C,
Medicare Advantage
• Medicare Part D
• Medicare Physician Fee
Schedule (MPFS)
• Medigap
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-6
Key Terms (Continued)
• Medi-Medi beneficiary
• Original Medicare Plan
• point-of-service (POS)
plan
• preferred provider
organization (PPO)
• primary care physician
(PCP)
• relative value scale
(RVS)
• resource-based relative
value scale (RBRVS)
McGraw-Hill
•
•
•
•
self-insured health plans
third-party payer
TRICARE
usual, customary, and
reasonable (UCR)
• usual fees
• workers’ compensation
insurance
• write off
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.1 Types of Health Plans
8-7
• Third-party payer—private or government
organization that insures or pays for health care
on behalf of beneficiaries
• Preferred provider organization (PPO)—
managed care network of health care providers
who agree to perform services for plan members
at discounted rates
– The policyholder pays an annual premium and a
yearly deductible.
– A PPO may offer either a low deductible with a higher
premium or a high deductible with a lower premium.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.1 Types of Health Plans (Continued)
8-8
• PPO features (continued):
– Members typically pay a copayment at the time of
service, and coinsurance may also be charged.
– Patients may see out-of-network doctors without a
referral or preauthorization; the amount they have to
pay will be higher.
• Health maintenance organization (HMO)—
managed care system in which providers offer
health care to members for fixed periodic
payments
– This type of health plan has the most stringent
guidelines and the narrowest choice of providers.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.1 Types of Health Plans (Continued)
8-9
• HMO features (continued):
– A Primary care physician (PCP) is a physician in a
managed care organization who directs all aspects of
a patient’s care; members are assigned to a PCP.
– Members must use their HMO’s network except in
emergencies or pay a penalty.
– HMOs are organized around one of three business
models: the staff model, the group or network model,
and the independent practice association model.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.1 Types of Health Plans (Continued)
8-10
• Point-of-service (POS) plan—managed care
plan that permits patients to receive medial
services from nonnetwork providers
– A POS plan is a hybrid of HMO and PPO networks.
– Members may choose from a primary or secondary
network.
– This kind of plan charges annual premiums and
copayments for office visits.
• Indemnity or fee-for-service plans require
premium, deductible, and coinsurance
payments.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.2 Consumer-Driven Health Plans
8-11
• Consumer-driven (directed) health plan
(CDHP)—medical insurance that combines a
high-deductible health plan with one or more
tax-preferred savings accounts that the patient
directs
• High-deductible health plan (HDHP)—health
plan that combines high deductible insurance
and a funding option to pay for patients’ out-ofpocket expenses up to the deductible
– First part of a CDHP
– Annual deductible over $1,000
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.2 Consumer-Driven Health Plans
(Continued)
8-12
• The second part of a CDHP involves one of
three types of funding options:
– Health reimbursement account (HRA)—CDHP
funding option where an employer sets aside an
annual amount for health care costs
– Health savings account (HSA)—CDHP funding
option under which funds are set aside to pay for
certain health care costs
– Flexible savings account (FSA)—CDHP funding
option that has employer and employee contributions
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.3 Private Insurance Payers and Blue
Cross and Blue Shield
8-13
• Group health plan (GHP)—plan of an employer
or employee organization to provide health care
to employees, former employees, and/or their
families
– Human resource departments manage the health
care benefits.
– Riders, or options, are often offered for vision and
dental services.
– During open enrollment periods, employees choose
the plans they prefer for the coming benefit period.
– This kind of health plan must follow federal and state
laws.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.3 Private Insurance Payers and Blue
Cross and Blue Shield (Continued)
8-14
• Federal Employees Health Benefits (FEHB)—
health care program that covers federal
employees
• Self-insured health plans—health insurance
plans paid for directly by the organization, which
sets up a fund from which to pay
– These do not pay premiums to insurance carriers or
managed care organizations.
– These set up their own provider networks or lease the
use of managed care organizations’ networks.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.3 Private Insurance Payers and Blue
Cross and Blue Shield (Continued)
8-15
• Employee Retirement Income Security Act of
1974 (ERISA)—law providing incentives and
protection for companies with employee health
and pension plans
– The law regulates self-insured health plans.
• Individual health plan (IHP)—medical
insurance plan purchased by an individual
• Blue Cross and Blue Shield Association
(BCBS)—licensing agency of Blue Cross and
Blue Shield plans
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans
8-16
• Medicare—federal health insurance program for
people sixty-five or older and some people with
disabilities
• Medicare Part A, Hospital Insurance (HI)—
program that pays for hospitalization, care in a
skilled nursing facility, home health care, and
hospice care
• Medicare Part B, Supplementary Medical
Insurance (SMI)—program that pays for
physician services, outpatient hospital services,
durable medical equipment, and other services
and supplies
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)
8-17
• Original Medicare Plan—Medicare fee-forservice plan
• Medigap—plan offered by a private insurance
carrier to supplement Medicare coverage
• Medicare Part C, Medicare Advantage—
managed care health plan under the Medicare
program
• Medicare Part D—Medicare prescription drug
reimbursement plans
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)
8-18
• Medicaid—federal and state assistance
program that pays for health care services for
people who cannot afford them
• Medi-Medi beneficiaries—people eligible for
both Medicare and Medicaid
• Dual-eligible—Medicare-Medicaid beneficiary
• TRICARE—government health program serving
dependents of active-duty service members,
military retirees and their families, some former
spouses, and survivors of deceased military
members
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)
8-19
• Civilian Health and Medical Program of the
Department of Veterans Affairs
(CHAMPVA)—health care plan for families of
veterans with 100 percent service-related
disabilities and the surviving spouses and
children of veterans who die from service-related
disabilities
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)
8-20
• Workers’ compensation insurance—state or
federal plan that covers medical care and other
benefits for employees who suffer accidental
injury or become ill as a result of employment
• Disability compensation programs—programs
that provide partial reimbursement for lost
income when a disability prevents an individual
from working
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.5 Setting Fees
8-21
• Fee schedule—document that specifies the
amount the provider bills for services
• Usual fees—normal fees charged by a provider
• Most payers use one of three methods to set the
fees that their plan will pay physicians:
– Usual, customary, and reasonable (UCR)—fees set
by comparing usual fees, customary fees, and
reasonable fees
– Relative value scale (RVS)—system of assigning
unit values to medical services based on their
required skill and time
– Resource-based relative value scale (RBRVS)—
relative value scale for establishing Medicare charges
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-22
8.5 Setting Fees (Continued)
• Medicare Physician Fee Schedule (MPFS)—
RBRVS-based allowed fees that are the basis
for Medicare reimbursements
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.6 Third-Party Payment Methods
8-23
• Payers use one of three main methods of paying
providers:
– Allowed charges
– Contracted fee schedules
– Capitation
• Allowed charge—maximum charge a plan pays
for a service or procedure
• Balance billing—collecting the difference
between a provider’s usual fee and a payer’s
lower allowed charge
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.6 Third-Party Payment Methods
(Continued)
8-24
• Write off—to deduct an amount from a patient’s
account
• Discounted fee-for-service—payment
schedule for services based on a reduced
percentage of usual charges
• Capitation (cap) rate—periodic prepayment to
a provider for specified services to each plan
member
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.7 Maintaining Insurance Information in
the PM/EHR
8-25
• Setting up insurance carriers correctly in the
PM/EHR is essential to getting claims paid in a
timely manner.
• To maintain insurance carrier information in
MCPR:
– Access the information by selecting Insurance on the
Lists menu.
– Select Carriers (to enter, edit, or delete carriers) or
Classes (for reporting) on the submenu that appears.
– Select the Carriers option; the Insurance Carrier List
dialog box is displayed.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.7 Maintaining Insurance Information in
the PM/EHR (Continued)
8-26
• Maintaining carrier information (continued):
– Use the Edit, New, and Delete buttons to change,
create, and delete insurance carriers.
– Use the Print Grid button to print the information.
– Close the dialog box using the Close button.
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
CHAPTER
7
Office Visit:
Examination and
Coding
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7-2
Learning Outcomes
When you finish this chapter, you will be able to:
7.1
7.2
7.3
7.4
7.5
7.6
Discuss the methods of entering documentation in
an EHR.
Compare the process of entering a progress note
with and without using a template.
Explain why e-prescribing reduces some medical
errors.
List the steps required to enter a new prescription.
Explain why ordering and receiving test results
electronically is more efficient than using paper
methods.
List the steps required to enter an electronic order.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7-3
Learning Outcomes (Continued)
When you finish this chapter, you will be able to:
7.7
7.8
7.9
7.10
7.11
7.12
7.13
Explain how orders are processed in an EHR.
Define medical coding.
Discuss the purpose of ICD-9-CM.
Discuss the purpose of the CPT/HCPCS code sets.
Demonstrate the process that is followed to select a
correct evaluation and management code.
Compare coding in a paper-based office with coding
in an office with an EHR.
Discuss the purpose of an electronic encounter form
in an EHR.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7-4
Key Terms
•
•
•
•
•
•
•
•
•
Alphabetic Index
Category I codes
Category II codes
Category III codes
computer-assisted
coding
Current Procedural
Terminology (CPT)
dictation
digital dictation
electronic encounter
form (EEF)
• evaluation and
management (E/M)
codes
• formulary
• HCPCS
• ICD-9-CM
• ICD-9-CM Official
Guidelines for Coding
and Reporting
• ICD-10-CM
• key components
• medical coding
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
Key Terms (Continued)
•
•
•
•
•
•
7-5
primary diagnosis
SOAP
Tabular List
template
upcoding
voice recognition
software
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.1 Methods of Entering Physician
Documentation in an EHR
7-6
• Dictation—process of recording spoken words
that will later be transcribed into written form
– Traditional method of documenting patient encounters
• Digital dictation—process of dictating using a
microphone, a headset connected to a
computer, a smart phone, or a PDA
• Voice recognition software—software that
recognizes spoken words
• Template—preformatted file that serves as a
starting point for a new document
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.2 Progress Notes in Medisoft Clinical
Patient Records
7-7
• Progress notes can be entered using dictation
and transcription, voice recognition software, or
templates, or with a combination of techniques
• SOAP—format used to enter progress notes;
stands for subjective, objective, assessment,
and plan
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.2 Progress Notes in Medisoft Clinical
Patient Records (Continued)
7-8
• To create a progress note:
– A patient chart must be open.
– Click the Note button on the toolbar and enter the
date and title.
– Then choose from one of the documentation entry
methods.
– If using a template, it will be inserted in the note; the
physician responds to its labels accordingly to
complete the note.
– If not using a template, the information is typed freely
by the physician.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.3 E-Prescribing and Electronic Health
Records
7-9
• E-prescribing reduces some medical errors by:
– avoiding many of the mistakes that occur with
handwritten prescriptions,
– providing a number of built-in safety checks, and
– checking to be sure the medication is in the formulary
of a patient’s health plan.
• Formulary—list of a plan’s selected drugs and
their proper dosages
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.4 Entering Prescriptions in Medisoft
Clinical Patient Records
7-10
To enter a new prescription in MCPR:
– Start from the Rx/Medications folder in a chart, or
click the Rx button; the Prescription dialog box will be
displayed.
– Complete the fields in the Prescription dialog box.
– Review the ten check boxes in the dialog box.
– Click the OK button to save the current prescription.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.5 Ordering Tests and Procedures
in an EHR
7-11
Electronic order entry is more efficient than paper
methods as it:
– reduces errors associated with handwritten and paper
orders,
– provides numerous safety and cost-control benefits,
– allows the user to delay sending out orders until
approval is received, and
– allows orders to be printed or transmitted
electronically.
• In addition, MCPR is capable of checking orders
against information specific to a patient.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.6 Order Entry in Medisoft Clinical
Patient Records
7-12
• In MCPR, physicians can enter orders for
laboratory, radiology, pathology, and other
diagnostic tests.
• To enter an electronic order in MCPR:
– Click on the Orders folder in the patient’s chart; the
Orders dialog box is displayed.
– Click the New button to enter a new order; the Order
dialog box will open.
– Complete the four sections of the Order dialog box.
– Click OK to record the orders.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.7 Order Processing in Medisoft Clinical
Patient Records
7-13
• To process an order:
– In MPCR, select Orders > Order Processing on the
Task menu; the Order Processing Select screen
appears, with the Select Orders dialog box on top.
– Use the filters in the Select Orders dialog box.
– The Order Processing Select dialog box will display
the orders that meet the criteria selected.
– Click the Edit button to view an order before it is
processed.
– To print an order for a patient, click the Forms button;
then click the OK button on the Standard Orders
Printing Select dialog box which appears.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7.7 Order Processing in Medisoft Clinical
Patient Records (Continued)
7-14
• To process an order (continued):
– To send an order electronically, right click the line that
contains the order; a menu will appear.
– Select the appropriate options from the menu.
– Click the OK button to send the order.
– Once the order has been printed or sent
electronically, its status will change from pending to
sent.
– To view orders that have been sent, select Sent as
the Order Status in the Select Orders dialog box.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
7-15
7.8 Medical Coding Basics
• Medical coding—process of applying the
HIPAA-mandated code sets to assign codes to
diagnoses and procedures
• In the physician practice coding environment,
the requi …
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