Chapter 1 Introduction to the Medical Billing Cycle

Chapter 1 Introduction to the Medical Billing Cycle

Medical Billing Specialists Ensure Financial Success 1. 2. 3. revenue cycle management (RCM) to maintain a balance of cash flow through management of accounts receivable and accounts payable Health information technology (HIT) incorporates practice management programs (PMPs) Electronic health records (EHR)

Know Medical Insurance Basics Third-party payers Medical insurance companies (private payers) Liability companies Government Agencies Health Benefits Covered Services Noncovered Services

Types of Plans Indemnity Plans Premium, deductible, coinsurance Payments received after service Managed Choice Care restrictions Lower deductibles, coinsurance

HMOs Networked providers and hospitals Focus on preventive care Capitation (PMPM) Cost Containment Restricting provider choice (PCP) Requiring preauthorization Controlling services and drug costs Cost Sharing (copay)

PPOs Network providers agree to be paid less No referrals or PCP Premiums and copays higher than HMO

Types of Providers Network providers Out of Network PAR non. PAR

Consumer Driven Health Plans High deductible PPO Low premium Medical savings account

Types of Payers Private Self-funded Government Sponsored

Billing Cycle

Healthcare Reform Signed into law 2010 Being implemented through 2014 Effects who has insurance and benefits they receive Some changes: Cannot be denied Dependents to age 26 Some preventive must be covered

Being Successful Skill Attributes Ethics Etiquette Certification

Questions?