Insurance
What is a TPL, MCO, and ACO and what are the differences between them?
TPL=Third Party Liability: Refers to the legal obligation of third parties to pay all or part of the expenditures for medical assistance furnished under a Medicaid state plan. Examples: BMC, THPP, Allways, and Fallon w/MH as a secondary insurance.
MCO= Medicaid Managed Care Organization: Provide comprehensive acute and in some cases long-term services and supports to Medicaid beneficiaries. MCO's accept a set per member per month payment for the Medicaid services specified in their contracts. Example: Commercial BMC, THPP, Fallon Health New England, all have contracted rates with MH to lower the monthly payments for policy holders they may not be eligible for MH standard due to income qualifications.
ACO= Accountable Care Organization: ACO's are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.
Bonus question* Does PPLM accept Medicare?
What appt types can be scheduled into an ANY10?
Contraception IUD Removal
STI Testing
Pregnancy Testing
PeP Follow up
PrEP Established
Can we see a minor without parental/guardian consent for STI testing?
Yes, we can see minors for all preventative services with out parental/guardian consent.
What does GAHT stand for?
Gender Affirming Hormone Therapy
How many people need to be present to count your batch?
Are you allowed to have a snack at the front desk?
No. there should be no eating at the front desk at all. You can have drinks but absolutely no food. OSHA violation takes into play and we want to also be considerate of our patients that may not have been able to eat since the night before to prep for their appt.
What is Code 1?
External Disturbance
Who is known or working and singing 9-5?
Dolly Parton
What is the first 3 things you ask the patient for when they arrive?
Appt time
First name first initial to last name
DOB
What is the name of the page we use on Confluence that lists CPT codes for charges that are on a claim?
Charge Accuracy Tool
If a patient has MH with Fallon what boxes do you check for supply sales?
Paraphrase what is the Request for Medical Services Consent states?
"The medical records release states, that the patient is giving us permission to see them and treat them."
What are the different commercial insurance plans? What are the differences in these plans?
PPO= Preferred Provider Organization: Patients still have a network of providers, but they are not restricted to seeing just those physicians.
HMO= Health Maintenance Organization: You must stay in your network of providers to receive coverage.
POS= Point of Service: Have lower costs, but with fewer choices. The real difference between a POS and a PPO is flexibility.
What appt types can be scheduled into an ANY20 slot?
Problem: - GYN Problem (abnormal bleeding, pain, etc.) - Breast Problem - Infection Check (vaginal/penile pain, itching, discharge, odor, sores, bumps, etc. and/or may need a physical exam) - IUD Check - Wart treatment
Implant Insertions
PrEP New/Restart
GAHT Established
IUD Insertion IUD Removal/Reinsertion
Implant Removal/Reinsertion
IUD Removal/Implant Insertion
Menopause Management
Prescription Barrier
UTI
How old do you have to be to get abortion services with out parent/guardian consent?
The patient needs to be 16 or older in order to receive abortion services at PPLM without a parent/guardian consent.
What is GAHT?
GAHT (Gender Affirming Hormone Therapy) aims to align the characteristics of an individual with their gender identity.
A patient is self-paying for a visit with cash. What is the proper way to count the cash the patient hands to you?
Count the cash in front of the patient. Count the cash one more time before entering in the amount in the patients chart.
What is the dress code for patient facing employees?
Business casual or scrubs. No jeans, no graphic tees no leggings. You may only wear sneakers if they are paired with scrubs.
Bonus question* Can you where your scrubs outside of the health center?
No. we do not want to cause attention to ourselves as PPLM employees. If you need to leave the facility you will need to change into your street clothes.
What is Code 2?
Fire
Who started in Titanic
Leonardo DiCaprio and Kate Winslet
How do you know if a patient would be eligible for sliding scale before screening them for sliding scale?
HINT: Income poverty level is listed under income. DPH poverty level is 300% while Title X poverty level is 250%. If a patient self report their financials and they are under the poverty line we can then tell the patient that they are eligible for some sort of reduced cost. We wouldn't fully know what the reduced cost is until we add Sliding scale as their way of payment.
What are the steps you take in order to submit a claim?
Go through all the demo information to make sure no information is missing in the patients chart.
Make sure that insurance was checked on DOS.
Make sure that charges are entered in accurately and the billing review tab is checked off.
If a patient comes in and has commercial insurance or an MCO with MH, what boxes would you check for supply sales?
Paraphrase the Acknowledgement of Notice of Privacy Practices.
"This consent states that we follow all HIPAA regulations and can not give out any of your information without your consent. However, some STI results if they came back positive we are legally obligated to report those to the Department of Public Health. They are reported anonymously."
If a patient comes with a BCBS and MH insurance plan, in what order would you add these insurance packages into the patients chart?
BCBS will be the primary payor and MH would be the secondary payor. If a patient has MH with any additional health insurance policy, MH will always be added a the secondary insurance.
What appt types can be scheduled in an ANY30 slot?
GAHT new/restart (Boston staff will book in an ANY30 and make sure that there is an open any10 right above or right below the ANY30. Book both the ANY30 and the ANY10 for the one GAHT patient.)
Implant Removal/IUD Insertion
PEP Start
Can a minor start their GAHT services with out parental/guardian consent?
No. A minor who would like to receive GAHT services would need to have a parent/guardian with them at their first initial visit. Parent/guardian doe not need to be a each visit after the first initial visit.
What does a patient need to do in order to get GAHT treatments here at PPLM?
Patient needs to be 18 or older or have a parent or guardian with them for the first initial visit.
What is the name of the form you fill out at the end of your shift when counting your money for the day?
Batch Reconciliation Form
How far in advance do you have to request time off?
at least 2 weeks in advance. Please speak to your manager as this could be site specific.
What is Code 3
Bomb Threat
Who sings WAP?
Cardi B and Meg the Statllion
If an appt is listed as an ANY10, ANY20 or an ANY30 with a note stating what the appt is what is the next step to making sure the clinician knows what the patient wants to be seen for?
The only exception is if the appt was booked online. We would not change the appt type. We would leave the appt as is.
When Quest charges are on the claim for a patient using insurance, what do we need to do to the claim?
What do you do with Quest charges on a claim when a patient is self-paying or using SS?
Make sure all charges being sent to Quest are unchecked and that specimen handling is check on the claim.
Keep the Quest charges check on the claim as well as specimen handling.
What fields need to be complete by reception before the bump sheet is ready for the HCA to call up the patient?
Pronouns
DOS label
Time of arrival/Time of the appt
Reception initials
Insurance
Preferred Name
A sticker for MH patients (SurgAB appt only)
Language
Escort (AB patients only)
LARC coverage
Explain the Non-Discrimination Consent.
We do not explain this consent to the patient. We want the patient to read this in full. Ask the patient if they would like a copy. If the patient does want a copy make sure you are NOT giving the one that has the barcode on it. We have pre-printed copies made.
A patient who is being seen for an AB service and has active United Health Care for their insurance. What needs to be done before the patient can be seen?
PACS would need to verify coverage for that appt type. A FIF (financial intake form) would need to be completed and added into the patients chart. If there is not a FIF attached to the patients chart, we would need to reach out to PACS team and ask them to call the insurance company to get a verification of benefits.
Bonus Question* Why do we pre-verify for this appt type? We pre-verify for this service because some plans do not have coverage or these services may be subject to a deductible.
What can you do if there are no available ANY30 slots?
Book in an ANY20 slot or a SAMEDAY slot with a clear note as to why you had to book an ANY30 appt into an ANY20 slot. (manager approval needed)
If a minor under the age of 16 wants to get an abortion and does not want their parents to find out. What would they need to do in order to get the abortion service?
The patient would need to get Judicial Bypass paperwork signed by a judge for the court. (PPLM will help them obtain that paperwork)
What clinicians are eligible to see GAHT patients at your site?
Boston: Gretchen, Julia, Molly, Arielle, and Margo
Central MA: Cailin, Karen, and Kathy
Springfield: Meaghan, Liz, and Maggie
What is the name of the form you fill out if there is a discrepancy with the cash you took in that day or if your drawer is short less than $100?
The Batch incident Report
What is considered excessive absences?
Excluding Legally Protected Absences, (A) two or more incidents of Unplanned Absence, Unplanned Tardy and/or Unplanned Leaving Early in a rolling 60-day period; or (B) four or more incidents of Unplanned Absence, Unplanned Tardy and/or Unplanned Leaving Early in a rolling 12-month period.
What is Code 4?
Internal Disturbance
Who is the host of Family Feud?
Steve Harvey
Bonus question* What is the name of Steve Harvey's daughter? HINT: She is currently dating Michael B. Jordan.
What appt type do we need to take full payment amount before the patient can be seen?
All AB services and Colposcopies.
If a patient self-paid for an AB visit what needs to be done once you have submitted the claim?
Apply the unapplied Credit.
How many labels should we print out for Appts?
FP 5-10
AB 10-15
RN visits 3-5
Paraphrase the Non-Covered Service Waiver.
Commercial Insurance "This consent states that you are allowing us to submit a claim to your insurance company for payment of services. If your insurance company finds you responsible for any portion of the claim, you will be financially responsible."
MH- "This consent isn't directly related to you. However if you came back and have a commercial insurance, it states that you would be financially responsible for services your insurance finds you responsible for."
Self-Pay/Sliding Scale- "This consent states that you are financially responsible for services rendered here at PPLM."
Does MH send out a summary of benefits to the policy holder?
Does Commercial insurance send out a summary of benefits?
MH does not send out a summary of benefits. MH covers all services in full so there is no need to send out a summary of benefits.
Commercial insurances do send out a summary of benefits. The policy holder pays a monthly cost for their health insurance and therefore would have a summary of benefits sent to them monthly stating what services were rendered and what total coverage was for those services.
What appt types have their own template that we would not book in an ANY10, ANY20 or ANY30?
These visit are also known as "Specialty Visits"
Annual (20)
SAME Day (20) EC, PEP, and Problem
Colposcopy
LEEP
Med AB
Post MAB
Cervical Dilator Insertion
Injection Visits: Depo w/refills on time, HPV 1,2 & 3, and Self injection teaching
Can a minor be seen for a UTI?
Yes, but, the patient would need to have a parent/guardian with them in order to be seen.
What is the best way to honor a GAHT patient at check-in?
Use the patient correct pronouns and preferred name.
When should your cash be locked up?
ALL THE TIME! You are responsible for the cash you take in and the cash box/drawer you are assigned for your shift. When you step away from your computer you should be locking your money up and taking the key with you, always!
What is the Employee Assistance Program? Who is eligible to use it?
he Employee Assistance Program (EAP) is a free, 24 hours/day, 7 days/week confidential resource provided to all employees, their dependents and their household members to help with personal challenges such as child/elder care, substance abuse, work/life balance, legal and financial services, crisis management, counseling, and much more. The EAP does not inform PPLM or release any information about the services they provide to any PPLM staff member and/or their dependents or household members. Participation in the EAP will not jeopardize employee’s reputation, job security or promotional opportunities.
Employees may contact an EAP counselor at 855-RSL-HELP (855-775-4357) or visit http://rsli.acieap.com.
What is the security extensions for your site?
Boston:111739
Worcester:111120
Springfield: 111206
What are the names of Kim K and Kanye West Children
North
Saint
Chicago
Palms
If a patient is under the age of 21 what would they need to provide before receiving AB services?
Valid photo ID.
If you are noticing an issue like a balance at the end of a visit and the patient is no longer in the health center. What steps do you need to take in order to attempt to collect the debt for that DOS?
You first want to double check the claim and make sure that all the charges are correct with the correct CPT codes and Modifiers.
If the is still a balance we want to reach out to the patient via phone and attempt to collect the debt over the phone.
If the patient was not able to pay over the phone or you were unable to contact the patient. You would need to add a detailed not for billing explaining what happened. You would add the note under the billing tab, patient account view and scroll to the bottom of the page.
When we are finished checking out a patient, what do we do with the bumpsheets?
Once you have completed a check out, bumpsheets need to be shredded ASAP. PHI should not be left around. IF charges are not entered into the claim yet, you can click done with check out on the claim screen and shred the bumpsheet. Once you hit done with check out. There will be a reminder on AthenaNet saying "Enter Charges". That will tell you that you still need to submit the claim for that patient.
Paraphrase Permission to use Your Email Address, Text, or Leave a Voicemail.
"This consent states that you are allowing us to contact you electronically with appt changes, reminder as well positive test results."
Bonus question* What consent do we give all of our AB patient?