Medicare
Ways you can qualify for Medicare
Age
Disability
Medical Diagnosis
What is considered protected health information?
Health information (e.g., diagnosis, test results) maintained with individually identifiable information (e.g., name, address)
As the person who checks in a patient, what are the 3 required documents you must have every chart?
Demographic page
Consent for Treatment
HIPAA form
A patient with an HMO insurance policy wants to be self-referred - is that OK? Under what condition?
Only if they are paying cash for everything including medication sometimes
Coordination of Benefits means?
Verifying and arranging insurance policies in order of their payment responsibilities
Why are medical receptionist one of the most important people within a medical practice
They make the first and lasting impression, they enter demographics and insurance that allow us to bill for services rendered
What does verifying insurance mean?
Ensuring a patient has active coverage with the insurance they provided by checking electronically or calling their insurance company
This part of Medicare pays for a patient's prescription medications
Medicare Part D - his is an additional cost to the patient
Is it a HIPAA violation to give a patient a copy of their own lab work
no - a patient has a right to their entire chart
What is a PCP and why is this important?
Primary care provider - the physician who issues the referral for policies requiring a referral - who our office note is generally faxed to
What type of commercial policy typically does not require a referral to be seen by a specialist?
PPO - Preferred provider Organization
Explain what is the Birthday Rule?
When a patient (usually a dependent child) is covered by more than one policy where they are not the policyholder - the policy where the policyholder's birthday comes first in the year
This is what an HMO patient needs in order to be seen by HCNT
Referral to the physician they are being seen by
Where would I go to verify a Medicare patient?
Novitasphere is the most accurate
Availity
If a patient had an advantage plan - traditional Medicare becomes the secondary instead of primary
NO _ they no longer have traditional Medicare at all - the advantage plan takes place of part A, B, and D
What does HIPAA stand for?
Health information portability and accountability act
A patient signs in as Judy Jones but her insurance card says Mary Judith Jones. How do you enter her name in the EMR?
Mary Judith Jones
What two payers are you NOT allowed to bill the patient?
Medicaid and Champ VA
A 67-year-old man has
UHC through his current employer and BCBS that his wife has through her current job and Medicare parts A and B - put them in order of payment responsibility
UHC
BCBS
Medicare
This is what a Medicare patient must sign if we know a service they are scheduled to receive will not be covered by Medicare
ABN - Advanced Beneficiary Notice
Where do you go to verify a patient's insurance with most commercial payers
Availity
The part of Medicare that most Americans get when they turn 65 with no cost to them
Medicare Part A
A husband calls to see if his wife made it to her appointment
Can I tell him? Why?
I can tell him only if he is on her HIPAA list if not no
What are the 3 MUST-HAVES in every patient chart
Patient Demographics
Consent for treatment
HIPAA form
What do you look for on the insurance card when trying to choose which insurance is the correct one?
Payor ID
PO Box or address
the card says: send medical claims to may have different name (network)
A 22-year-old patient gives you a Medicaid card. They also said they have a plan from their job but have never used it.
Which will be primary?
The employer provided - Medicaid always last payer
If a patient uses foul language with me - It is OK to use the same language back to them
Definitely not - always remain calm using correct non-threatening tones and words -
If a patient's insurance was verified 2 months ago - do I need to verify it for today's visit?
Yes, people can change policies month to month sometimes.
This type of Medicare has varying costs to the patient and is governed by Medicare but acts like a commercial policy requiring authorizations and sometimes referrals
Medicare Part C - Medicare Advantage plans
I heard a coworker talking about a patient and realized they were my neighbor. I looked in their chart because I am worried about them, and I wanted to see the severity of what was going on so I could help them.
Is this OK?
No - you can only access a chart if needed to perform your job.
What is the one thing you do not include in when entering a patient's demographic information?
punctuation
A patient presents an out of state Medicaid card - can we accept it?
Not in most cases - Medicaid is a state funded insurance that usually is only good in that state
Which payer is considered the payer of last resort?
Medicaid
What happens if a patient refuses to sign the consent to treat or consent for electronic records?
They must seek other care- mot with HCNT
Are insurance companies bound by what they tell you when you verify coverage?
No unfortunately! They are not legally bound because there are laws for keeping coverage up to 90 days past the due date for premium coverage. They will either deny the claim or recoup the money.