Revenue Cycle Management System

Patient Doctor Billing Office Pacific, R1, E4E, NTT Data

Outsource
Record--Audio
convert audio file into text
Medical Transcription 6-7

Tratment--- CPT--5 digit 71045

Medical Coding Disease ---- ICD-DX Code -3 to 7 [Link]

Editing Add demographic-- add patient information

Charge Posting

Insurance

Paid EOB Deny EOB

Payment Posting Account Receivable

Conversation between doctor and patient is recorded in audio form. That recorded file is sent to the billing
office for which we are workingS.

Recorded File is sent to Medical Transcription. They transcript the audio into Text.

A medical coder translates text files into a set of codes known as CPT and ICD. CPT for treatment and ICD for the disease.

Editing adds demographic Information.

Charge posting prepares a claim and sent to the insurance.

If the claim is paid it is sent payment posting to post payment is software.

If the claim is denied it is sent to Account Receivable.

CPT: Current Procedure Terminology

Five digit code which describe about treatment.

ICD: International Classification of disease.

3-7 character code that describes the disease and condition of the disease.

Modifier: Two-digit alphanumeric code that enhances CPT without changing its actual meaning.

POS: Place of service is physical location where service is provided.

 BASIC HEALTH INSURANCE TERMINOLOGIES

PROVIDER: The physician who provides medical treatment to a patient for any illness is the provider. He
is also called the rendering physician.
PAYER: It refers to entities other than the patient that finance or reimburse the cost of health services. In
most cases, this term refers to insurance carriers, other third-party payers, or health plan sponsors
(employers or unions).
PATIENT: A patient is any recipient of health care services. The patient is most often ill or injured and in
need of treatment by a advanced practice registered nurse, physiotherapist, physician, physician
assistant, psychologist, podiatrist, veterinarian, or other health care provider.
PREMIUM: This is a periodical payment, usually monthly, made to purchase a medical insurance
coverage. The premium paid by numerous individuals to an insurance company; contribute to a fund,
which protects these individuals against the cost of medical care when they require it.

BENEFITS: The money that a patient's medical coverage pays to compensate for the medical services
provided to the patient.

BENIFICIARY: A person who is eligible for the benefits under an insurance coverage. He is either the
person who pays the premium or a dependent of that person.
SUBSCRIBER: The person who pays the premium to purchase an insurance policy. This person may
either pay the premium himself or as in most cases, the person's employer may pay the premium or a
part of it on his behalf. It is very common in the US for an employer to purchase medical policies for its
employees.

DEPENDENT: The spouse and children of the subscriber who are eligible for medical care under the
insurance contract.

PRIMARY CARE PHYSICIAN (PCP): The PCP is usually a general practitioner. He is the equivalent of a
family doctor, who when specialized treatment is required, refers the patient to a specialist. For this
reason, he is also called the Referring Physician.

HIPAA: Health Insurance Portability and Accountability Act (1996). This federal act sets standards for
protecting the privacy of your health information.

NPI (National Provider Identifier): A National Provider Identifier or NPI is a unique 10-digit identification
number issued to health care providers in the United States by the Centers for Medicare and Medicaid
Services (CMS).

TAX ID NUMBER: A number assigned by the federal government to doctors and hospitals for tax
purposes.

CMS (Centers for Medicare and Medicaid Services): The federal agency that runs the Medicare
program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure
that the beneficiaries in these programs are able to get high quality health care.

SSN (Social Security Number): In the United States, a Social Security number (SSN) is a nine-digit
number issued to U.S. citizens, permanent residents, and temporary (working) residents. (SSN Format –
XXX-XX-XXXX)
 Insurance Types

Federal Insurance

a) Medicare 80%/( 20% paid by Patient b) Tricare (For Uniformed Services)

Defence Services
Medicare Eligibility

a) Medicare is for US citizen 65 years or above 65 year of age

b) Person suffering from End stage Renal(Kidney) disease.
c) US citizen who is permanent disabled

State Insurance

a) Medicaid

1)This is for poor people. 2) No out of pocket expenses. 3) Medicaid is always the last payer.

Commercial Insurance 80K insurance in USA

BCBS, CIGNA, AETNA, HUMANA, UHC, UMR, OXFORD, AARP

OUT OF POCKET EXPENSES: Below three are also called out of pocket expenses

Deductible:PR1 & AN001

Fixed annual amount paid by secondary insurance or patient before he can take benefits from the
insurance company.

Co-insurance: PR2 & AN002

A specified percentage of the allowed amount paid by secondary insurance or patient.

Co-payment: PR3 & AN003

Small dollar amount paid by secondary insurance or patient on every visit.

Difference between EOB and ERA?

EOB: Explanation of Benefit

Financial Statement which contains payment or denial information.

ERA: Electronic Remittance advice

An electronic form of EOB which contain the payment or denials information. We receive ERA from
Clearing House.
 BASIC TERMINOLOGY

AOB: Assignment of Benefit Insurance----Aob ----- Doctor

Form signed by the patient authorizing the doctor to collect payment directly from Insurance Company.

ABN: Advance Beneficiary Notice

Form signed by Medicare patient, if Medicare denies making payment then patient has to pay.

COB: Coordination of Benefits

This is the process by which a health insurance company determines if it should be the primary or
secondary payer of medical claims for a patient who has coverage from more than one health insurance
policy.

or

If the patient has more than one insurance he needs to inform the insurance which insurance will act as
primary secondary or tertiary.

Sequestration

Two percent Reductions are done by Medicare from the Allowed amount which needs to be a w-riteoff

Medicare Crossover

Once Medicare has paid its portion it transfers the remaining balance to secondary insurance.

Difference between Balance Bill and Contractual Adjustment?

Contractual Adjustment: CO45

Difference between the Billed amount and the Allowed amount in case of a participating provider.

Balance Bill: (This is Patient Responsibility)

Difference between the Billed amount and the Allowed amount in case of a non-participating provider.
Difference between recoupment and offset?

Recoupment:

Recoupment is a request for a refund when Insurance overpays a claim.

Offset:

If the doctor did not refund overpayment then insurance adjusts overpayment in the next claims.

Or

The withholding of payment to satisfy a refund request from a previous claim.

Forwarding Balance:

Forwarding balance means that a negative value represents a balance moving forward to future
payment advice. A positive value represents a balance being applied from a previous Remittance Advice
(RA). (Remittance advice refer to EOB or ERA)

Managed care Plan

There are three types of Managed care Plan:-

Health Maintenance Organization (HMO)

In this plan, the patient can visit the only in-network healthcare provider. To visit a specialist patient
need to take referral number from Primary care physician (PCP is a general doctor who is not a
specialist). Taking a referral number from PCP is patient responsibility.

Preferred Provider Organization (PPO)

In this plan, the patient can visit an in-network provider as well as out of network provider. The patient
can directly visit a specialist.
Point of Service (POS) (a combination of HMO and PPO)

In this plan, the patient can visit an in-network provider as well as out of network provider. To visit a
specialist patient need to take referral number from Primary care physician (PCP is a general doctor who
is not a specialist). Taking a referral number from PCP is patient responsibility.

COBRA: Consolidated Omnibus Budget Reconciliation Act

This is a federal act under which employees can continue his previous company insurance for a
maximum of 18 Months by paying the premium.

Capitation: CO24

This is a contract under which insurance pays to the provider on the basis of per member per month.
Parts of Medicare
There are Four parts of Medicare

Part A-Hospital Claim

Part B- Professional Claim(It include Radiology, DME, Out Patient & pathology)
Part C- Medicare Advantage Plan
Part D- Prescription Drugs

Medicare Part C is provided by commercial insurance which replace original

medicare Plan.

What is a “spenddown”?

If a consumer has an income that exceeds the Medicaid need standard, the consumer can use
incurred medical expenses that will reduce his/her income to the Medicaid need standard.

Sections of CPT Codes 71045 to 71048-chest X-Ray

77065 to 77067-Mammography
EVALUATION & MANAGEMENT (99201 TO 99499) 77063 & G0279-Tomosynthesis
ANESTHESIOLOGY (00100 TO 01999,99100-99140)
SURGERY (10040 TO 69990)
RADIOLOGY (70010 TO 79999 )
PATHOLOGY & LABORATORY (80048 TO 89399)
MEDICINE (90281 TO 991990)