Registration FSC/Plans & Invoice FSC

Transcription

1 Registration FSC/Plans & Invoice FSC Overview Introduction This lesson introduces you to key terms and structure related to FSC/Plan Assignment. You will learn why an invoice FSC may be different from a Registration FSC/Plan for a given episode of care. You will also learn how to apply the above to specific situations. When the information can be obtained and completed prior to the patient s appointment, all the necessary pre-appointment work can be completed before the patient arrives. This assures patient satisfaction, provider satisfaction and less stress for staff. Each staff member will know exactly how they fit into the Patient Financial Services (PFS) process and what is expected. It results in better customer service and increased revenue for Washington University School of Medicine (WUSM). Objectives Upon completion of this lesson you should: Understand the PFS (Patient Financial Services) Process Understand the importance of collecting and maintaining accurate and current demographic and billing/insurance information Understand the impact of incorrect FSC/Plan assignment Know the components of a patient s account Understand how to determine if a patient has a invoice that is a Special Billing situation Know the different types of FSC/Plans: o Registration o Invoice o Invoice-Only o E-Case Management 1

2 Prerequisites Prior to beginning this lesson, you should have: Met the prerequisites specified for the current module 2

3 PFS (Patient Financial Services) Process 1. A patient enters a clinic for services. If the patient is new to the clinic, the patient is registered; if not new to the clinic, the patient s registration and insurance information is updated. 2. The patient sees a provider, and charges are entered in the form of invoices that are assigned to a particular financial status classification (FSC). 3. Night jobs places these invoices in the appropriate claim form queue based on their FSC. 4. Claims are sent out in the form of paper, Electronic Media Claims (EMC), or Electronic Data Interchange (EDI). 5. Payment is received from insurance carrier and is posted to the account. 6. Any remaining balance, due from the patient, will be billed to the patient in the form of a statement. 7. Payment is received from patient and is posted to the account. 3

4 Review: Keys to Success Remember Key to Success number 2 and 3: 2. Understand the basics of the health insurance environment: Demographic information is patient specific identification information. Billing/Insurance information is payor specific data required for receiving payment. 3. Collecting and maintaining accurate and current demographic and billing/insurance information: Five critical questions: 1. Name 2. Address 3. Date of birth 4. Primary telephone number 5. Health insurance information The staff who confirms information are: Schedulers Front Desk Pre-visit/pre-certification Accounts Receivable follow-up 4

5 How Does Demographic and Billing Insurance Information Stay Current? All patient registration forms include required Demographic and Billing/Insurance information. Patient reviews the patient registration form (face-sheet) during check-in. A P-FSC/Plan Assignor immediately enters any changes to Demographic or Billing/Insurance information in IDX. Once the Demographic and Billing/Insurance information is available, a Financial Status Classification (FSC)/Plan is assigned. A FSC/Plan is a name/mnemonic/numeric code assigned to Billing/Insurance information. Example: o Name: CIGNA HMO o Numeric: 500 o Mnemonic: CGH Correctly identifying the patient s Registration FSC/Plan is one of the most important aspects of Registration. Failure to do so can significantly affect revenues and can result in unnecessary problems for the patient. 5

6 What Happens When a FSC/Plan is Assigned Incorrectly? The impact of an incorrect FSC/Plan assignment can result in: Claims being submitted to the incorrect health insurance carrier. Mailing claims to an incorrect claims address for the health insurance company. The claim submitted to the secondary health insurance company rather than the primary insurance company. Filing an invoice to an incorrect or incomplete FSC/Plan at the time of charge entry can result in claim edits and cause delays in submitting the claim to the health insurance company. Scheduling an appointment for a patient who has a non-contracted health insurance plan. Managed Care Plans denying claims due to referral requirements not being met. Missing claim filing deadlines. However, when the correct FSC/Plan is assigned: Claims are processed with the first submission. No additional re-work to identify the correct payor by AR staff. The University will receive payment for services rendered and not have to perform write-offs for untimely filing. 6

7 Registration FSC/Plans Registration FSC/Plans are the foundation of a patient s account. Registration FSC/Plan is the name/mnemonic/numeric code assigned for the payor/plan. Some patients may have more than one Registration FSC/Plan assignment. Example: Priority Anthem Blue Access PPO Priority Healthlink/American Benefit Adm Priority 3 48 Mutual of Omaha (Commercial Insurance) Priority 4 51 Reliable (Commercial Second) Example: Plan Level - Visit Insurance Plan Screen Example: Registration Level Manage Insurance Information Screen 7

8 If the patient does not have insurance, what is the Registration FSC/Plan? Once verified that there is no health insurance coverage for the patient assign the following FSC/Plan: o FSC/Plan: Patient Self Pay o Mnemonic: PSP o Numeric: 976 The Patient Self-Pay FSC/Plan is used when the patient has verified they do not have health insurance coverage. Example: Plan Level - Visit Insurance Plan Screen Example: Registration Level Manage Insurance Information Screen 8

9 Invoice FSC The Invoice FSC is a name/mnemonic/numeric code assigned to an invoice that directs the invoice to the next step of the billing process. At the time of charge entry, the IDX system will default to the highest priority Registration FSC/Plan assigned to the visit. When the invoice is created, the invoice links to the visit. The visit plan will default as the Invoice FSC. Example: Plan Level - Visit Insurance Plan Screen Example: View Invoice Detail Invoice FSC 9

10 Invoice FSC 10

11 Below is a diagram showing the components of a patient s account. Registration Information Visit Created: Demographic Information Billing/Insurance Information Schedlink Interface Manual Patient Charge Information Visit Insurance Plan Assigned Registration FSC Registration FSC Special Billing Plan Charge Entry Invoice Created linked to the visit Invoice with Invoice FSC assigned based on Visit Plan 11

12 When is the Registration FSC/Plan different from the Invoice FSC? The Invoice FSC will differ from the Registration FSC in the following examples: Special Billing Invoice-Only FSC Employer Case Management Billing (E-Case) We will discuss each of these examples in following pages. 12

13 What is Special Billing? Special Billing is any situation where the invoice will be sent to a payor other than the payor(s) in registration. Examples: A way of grouping invoices related to an episode of care Invoices grouped together can range over several months Interrupts the patient s regular billing cycle Allows you to analyze financial information Worker s Compensation Carve-Outs o Example: Psychiatry and Ophthalmology Research Donor Transplant Special arrangements International billing When the payor for an episode of care is different from the Registration FSC/Plan the Invoice FSC is determined by what Plan is on the visit. 13

14 Schedulers Responsibility The scheduler will select Y for Special Billing on the Appointment Data Form (ADF) when the patient has informed them the appointment is related to a special billing situation. Note: Some departments may have recurring special billing situations that are identified at the time of scheduling an appointment. The Special Billing field on the Appointment Data Form (ADF) is a system required field and must be answered before the Appointment Data Form (ADF) can be completed. Example: Appointment Data Form (ADF) Special Bill Question 14

15 If the Special Bill field is answered N, continue with scheduling process. If the Special Bill field is answered Y, the system branches to the Special Billing Screen where the Special Billing questions are completed. Example: Appointment Data Form AVM SPECIAL BILLING Screen 15

16 Example: An established patient with CIGNA POS as primary insurance calls to give Worker s Compensation insurance coverage for a recent injury. o o o Registration FSC is CIGNA Healthcare HMO FSC/Plan CIGNA Healthcare HMO Mnemonic CGH Numeric 500 Visit Plan is Workers Compensation FSC/Plan Workers Compensation Mnemonic WRK Numeric 880 Invoice FSC is Workers Compensation FSC/Plan Workers Compensation Mnemonic WRK Numeric 880 Example: CIGNA HMO (500 CGH) is Priority 1 in Registration Example: Visit Plan is Worker s Compensation 16

17 Example: Invoice FSC is Worker s Compensation The Worker s Compensation (880-WRK) FSC ensures the invoice is submitted to the correct payor and allows for a more efficient claim follow-up process to the Worker s Compensation insurance. 17

18 Will a Patient Always Have a Registration FSC/Plan? The answer is NO. A patient will not always have a registration FSC/Plan. The following types of patients may not have a registration FSC/Plan. Donor patient Research patient Worker s Compensation patient 18

19 Invoice-Only FSC An Invoice-Only FSC can only be assigned or displayed on the Invoice. An Invoice-Only FSC cannot be assigned or displayed as a Registration FSC or a Visit Plan. Example: A patient has Medicare Part B as primary insurance and Medicaid MO as the secondary insurance. The patient is registered with Medicare Part B/A&B (81-MPB) as primary (priority 1) and Medicaid MO Healthnet (101-MCD) as secondary (priority 2). Example: Plan Level - Visit Insurance Plan Screen At the time of charge entry, the Registration FSC/Plan of Medicare Part B/A&B (81-MPB) is defaulted at the encounter level. After the Medicare Part B/A&B (81-MPB) payment is received, the Invoice FSC is automatically transferred to: o After Medicare, Medicaid MO (102-WAM) Example: Invoice Inquiry Screen In most cases, Medicare Part B automatically performs claim crossovers to Medicaid MO. The Medicare EOB (Explanation of Benefits) will indicate the claim was sent by Medicare to the secondary payor. o Crossover claims will be discussed in more detail later in this module. 19

20 E-Case Management FSC/Plans An E-Case Management FSC/Plan is a means of grouping invoices that are related for an episode of care. The system views a case as a single unit. This enables you to analyze financial information within a case and to compare information among cases. You can access all of the financial information related to a case in Patient Inquiry, Invoice Inquiry and in BAR reports. Example: A patient receives a mammogram at the BJC Breast Health Center. The fees related to the mammogram are billed to the BJC Breast Health Center. BJC Breast Health Center pays the claim from funds available through the Susan G. Komen grant. 20

21 Statement and Insurance FSC An invoice s FSC determines if a statement or an insurance claim is produced for the charges in the invoice. A FSC can be a statement producing FSC or a claim producing FSC. A statement producing FSC causes a statement to be produced for outstanding balances. Example: Guarantor Statement 21

22 A claim producing FSC causes an insurance claim (HCFA) form to be produced for outstanding balances. Example: HCFA 1500 Claim Form Submitted to the Payor 22

23 Both statements and insurance claim forms include information such as: The name of the services or procedures performed for a patient. The date the services or procedures were performed. The charges associated with the services or procedures. Any previous payments or other adjustments to a patient s account. Insurance claims contain more in-depth information than statements. Insurance carriers usually require detailed information regarding a patient s medical procedure before they will remit payment. An insurance claim may have the following additional information: Code numbers corresponding to the services rendered (usually called CPT codes). Number of units of the procedure provided. For example, one day of daily care, or units of anesthesia. Diagnosis number associated with the procedure (usually called ICD-9 codes). Name of the doctor performing the service(s) or procedure(s). ID number assigned by the insurance carrier to the physician or to Washington University School of Medicine. Certificate number of the subscriber s insurance policy. 23

24 Lesson Summary In this lesson you learned: The PFS (Patient Financial Services) Process The importance of collecting and maintaining accurate and current demographic and billing/insurance information The impact of incorrect FSC/Plan assignment The components of a patient s account How to determine if a patient has a invoice that will be Special Billing The different types of FSC/Plans: o o o o Registration Invoice Invoice-Only E-Case Management 24