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Not Protecting Patients from Out-of-Network Fees The majority of patients are not knowledgeable about medical claims procedures or insurance policies. Patients frequently pay a price in the form of high deductibles or increased co-insurance obligations if a provider treats them outside of the network. Some insurance plans don't pay anything for out-of-network procedures of medical coding services, thus the patient must bear all expenses. Providers must have office policies that specify how out-of-network patients are to be invoiced in order to safeguard patients from this scenario. Additionally, and wherever possible, you should check the patient's insurance coverage before any appointment and let them know what is expected of them in terms of copayments, deductibles, and coinsurance. (You can typically discover the patient's responsibility information on their insurance card.) Head to Chapter 6 for a quick recap of the various insurance plan types. Neglecting to Check Prior Authorization Some procedures need prior authorization, or the payer's consent to treat the patient, from the provider before they can be carried out. When a primary care physician refers a patient to another provider for treatment or testing, the claim could be rejected if the required authorizations or referrals weren't obtained. Liability for the billed charges is subsequently assigned to either the provider or the patient, depending on the terms of the patient's plan. For this reason, determining if planned operations require prior authorization is essential to making sure the provider abides by the terms of his agreement with a payer and receives the agreed-upon payment for the service he renders. Always request that the doctor make a list of all potential operations and inquire about any necessary authorizations. It is preferable to obtain authorization up front than to learn that it was necessary just after the claim has been submitted. Chapter 11 has more information on referrals and prior approvals. Invasion of Patient Privacy You, the coder, have access to the patient's clinical data as well as personal demographic data, such as their Social Security number, birth date, address, etc. It should go without saying that you should protect this information just as you would your own due to the risk of identity theft and the consequences of breaking the Health Insurance Portability and Accountability Act (HIPAA). HIPAA regulates who, when, and what information can be shared about a patient, and those who violate it risk paying hefty fines as well as possible jail time. Visit Chapter 4 for further details on HIPAA and methods for safeguarding patient privacy. Following a Careless Manager's Example The majority of coding managers are aware of proper coding procedures, follow them, and anticipate that you will do the same. Sadly, you can come with a manager who is unaware of the proper coding principles or who, even if aware of them, likes to ignore or bend them. Modifiers may be viewed by these coding managers as a tool to enhance reimbursement rather than a tool to increase specificity when reporting services, for example, and they may question the coding of claims when reimbursement is low. Refuse to comply if your manager or other superior urges you to code improperly. Instead, act morally and inform a leader of the office about the situation so they can take appropriate action. You might annoy the shady management, but you'll have a far better night's sleep! When you're compelled to code in doubtful or unethical ways, Chapter 18 provides solutions you can take. Ten Abbreviations to Imprint in Your Mind It's like one giant bowl of alphabet soup in the realm of medical billing and coding. There is an abbreviation for just about every word you encounter every day. Every office learns the acronyms unique to that practice, but several are recognized industry-wide and are familiar to everyone who works in the healthcare sector. In this chapter, I go over a few more of the abbreviations and acronyms that medical offices frequently use. Some states have laws governing the use of clinical acronyms and abbreviations in medical documents for dental billing company. These state requirements often demand that each acronym have just one meaning and that this meaning be recorded on a list that is accessible to all clinical professionals. However, since acronyms and abbreviations for administrative personnel aren't often controlled, you might find even more in-house acronyms circulating around the workplace, which isn't always a negative thing. Do you really want to spend the entire day mumbling "Health Insurance Portability and Accountability Act" when you can just say "HIPAA"?
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