SHEARWATER ORIENTATION (Day 1)
SHEARWATER ORIENTATION (Day 1)
SHEARWATER ORIENTATION (Day 1)
Health Insurance
- has more expensive in healthcare, they spend more uninsured, are only
benefited in public healthcare (limited health services coverage)
- Health Insurance is a must have
- In the PH paying yet only defined services would be covered.
- 1800, insurance started (health insurance )
- 1920 insurance for health insurance in teachers (Blue Cross Plan, biggest
insurance in the US)
- 1935, SSS act signed become old age insurance
- 1936, popularized student insurance
- 1985, COBRA subsidized, if an employee is retired, they still are covered with
health expenditure, cobra protects their health.
- ACA- also known as Obama Care (covers at least ten services) should be health
services only
2 types of network:
1. In-network provider (INN) kasali sa insurance/
2. Out-of network (ONN) hindi kaslai sa insurance magbabayad ka pa rin. In US
insurance should be at the right amount before beneficiaries would be available.
Coinsurance
- is in percentage, payment before beneficiaries to patients if Out-of-pocket is
reached, the insurance should be covered by the payment.
Pre-auth/ Pre- Authorization
- nurse checking if the health care/ review before performing or providing care.
checking of intervention
Predetermination
- determine if how much will be the bill for the service
Insurance Types:
Medicare (US)
- serves 65yrs old, younger disabled, and dialysis patients and can be compared
to PhilHealth.
Medicaid
- partner of medicare, if low income, may avail in here, ex. prescription drugs
PRIVATE INSURANCE
Types:
a. HMO
b. PPO
HMO
- limited consultation, limited variation, before needs referral to be able to be seen
by your chosen physician.
- limited independence in choosing services (out of network no freedom).
- can't be out of network.
- Needs referral.
PPO
- larger services, has freedom, can be direct from the chosen physician.
- can be outside to see the doctor of the network setup.
- Does not need a referral to see another doctor.
Catastrophic
Medical Coding
CPT
- current terminology, ,mostly code for medical procedures
- 5 digits/characters
- suffix is the letter
HCPCS
- for drugs, supplies, and medical equipments
- Level II mostly used
- 5 character, one letter(start) then the rest is numbers/digits
POS
- code for place of the service
- saan ginawa
- 2 character
LAWS
HIPPA
- supreme law about health information (privacy), information of patients.
- II.
- NPI
- Transactions and Code Sets Standards
- minimum necessary rule- practice to limited disclosed information
- bare minimum
HIPPA privacy rule- protection of health data
(AFTERNOON SESSION)
REVENUE CYCLE MANAGEMENT
- Patient Pre-Authorization = should be accured by low income erners limited
freedom in choosing health service (para ma check na siya ng physician)
- Eligibility & Benefits Verification = done before consulting (baka di pa
beneficiaries si patient siya pa mag suffer in payment)
- Claims Submission = final stage/overall process (where medical coding
happens) nurses does not have responsibility anymore once px is discharged.
[Physician & Hospital talks regarding payment].
- Payment posting = dicission making happens (specific approved/denied).
- Denail Management = ex. denied due to error, check code then resubmit. if
coding has error, chart is return edited then corrects the errors in medical coding.
- AR Follow-Up = health care provider's responsibility to follow up px to the
remaining balance.
- Reporting = internal, means depends on the facility. crucial part.. then start
again ti step 1.
KNOWLEDGE CHECK
- Deep vien thrombosis = term thrombosis
- Adhesive bursitis of the shoulder = Bursitis is the main term
- Acute respiratory failure = failure is the term
- Acute kidney failure =
- Crohn's disease (emponym = named after a specific person) [rec. look for the
eponym for easier to be located]
● code are not to be assume, what the doctors input that should be encoded.
Agenda tom:
-tabular list
-translate coding of dx
-review od discussio
Reminders:
- wag kain sa hallway at elev., pwedi dala kain at tubig.. kasi may corresponding
penalty
- pag asa loob na ng office pwedi kumain.
- Millstone are the venue for on-site activiries