CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 4 Scheduling

CHAPTER

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

4Scheduling


Learning Outcomes

When you finish this chapter, you will be able to:4.1 Describe the two methods used to schedule

appointments.

4.2 Explain the method used to classify patients as new or established.

4.3 List the three categories of information new patients provide during telephone preregistration.

4.4 Identify the information that needs to be verified for established patients when making an appointment.

4.5 Describe covered and noncovered services under medical insurance policies.

4-2


Learning Outcomes (Continued)

When you finish this chapter, you will be able to:4.6 List the three main points to verify with the payer

regarding a patient’s benefits prior to a visit.

4.7 Explain when a preauthorization number or referral document is required for a patient’s encounter.

4.8 List the four main areas of Medisoft Network Professional’s Office Hours window.

4.9 Demonstrate how to enter an appointment.

4.10 Demonstrate how to book follow-up and repeating appointments.

4.11 Demonstrate how to reschedule an appointment.

4-3


Learning Outcomes (Continued)

When you finish this chapter, you will be able to:4.12 Demonstrate how to create a recall list.

4.13 Demonstrate how to enter provider breaks in the schedule.

4.14 Demonstrate how to print a provider’s schedule.

4-4


Key Terms

• benefits

• capitation

• coinsurance

• copayment (copay)

• covered services

• deductible

• established patient (EP)

• fee-for-service

• health plan

• indemnity plan

• managed care

4-5

• medical insurance• new patient (NP)• noncovered services• nonparticipating

(nonPAR) provider• Office Hours break• Office Hours calendar• Office Hours patient

information• out-of-network• out-of-pocket


Key Terms (Continued)

• participating (PAR) provider

• patient portal

• payer

• policyholder

• preauthorization

• preexisting condition

• premium

• preregistration

• preventive medical services

4-6

• provider• provider’s daily schedule• provider selection box• referral• referral number• schedule of benefits


4.1 Scheduling Methods 4-7

• Patient appointments may be scheduled via telephone or online.

• Patient portal—secure website that enables communication between patients and health care providers for tasks such as scheduling, completing registration forms, and making payments


4.1 Scheduling Methods (Continued) 4-8

• Scheduling systems include these methods:– Open hours– Stream scheduling– Double-booking– Wave scheduling


4.2 New Versus Established Patients 4-9

• New patient (NP)—patient who has not received professional services from a provider (or another provider with the same specialty in the practice) within the past three years

• Established patient (EP)—patient who has received professional services from a provider (or another provider with the same specialty in the practice) within the past three years

• Preregistration—process of gathering basic contact, insurance, and reason for visit information before a new patient comes into the office for an encounter


4.3 Preregistration for New Patients 4-10

• During preregistration, new patients usually provide three types of information:– Demographic information– Basic insurance information– Reason for the visit (also known as the chief

complaint)


4.3 Preregistration for New Patients (Continued)

4-11

• Participating (PAR) provider—provider who agrees to provide medical services to a payer’s policyholders according to the terms of the plan’s contract

• Nonparticipating (nonPAR) provider—provider who chooses not to join a particular government or other health plan


4.4 Appointments for EstablishedPatients

4-12

• Medical offices verify established patients’ information prior to an appointment; such information includes:– changes to a patient’s address,– changes to a patient’s health plan or employment.

• The reason for the visit should also be established to schedule the correct amount of time for the encounter.

• Patients’ account balances are checked as well.


4.5 Insurance Basics 4-13

• Medical insurance—financial plan that covers the cost of hospital and medical care

• Policyholder—person who buys an insurance plan; the insured, subscriber, or guarantor

• Health plan—individual or group plan that either provides or pays for the cost of medical care

• Payer—health plan or program• Premium—money the insured pays to a health

plan for a health care policy; usually paid monthly


4.5 Insurance Basics (Continued) 4-14

• Benefits—amount of money a health plan pays for services covered in an insurance policy

• Schedule of benefits—list of the medical expenses that a health plan covers

• Provider—person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business



• Covered services—medical procedures and treatments that are included as benefits under an insured’s health plan– These may include primary care, emergency care,

medical specialists’ services, and surgery.

• Preventive medical services—care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests



• Noncovered services—medical procedures that are not included in a plan’s benefits; these things may include:– Dental services, eye care, treatment for employment-

related injuries, cosmetic procedures, infertility services, or experimental procedures

– Specific items such as vocational rehabilitation or surgical treatment of obesity

– Prescription drug benefits– Treatment for preexisting conditions—illnesses or

disorders of a beneficiary that existed before the effective date of insurance coverage



• Indemnity plan—type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits

• Deductible—amount that an insured person must pay, usually on an annual basis, for health care services before a health plan’s payment begins

• Coinsurance—portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage



• Out-of-pocket—expenses the insured must pay before benefits begin

• Fee-for-service—health plan that repays the policyholder for covered medical expenses

• Capitation—prepayment covering provider’s services for a plan member for a specified period



• Managed care—system that combines the financing and delivery of appropriate, cost-effective health care services to its members; basic types include:– Health maintenance organizations (HMOs)– Point-of-service (POS) plans– Preferred provider organizations (PPOs)– Consumer-driven health plans (CDHPs)

• Out-of-network—provider that does not have a participation agreement with a plan



• Preauthorization—prior authorization from a payer for services to be provided

• Copayment (copay)—amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter

• Referral—transfer of patient care from one physician to another


4.6 Eligibility and Benefits Verification 4-21

• Except in a medical emergency, the following information should be obtained/verified from a patient’s health plan before an encounter:– Patient’s general eligibility for benefits– Amount of the copayment for the visit, if one is

required– Whether the planned encounter is for a covered

service that is medically necessary under the payer’s rules

• Patients should be informed if their policy does not cover a planned service.


4.7 Preauthorization, Referrals, andOutside Procedures

4-22

• Managed care payers often require preauthorization before a patient:– sees a specialist,– is admitted to the hospital, or– has a particular procedure.

• If the payer approves the service, it issues a preauthorization number that must be entered in the PM and included on the claim.

• Referral number—authorization number given by a referring physician to the referred physician


4.8 Using Office Hours—Medisoft Network Professional’s Appointment Scheduler

4-23

The Office Hours window contains four main areas:– Provider selection box—selection box that

determines which provider’s schedule is displayed in the provider’s daily schedule

– Provider’s daily schedule—listing of time slots for a particular day for a specific provider that corresponds to the date selected in the calendar

– Office Hours calendar—interactive calendar that is used to select or change dates in Office Hours

– Office Hours patient information—area that displays information about the patient who is selected in the provider’s daily schedule


4.9 Entering Appointments 4-24

To enter an appointment in Medisoft Clinical:– Select the appropriate provider from within the Office

Hours program.– Choose an appointment time slot.– Complete the fields in the New Appointment Entry

dialog box.– Click the Save button to enter the information on the

schedule.


4.10 Booking Follow-up and RepeatingAppointments

4-25

• To create follow-up appointments in Office Hours:– Click the Go to a Date shortcut button on the toolbar;

the Go To Date dialog box will be displayed to allow a choice of date.

– After a future date option is selected, click the Go button to close the dialog box and begin the search.

– The future date will be located and displayed in the calendar schedule accordingly.


4.10 Booking Follow-up and RepeatingAppointments (Continued)

4-26

• To create repeating appointments in Office Hours:– Open the New Appointment Entry dialog box.– Click the Change button; the Repeat Change dialog

box is displayed.– Make selections and enter information in the Repeat

Change dialog box.– When done, click the OK button, and then the Save

button, to enter the repeating appointments on the schedule.


4.11 Rescheduling and Canceling Appointments

4-27

To locate an appointment that needs to be rescheduled:– Click the Appointment List option on the Office Hours

Lists menu; the Appointment List dialog box appears.– Use the Cut and Paste commands to move an

appointment.– Use the Cut command to cancel an appointment.


4.12 Creating a Patient Recall List 4-28

To create or maintain a recall list in MNP:– Click Patient Recall on the Lists menu; the Patient

Recall List dialog box is displayed.– Patients are added to the recall list by clicking the

New button in the Patient Recall List dialog box or by clicking the Patient Recall Entry shortcut button; the Patient Recall dialog box is displayed.

– After the information has been entered in the dialog box, click the Save button.


4.13 Creating Provider Breaks 4-29

• Office Hours break—block of time when a physician is unavailable for appointments with patients

• To set up a break for a current provider:– Click the Break Entry shortcut button; the New Break

Entry dialog box will appear.– Enter the information in the dialog box, and click the

Save button to enter the break(s).


4.14 Printing Schedules 4-30

• To print a provider’s schedule within Office Hours:– Use the Appointment List option on the Office Hours

Reports menu to view a list of all appointments for a provider for a given day.

– The report can be previewed on the screen or sent directly to the printer.

• Alternatively, click the Print Appointment List shortcut button.

Documents

CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 4 Scheduling