Chapter 1 introduces the environment in which patient account specialists work. In the growing health care industry, patient account specialists help ensure the financial health of facilities by performing important tasks such as checking patients' medical insurance coverage and following up on delayed or unpaid bills. They are employed by a number of different types of facilities. This chapter covers the major inpatient care facilities and then describes the facilities that provide outpatient care.

Because the topic is critical to the billing function, Chapter 1 also discusses the sources of the payments hospitals receive for their services. Some patients pay for the services themselves. Many patients have medical insurance that covers a portion of the bill, but they are also responsible for some costs. Medical insurance companies use various methods of calculating the payments for facilities' services, which are explained in the chapter.

Patient account specialists work in a regulated environment. Federal and state laws govern physicians and clinical and administrative hospital staff members to ensure high-quality health care services for all patients. This chapter presents the major regulatory agencies, the groups that review facilities, and the standards for business conduct.

Federal health care regulation under the Health Insurance Portability and Accountability Act (HIPAA) requires hospitals to protect the confidentiality of patient information. This chapter provides background information on HIPAA and discusses four key areas of HIPAA legislation—the Privacy Rule, the Security Rule, the Electronic Health Care Transactions and Code Sets Rule, and HIPAA enforcement.

Learning Objectives