Higher health care costs and an aging population mean that medical providers are experiencing financial pressures and have an increasing need for knowledgeable patient account specialists.
Some important duties performed by patient account specialists are: (a) verifying patients' medical insurance coverage and other payment arrangements; (b) ensuring that government regulations are satisfied in all billing activities; (c) resolving problems so that pending claims can be sent; (d) completing insurance forms with technical accuracy; (e) following up on claims and bills that are denied or not paid; (f) answering questions about charges and payments; and (g) using interpersonal skills in dealing with insurance companies and patients.
Inpatient hospital services—offered by acute care facilities, skilled nursing homes, intermediate care facilities, and hospice centers—provide health care for patients whose conditions or treatments usually require overnight stays in the facility. Outpatient services—offered by some hospital departments (such as an emergency
department), ambulatory surgical centers, clinics, and home health agencies—provide care for patients whose conditions or treatments do not require overnight stays in a facility.
Indemnity medical insurance plans reimburse beneficiaries according to the contract's schedule of benefits in exchange for payment of a specified premium, deductible, and coinsurance. Managed care plans, in contrast, have contracts with both beneficiaries and providers that control the delivery and the cost of health care services. In exchange
for lower premiums and other cost reductions, plan members agree to a reduced choice of health care providers and tighter regulation of access to services.
Private-sector payers of medical insurance benefits are either for-profit or nonprofit organizations. Most private health insurance is employer sponsored, and much of this business belongs to very large national companies. Government-sponsored health care programs include Medicare, Medicaid, TRICARE, and CHAMPVA.
Payers use three main methods to pay hospitals for services: (a) costbased reimbursement, under which payments are based on the costs of treating the patient; (b) per diem, a set rate per day of hospitalization; and (c) prospective payment, under which the payer determines national averages in advance for hospital stays based on patients' diagnoses, taking into account factors that affect patients' outcomes.
Hospitals are regulated by the federal government and by state law. Several organizations also accredit them, providing information about patient satisfaction with their services.
Each facility has its own written guidelines regarding billing procedures that need to be followed to ensure compliance with federal regulations, private payer policies, and internal procedures. These policies are based on building good working relationships with patients and payers.
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) were written because of concern over the rising cost of health care. To cut back on the overhead associated with administrative and financial transactions, Title II required the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers, resulting in the current HIPAA Electronic Health Care Transactions and Code Sets standards. Title II also addressed the need for security and privacy of the health data that are exchanged electronically. This concern resulted in the HIPAA Privacy Rule and the HIPAA Security Rule. Finally, to enforce all the Administrative Simplification provisions legislated under HIPAA, the HIPAA Final Enforcement Rule was enacted.
