Medical insurance
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Medical Insurance. Lisa H. Young, RN, BSN MA Ed. Working with Medical Insurance and Billing Chapter 1. Three ways that medical insurance specialist help ensure the financial success of physician practices. (pages 3-7) Following all procedures carefully Communicating effectively

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Medical insurance

Medical Insurance

Lisa H. Young, RN, BSN MA Ed

Working with medical insurance and billing chapter 1

Working with Medical Insurance and BillingChapter 1

  • Three ways that medical insurance specialist help ensure the financial success of physician practices. (pages 3-7)

    • Following all procedures carefully

    • Communicating effectively

    • Using health information technology

Working with medical insurance and billing

Working with Medical Insurance and Billing

  • Covered and Uncovered services under medical insurance policies (pages 7-8)

    • Covered: primary care, emergency care, medical specialists’ services and surgery; eligible for members; listed under the schedule of benefits of an insurance policy

    • Non-covered: are identified by the insurance policy as services for which it will not pay

Working with medical insurance and billing1

Working with Medical Insurance and Billing

  • Indemnity and Managed Care Approaches to Health Plan Organizations (pages 9 – 11)

    • Indemnity: the payer protects the member against loss form the costs of medical services and procedures

    • Managed: Restricted choice of providers and treatments in exchange for lower premiums, deductibles, and other charges

Working with medical insurance and billing2

Working with Medical Insurance and Billing

  • Health maintenance organizations (HMO) control healthcare costs by:

    • Creating a restricted number of physicians for members

    • Controlling the use of services

    • Controlling drug costs

    • Using cost-sharing methods

      (pages 11 – 14)

Working with medical insurance and billing3

Working with Medical Insurance and Billing

  • Preferred provider organization (PPO)

    • Create a network of hospitals and other providers for members to use at negotiated, reduced fees

    • Are the most popular type of healthcare

    • Generally require the payment of premium and copayments from patients

      (pages 14 – 15)

Working with medical insurance and billing4

Working with Medical Insurance and Billing

  • Consumer-driven health plan (page 16)

    • CDHPs combine a high-deductible, low-premium PPO with a pretax savings account to cover out-of-pocket medical expenses up to the amount of the deductible

    • Comparison of Health Plan Options

      Table 1.2 on page 16

Working with medical insurance and billing5

Working with Medical Insurance and Billing

  • Three major types of medical insurance payers:

    • Private payers

    • Employer sponsored

    • Government-sponsored

      (pages 17 – 18)

Working with medical insurance and billing6

Working with Medical Insurance and Billing

  • Ten steps in Medical Billing Cycle (pages 18-24)

    • Preregister patients

    • Establish financial responsibility

    • Check in patients

    • Coding compliance

    • Billing compliance

    • Check out patients

    • Prepare and Transmit claims

    • Generate patient statements

    • Follow up payments and collections

Working with medical insurance and billing7

Working with Medical Insurance and Billing

  • Professionalism and etiquette contribute to career success

    • Vital quality for all office personnel

    • Develop skills and attributes to perform work successfully

    • Strong code of ethics

    • Correct etiquette

      (pages 25-27)

Working with medical insurance and billing8

Working with Medical Insurance and Billing

  • Professional certification for career advancement (pages 27-28)

    • Membership in a professional organization

    • Certification for a professional organization

    • Certification through education, experience, and an exam

Ehr hipaa and hitech chapter 2

EHR, HIPAA, and HITECHChapter 2

  • Accurate documentation with medical records (pages 36- 43)

  • Electric health records (EHRs)

    • Immediate access to health information

    • Computerized physician order management

    • Automated alerts and reminders

    • Electronic communication and connectivity

    • Patient support

    • Administration and report

    • Error reduction

Documentation of patient encounters

Documentation of Patient Encounters

  • Patient’s name

  • Encounter date and reason

  • Appropriate history and physical examination

  • Review of all tests that were ordered

  • Diagnosis

  • Plan of care, or notes on procedures or treatments that were given

  • Instructions or recommendations that were given to the patient

  • Signature of the provider who saw the patient

Patient medical record

Patient Medical Record

  • Biographical and personal information

  • Records of all communications

  • Records of prescriptions

  • Scanned records

  • Drug & environmental allergies

  • Up-to-date immunization record

  • Previous & current diagnoses

  • Records of referral letters

  • Hospital admissions

  • Records of missed or canceled appointments

  • Requests for information about the patient.

Ehr hipaa and hitech


  • HIPAA is a law designed to:

    • Protect people’s private health information

    • Health insurance coverage for employees with a change or lose of their jobs

    • Uncover fraud and abuse

    • Standards for electronic transmission of healthcare transactions

      (pages 44 - 47)

Ehr hipaa and hitech1


  • ARRA of 2009 includes rules in the HITECH Act:

    • Provisions concerning the standards for electronic transmission of healthcare data

    • Guides the use of federal stimulus money to promote the adoption and meaningful use of health information technology, mainly using EHRs.

Ehr hipaa and hitech2


  • Covered entities and business associates

    • Covered entity is a health plan, healthcare clearinghouse, healthcare provider who transmits health information in electronic form

    • Business associates, such as a law firm or billing service, work for the covered entity and agree to follow HIPAA regulations to safeguard PHI

    • Electronic data interchange is used to facilitate transaction of information

      (pages 47-49)

Ehr hipaa and hitech3


  • HIPAA Privacy Rule (pages 49 - 57)

    • Regulates the use and disclosure of patients’ PHI

    • Use and disclosure of PHI is permitted for patients’ treatment, payment, and healthcare operations (TPO)

    • PHI may be released for court cases, workers’ compensation cases, statutory reports, and research

    • Providers are responsible for protecting their patients’ PHI

Her hipaa and hitech


  • Purpose of the HIPAA Security Rule

    • Protect the confidentiality, integrity, and availability of health information

    • Use of encryption, access control, passwords, log files, backups to replace items after damage, and by developing security policies to handle violations when they do occur.

      (pages 57 – 58)

Ehr hipaa and hitech4


  • HITECH Breach Notification Rule

    • Requires covered entities to notify affected individuals following the discovery of a breach of unsecured health information

    • Covered entities have specific breach notification procedures (see page 59)

    • Breach occurs, individuals involved must receive a notification of the breach, which includes 5 key points of information, pg 59.

      (pages 58 – 60)

Ehr hipaa and hitech5


  • Electronic Health Care Transactions and Code Sets (TCS) (pages 60- 62)

    • Establish standards for the exchange of financial and administrative data

    • Require covered entities to use common electronic transaction methods and code sets

    • Four National Identifiers are for employers, healthcare providers, health plans and patients

Ehr hipaa and hitech6


  • Guard against potentially fraudulent situations

    • Regulations have been enacted to prevent fraud and abuse in healthcare billing

    • OIG has the task of detecting healthcare fraud and abuse and related law enforcement

    • FCA prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim

    • FERA strengthens the provisions of the FCA

      (pages 63 – 66)

Ehr hipaa and hitech7


  • Enforcement of HIPAA (pages 66 – 68)

    • Reconcile differences in enforcement procedures

    • Office for Civil Rights enforces HIPAA privacy standards and CMS enforces all other standards

    • OIG combats fraud and abuse in health insurance and healthcare delivery

Ehr hipaa and hitech8


  • Compliance plans include:

    • Consistent written policies and procedures

    • Appointment of a compliance officer and committee

    • Training plans

    • Communication guidelines

    • Disciplinary systems

    • Ongoing monitoring and auditing of claim preparation

    • Responding to and correcting errors

    • A sign that the practice has made a good-faith effort to achieve compliance

      (pages 68 – 70)

Patient encounters and billing information chapter 3

Patient Encounters and Billing InformationChapter 3

  • Classifying patients as new or established

    • Gather accurate information from patients to perform billing and medical care

    • New patients (NP)are those who have not received any services form the provider within the past three years

    • Established patients (EP) have seen the provider within the past three years

    • Established patients review and update the information that is on file about them

      (page 78)

Patient encounters and billing information

Patient Encounters and Billing Information

  • Five categories of information required of new patients (pages 78 – 87)

    • Basic personal preregistration and scheduling information

    • Patient’s detailed medical history

    • Insurance data for the patient or guarantor

    • A signed and dated assignment of benefits statement by the policyholder

    • Signed Acknowledgement of Receipt of Notice of Privacy Practices authorizing the practice to release the patient’s PHI for TPO purposes

Patient encounters and billing information1

Patient Encounters and Billing Information

  • Information for established patients is updated:

    • Patient information forms are reviewed once a year by the patient

    • Patients are asked to double-check their information at their encounters

    • The PMP is updated to reflect any changes needed

      (pages 87 – 89)

Patient encounters and billing information2

Patient Encounters and Billing Information

  • Eligibility for insurance benefits:

    • The provider checks the patient’s information form and medical insurance card

    • Contacts the payer to verify the patient’s general eligibility for benefits and the amount of copayment or coinsurance that is due at the encounter

    • Planned encounter a covered service considered medically necessary by the payer

      (pages 90 – 93)

Patient encounters and billing information3

Patient Encounters and Billing Information

  • Referral or preauthorization approval

    • Preauthorization is requested before a patient is given certain types of medical care

    • Referrals; the provider often needs to issue a referral number and a referral document in order for the patient to see a specialist under the terms of the medical insurance

    • Providers must handle these situations correctly to ensure that the services are covered if possible

      (pages 93 – 95)

Patient encounters and billing information4

Patient Encounters and Billing Information

  • Primary insurance for patients who have more than one health plan:

    • Patient information forms, insurance cards

    • Provider determines which policy is the primary insurance

    • Information entered in PMP and communication with payers are performed

      (pages 95 – 97)

Patient encounters and billing information5

Patient Encounters and Billing Information

  • Encounter forms:

    • Lists of medical practice’s most commonly performed services and procedures and often its frequent diagnosis

    • Provider checks off the services and procedures a patient received, and the encounter form is then used for billing

      (pages 98 – 100)

Patient encounters and billing information6

Patient Encounters and Billing Information

  • Eight types of charges collected from patients at the time of encounter:

    • Previous balance

    • Copayments

    • Coinsurance

    • Non-covered or over-limit fees

    • Charges of nonparticipating providers

    • Charges for self-pay patients

    • Deductibles for patients with CDHPs

    • Charges for supplies and copies of medical records

      (pages 100 -102)

Patient encounters and billing information7

Patient Encounters and Billing Information

  • Real-time claims adjudication tools in calculating time-of-service payments

    • Allow the practice to view, at the time of service, what the health plan will pay for the visit and what the patient will owe

    • Provide valuable information and checks so that the practice and patients are aware of the expected costs and coverage

    • Inform or remind patients of the financial policy and give estimates of the bills they will owe

      (pages 102 – 105)

Patient encounters and billing information8

Patient Encounters and Billing Information

  • Purpose of ICD-10-CM (pages 113 – 114)

    • Diagnostic coding

    • Codes made of three to seven alphanumeric characters

    • Addenda to codes

Diagnostic coding icd 10 cm chapter 3

Diagnostic Coding: ICD-10-CMChapter 3

  • Organization of ICD-10-CM (pages 114 -115)

    • Two major parts; Tabular List & Alphabet Index

    • Alphabet Index:

      • Neoplasm Table

      • Table of Drugs and Chemicals

      • Index to External Causes

    • Conventions followed

Diagnostic coding icd 10 cm

Diagnostic Coding:ICD-10-CM

  • Alphabet Index (pages 115-118)

    • Structure

    • Content

    • Key conventions

Diagnostic coding cid 10 cm

Diagnostic Coding:CID-10-CM

  • Tabular List (pages 118 – 122)

    • Structure

    • Content

    • Key Conventions

Diagnostic coding icd 10 cm1

Diagnostic Coding:ICD-10-CM

  • ICD-10-CM Official Guidelines for Coding and Reporting (pages 123-128)

    • Rules for outpatient coding

      • Primary diagnosis first followed by current coexisting codintions

      • Sequelae

      • Code to the highest level of certainty

      • Code to the highest level of specificity

Diagnostic coding icd 10 cm2

Diagnostic Coding:ICD-10-CM

  • Steps for assigning correct ICD-10-CM diagnosis codes (pages 133-135)

    • Step 1: Review complete medical documentation

    • Step 2: Abstract the medical conditions form the visit documentation

    • Step 3: Identify the main term for each condition

    • Step 4: Locate the main term in the Alphabetic Index

    • Step 5: Verify the code in the Tabular List

    • Step 6: Check compliance with any applicable Official Guidelines and list codes in appropriate order

Diagnostic coding icd 10 cm3

Diagnostic Coding:ICD-10-CM

  • Difference between ICD-9-CM and ICD-10-CM codes (pages 135-137)

    • 10 offers major advantages because many more categories for disease and other health-related conditions are available thus more flexibility for adding new codes in the future

    • Federal government has prepared GEMS to help coders transition from 9 to 10.

Procedural coding cpt and hcpcs chapter 5

Procedural Coding: CPT and HCPCSChapter 5

  • CPT Code Set (pages 144-146)

    • Category I codes: procedure codes found in the main body of CPT

    • Category II codes: optional CPT codes that track performance measures

    • Category III codes: temporary codes for emerging technology, services, and procedures

Procedural coding cpt and hcpcs

Procedural Coding: CPT and HCPCS

  • Organization of CPT (pages 146-151)

    • CPT Index

    • Six sections of Category I codes

      • Evaluation and Management

      • Anesthesia

      • Surgery

      • Radiology

      • Pathology and Laboratory

      • Medicine

Procedural coding cpt and hcpcs1

Procedural Coding:CPT and HCPCS

  • CPT format and symbols (pages 151 – 153)

    •  (bullet or black circle)

    • ▲ (triangle)

    • ►◄ (facing triangles)

    • + (plus sign)

    • (lightening bolt)

    • # (number sign)

Procedural coding cpt and hcpcs2

Procedural CodingCPT and HCPCS

  • Assigning modifiers to CPT codes

    (pages 153 – 156)

  • CPT Modifiers: Description and Common Use in Main Text Sections- Table 5.2 pg. 156

  • Modifiers are shown by adding a space and the two-digit code to the CPT code

Procedural coding cpt and hcpcs3

Procedural Coding:CPT and HCPCS

  • Six steps for selecting CPT procedure codes to patient scenarios. (pages 157- 159)

    • Step 1: review medical documentation

    • Step 2: medical procedures

    • Step 3: identify main term for procedures

    • Step 4: locate main terms in CPT Index

    • Step 5: verify the code in CPT main text

    • Step 6: determine the need for modifiers

Procedural coding cpt and hcpcs4

Procedural Coding:CPT and HCPCS

  • Using key components in selecting CPT Evaluation and Management codes

    (pages 159-171)

    • Step 1: category and subcategory of service table 5.3 page 160

    • Step 2: extent of history

    • Step 3: extent of the examination

    • Step 4: complexity of medical decision making

    • Step 5: requirements to report the service level

    • Step 6: service level

    • Step 7: complete documentation

    • Step 8: assign code

Procedural coding cpt and hcpcs5

Procedural Coding:CPT and HCPCS

  • Anesthesia section of CPT Category I codes (pages 172 – 173)

    • Physical status modifiers

    • Add-on codes

      • P1: healthy patient

      • P2: mild systemic disease

      • P3: severe systemic disease

      • P4: severe systemic disease –life threatening

      • P5: not expected to survive without surgery

      • P6: Brain-dead; organ donor

Procedural coding cpt and hcpcs6

Procedural Coding:CPT and HCPCS

  • Surgery section of CPT Category I Codes

    • Surgical packages include all the usual services in addition to the operation itself,

    • Separate procedures means that the procedure is usually done as an integral part of a surgical package, but no in all situations.

      (pages 173 – 177)

Procedural coding cpt and hcpcs7

Procedural Coding:CPT and HCPCS

  • Radiology section of CPT Category I codes (pages 177 – 179)

    • Two parts:

      • The technical component

      • The professional component

Procedural coding cpt and hcpcs8

Procedural Coding:CPT and HCPCS

  • Pathology and Laboratory section of CPT Category I codes (pages 179- 180)

    • Code for laboratory panels are bundled codes.

      Example of laboratory panel would be the electrolyte panel which requires:

      Carbon dioxide, chloride, potassium, and sodium

Procedural coding cpt and hcpcs9

Procedural Coding:CPT and HCPCS

  • Medicine section of CPT Category I codes (pages 180 – 182)

    • Immunization codes

Procedural coding cpt and hcpcs10

Procedural Coding:CPT and HCPCS

  • Category II vs Category III codes

    (page 182)

    • Category II & Category III codes both have five characters

    • Category II codes are for tracking performance

    • Category III codes are temporary codes for new procedures

Procedural coding cpt and hcpcs11

Procedural Coding:CPT and HCPCS

  • Purpose of HCPCS codes and its modifiers

    (pages 183 – 189)

    HCPCS: healthcare common procedure coding system

    Divided into 2 sections:

    Level 1 which are CPT codes

    Level 2 which are HCPCS codes

Visit charges and compliant billing chapter 6

Visit Charges and Compliant BillingChapter 6

  • Importance of code linkage on healthcare claims (page 198)

    • Determine the medical necessity of charges

    • Comply with all applicable regulations and requirements

    • Complaint with each payer’s rules

Visit charges and complaint billing

Visit Charges and Complaint Billing

  • Medicare’s Correct Coding Initiative (CCI)

    (pages 198- 203)

    • Edit formats

    • Medically unlikely edits

Visit charges and complaint billing1

Visit Charges and Complaint Billing

  • Types of coding and billing errors

    (pages 203 – 204)

    Errors relating to code linkage and

    Medical Necessity

    Errors relating to the coding process

    Errors relating to the billing process

Visit charges and complaint billing2

Visit Charges and Complaint Billing

  • Major strategies that ensure complaint billing (pages 205-208)

Visit charges and complaint billing3

Visit Charges and Complaint Billing

  • Use of audit tools to verify code selection

    (pages 208 – 213)

    • Selecting the Code

      • Extent of patient history- HPI (history of present illness

      • Location (where on the body)

      • Quality (character of pain)

      • Severity (rank of the symptom or pain scale)

      • Duration (how long the symptom)

      • Timing (when symptom or pain occurs)

      • Context (the situation that is associated with pain or symptom

      • Modifying factors (what has been done to change pain or symptoms

      • Associated signs and symptoms

Visit charges and complaint billing4

Visit Charges and Complaint Billing

  • Physician Fee Schedules

    (pages 213 – 215)

    Typical ranges of physician’s fees nationwide are published in commercial databases. Table 6.6 page 214

    Medical insurance specialists update the practice’s fee schedules when new codes are released.

Visit charges and complaint billing5

Visit Charges and Complaint Billing

  • Methods for setting payer fee schedules

    (pages 215 – 216)

    • Charge-based fee structures

      • UCR: usual, customary, and reasonable payment structure

    • Resource-based fee structures

    • Relative Value Scale (RVS)

    • Resource-Based Relative Value Scale (RBRVS)

Visit charges and complaint billing6

Visit Charges and Complaint Billing

  • Calculating RBRVS payments under the Medicare Fee Schedule (pages 216 – 218)

    • Determine procedure code for service

    • Use MPFS to find 3 RVUs

    • Use Medicare GPCI to find 3 practice cost indices

    • Multiply each RVU by the GPCI

    • Add the 3 adjusted totals, and multiply the sum by the annual conversion factor

    • Example page 217

Visit charges and complaint billing7

Visit Charges and Complaint Billing

  • Calculating payments for participating and nonparticipating providers

  • How balance billing regulations affect the charges due from patients

  • Examples pages 219 & 220

    (pages 218 – 221)

Visit charges and complaint billing8

Visit Charges and Complaint Billing

  • Capitation schedule (pages 221 – 222)

    • Billing for covered services

    • Billing for non-covered services

Visit charges and complaint billing9

Visit Charges and Complaint Billing

  • Patient Checkout Process

    (pages 222 – 224)

    • Payment using credit and debit cards must follow Payment Card Industry Data Security Standards (PCI DSS), Set requirements to safeguard payment card numbers, expiration dates, verification codes, and other personal data.

Healthcare claim preparation and transmission chapter 7

Healthcare Claim Preparation and Transmission Chapter 7

  • Electronic Claim Transaction

  • Paper Claim Form (pages 235 – 236)

    Example of CMS-1500 figure 7.1 page 237

Healthcare claim preparation and transmission

Healthcare Claim Preparation and Transmission

  • CMS-1500 Claim (pages 236 – 244)

    • Patient information section

Healthcare claim preparation and transmission1

Healthcare Claim Preparation and Transmission

  • Four different types of providers (page 244)

    • Billing provider

    • Pay-to provider

    • Rendering provider

    • Referring provider

Healthcare claim preparation and transmission2

Healthcare Claim Preparation and Transmission

  • CMS-1500 Claim (Page 244-256)

    • Physician information

    • Supplier information

Healthcare claim preparation and transmission3

Healthcare Claim Preparation and Transmission

  • HIPPA 837P Claim (pages 257-260)

    • Hierarchy of data elements

Healthcare claim preparation and transmission4

Healthcare Claim Preparation and Transmission

  • HIPAA 837P Claim Transaction (pgs. 260 – 266)

    • Five sections

      • Provider information

      • Subscriber information

      • Claim information

      • Service line information

Healthcare claim preparation and transmission5

Healthcare Claim Preparation and Transmission

  • Importance of checking claims prior to submission even with software (pages 266 -267)

Healthcare claim preparation and transmission6

Healthcare Claim Preparation and Transmission

  • Methods of electronic claims

    • Direct transmission approach

    • Clearinghouses

    • Online direct data entry (DDE)

Private payers bluecross blueshield chapter 8

Private Payers/BluecrossBlueshieldchapter 8

  • Employer-sponsored and self-funded health plans (pages 278 – 280)

    • Group Health Plans (GHPs)

    • Employees Health Benefits (FEHB) Program

    • Employee Retirement Income security Act (ERISA)

    • Summary Plan Description (SPD)

    • Third-party Claims Administrators (TPAs)

    • Administrative Services Only (ASO)

Private payers bluecross blueshield

Private Payers/BluecrossBlueshield

  • Major features of group health plans regarding eligibility, portability, and required coverage. (pages 280 – 282)

    • COBRA

    • HIPAA

Private payers bluecross blueshield1

Private Payers/BluecrossBlueshield

  • Provider payment under the various private payer plans (pages 283 – 286)

    • PPOs

    • HMOs and POS

    • Indemnity Plans

Private payers bluecross blueshield chapter 81

Private Payers/BluecrossBlueshieldchapter 8

  • Consumer-driven health plans use three types of funding options for out-of-pocket expenses (pages 286 – 289)

    • Reimbursement accounts

    • Health savings accounts

    • Flexible savings (spending) accounts

Private providers bluecross blueshield

Private Providers/BluecrossBlueshield

  • Major private payers (pages 289 – 293)

    • Provide complete insurance services:

      • Contracting with employers & with individuals to provide insurance benefits

      • Setting up physician, hospital, and pharmacy networks

      • Establishing fees

      • Processing claims

      • Managing the insurance risk

Private providers bluecross blueshield1

Private Providers/ BluecrossBlueshield

  • Participation contracts have five main parts (pages 293 – 297)

    • Introductory section

    • Contract purpose/covered medical services

    • Physician’s responsibilities

    • Plan’s responsibilities toward provider

Private providers bluecross blueshield2

Private Providers/BluecrossBlueshield

  • Contract plans (pages 298 – 303)

    • Collect copayments

    • Bill for surgical procedures

Private providers bluecross blueshield3

Private Providers/BluecrossBlueshield

  • Plan summary grids (pages 303 – 305)

    • What services are covered under the plan?

    • Which services are not covered?

    • What are the plan’s billing rules-the bundling and global periods?

    • What is the patient responsible for paying at the time of the encounter and after adjudication?

Private providers bluecross blueshield4

Private Providers/BluecrossBlueshield

  • Private Payer Claims (pages 305 – 311)

    • Preregister patients

    • Financial responsibility for visits

    • Check in patients

    • Review coding compliance

    • Check billing compliance

    • Check out patients

    • Prepare and transmit claims

Private providers bluecross blueshield5

Private Providers/BluecrossBlueshield

  • Billing for capitated services (pages 311 – 312)

Medicare chapter 9

Medicare Chapter 9

  • Eligibility requirements for Medicare program coverage (page 322)



  • Part A (Hospital Insurance)

  • Part B (Supplementary Medical Insurance)

  • Part C (originally called Medicare +Choice)

  • Part D (authorized under the Medicare Modernization Act)

    (pages 322 – 324)



  • Medicare Part B

    • Types of medical and preventive services covered

    • Types of medical and preventive services excluded (pages 324 – 329)



  • Process in assisting a patient to complete an ABN form correctly (pages 333-335)

    • Five sections and ten blanks must be completed

      • Header

      • Body

      • Options

      • Additional information

      • Procedures not reasonable or medically necessary



  • Calculate fees for nonparticipating physicians that do and do not accept assignment. (pages 336 – 338)



  • Original Medicare Plan Features

    (pages 338 – 340)



  • Medicare Advantage Plans (pages 340 – 341)

    • Features

    • Coverage offered



  • Medigap plans (pages 342 – 343)



  • Medicare program

  • Medical Review (MR) program

  • Recovery auditor program

  • ZPIC program

    (pages 343 – 347)



  • Preparing accurate Medicare primary claims (pages 347 – 350)

Medicaid chapter 10

Medicaid Chapter 10

  • Purpose of the Medicaid program (page 359)



  • General eligibility requirements (pages 359 – 362)



  • Income and asset guidelines used by most states to determine eligibility for Medicaid (pages 362 – 365)



  • The importance of verifying a patient’s Medicaid enrollment (pages 365 – 369)



  • Services Medicaid does not usually cover

    (pages 369 – 370)



  • Types of plans that states offer Medicaid recipients (pages 370 – 372)



  • Claim filing procedures when a Medicaid recipient has other insurance coverage

    (page 372)



  • Preparing accurate Medicaid claims

    (pages 372 – 374)

Tricare and champva chapter 11


  • Eligibility requirements for TRICARE (page 382)

Tricare and champva


  • TRICARE participating providers

  • TRICARE non-participating providers

    (pages 382 – 384)

Tricare and champva1


  • TRICARE programs (pages 384 – 387)

    • Standard

    • Prime

    • Extra

Tricare and champva2


  • TRICARE for life program (pages 387 – 388)

Tricare and champva3


  • Eligibility requirements for CHAMPVA

    (pages 388 – 392)

Tricare and champva4


  • Preparing TRICARE and CHAMPVA claims

    (pages 392 – 394)

Workers compensation and disability automotive insurance chapter 12

Workers’ Compensation and Disability/Automotive InsuranceChapter 12

  • Federal Workers’ Compensation Plans

    (pages 403 – 404)

    • Federal Employees’ Compensation Program

    • Longshore and Harbor workers’ Compensation Program

    • Federal Black Lung Program

    • Energy Employees’ Occupational Illness Compensation Program

Workers compensation and disability automotive insurance

Workers’ Compensation and Disability/Automotive Insurance

  • State Workers’ Compensation Benefits

    • Medical Expenses

    • Lost wages

      (pages 404 – 406)

Workers compensation and disability automotive insurance1

Workers’ Compensation and Disability/Automotive Insurance

  • Work-related injuries classifications (pages 406 – 408)

    • Injury without disability

    • Injury with temporary disability

    • Injury with permanent disability

    • Injury requiring vocational rehabilitation

    • Injury resulting in death

Workers compensation and disability automotive insurance2

Workers’ Compensation and Disability/Automotive Insurance

  • Responsibility of the physician’s record for a workers’ compensation case (Pages 408 – 414)

Workers compensation and disability automotive insurance3

Workers’ Compensation and Disability/Automotive Insurance

  • Social Security Disability Insurance (SSDI)

    page 415

  • Supplemental Security Income (SSI) pg. 415

  • Automotive Insurance (pages 416 – 417)

Payments ras appeals and secondary claims chapter 13

Payments (RAs), Appeals, and Secondary Claims Chapter 13

  • Claim adjudication process (pages 429 – 432)

Payments ras appeals and secondary claims

Payments (RAs), Appeals, and Secondary Claims

  • Procedure for following up on claims after they have been sent to payers (pages 432-436)

Payments ras appeals and secondary claims1

Payments (RAs), Appeals, and Secondary Claims

  • Remittance Advice (RA) (pages 436 – 442)

Payments ras appeals secondary claims

Payments (RAs), Appeals, Secondary Claims

  • Points reviewed on RA (pages 442 – 443)

    • Check the patient’s name, account number, insurance number and date of service against the claim

    • Verify that all billed CPT codes are listed

    • Check the payment for each CPT against the expected amount

    • Analyze the payer’s adjustment codes to locate all unpaid, downloaded, or denied claims for closer review

    • Pay special attention to RAs for claims submitted with modifiers

    • Decide whether any items on the RA need clarifying with the payer, and follow up as necessary.

Payments ras appeals secondary claims1

Payments (RAs), Appeals, Secondary Claims

  • Process for posting payments

  • Managing denials

    (pages 443 – 445)

Payments ras appeals secondary claims2

Payments (RAs), Appeals, Secondary Claims

  • Purpose of the appeal process

  • Steps for the appeal process

    (pages 445 – 448)

Payments ras appeals secondary claims3

Payments (RAs), Appeals, Secondary Claims

  • What may affect claim payments:

    • Appeals

    • Postpayment audits

    • Overpayments

      (pages 448 – 449)

Payments ras appeals secondary claims4

Payments (RAs), Appeals, Secondary Claims

  • Procedures for filing secondary claims

    (pages 449 – 450)

Payments ras appeals secondary claims5

Payments (RAs), Appeals, Secondary Claims

  • Procedures for complying with the Medicare Secondary Payer (MSP)

    (pages 451- 455)

Patient billing and collections chapter 14

Patient Billing and CollectionsChapter 14

  • Structure of a Financial Policy (pages 461 – 464)

Patient billing and collections

Patient Billing and Collections

  • Purpose of patient’s statements

  • Content of patient’s statements

  • Procedure for working patient’s statements (pages 464 – 467)

Patient billing and collections1

Patient Billing and Collections

  • Individual patient billing

  • Guarantor billing (pages 467 – 468)

Patient billing and collections2

Patient Billing and Collections

  • Responsibilities of each position in the medical office involved in billing and collections (pages 468 – 469)

Patient billing and collections3

Patient Billing and Collections

  • Process to collect outstanding balances

  • Methods to collect outstanding balances

    (pages 470 – 474)

Patient billing and collections4

Patient Billing and Collections

  • Federal laws that govern credit arrangements (pages 474 – 476)

    • Equal Credit Opportunity Act (ECOA)

    • Truth in Lending Act

Patient billing and collections5

Patient Billing and Collections

  • Tools used to locate unresponsive or missing patients (pages 476 – 479)

Patient billing and collections6

Patient Billing and Collections

  • Procedures for clearing uncollectible balances (pages 479 – 481)

Patient billing and collections7

Patient Billing and Collections

  • Purpose of a Retention Schedule

    (page 481)

Completing cms 1500 form

Completing CMS 1500 Form

  • Chapter 15

  • Claim Case Studies 15.1 = 15.20

  • Complete paper claim

  • Table 7.2 Selected Place of Service Codes


Ra secondary case studies

RA/ Secondary Case Studies

  • Chapter 16

  • Claim Case Studies 16.1- 16.24

Hospital billing and reimbursement chapter 17

Hospital Billing and Reimbursement Chapter 17

  • Hospital services (pages 530 – 540)

  • Inpatient

  • Outpatient

Hospital billing and reimbursements

Hospital Billing and Reimbursements

  • Major steps for hospital billing and reimbursement (pages 540 – 550)

Hospital billing and reimbursements1

Hospital Billing and Reimbursements

  • Coding diagnoses for hospital inpatient cases

  • Coding diagnoses for physician’s office

    (pages 551 - 552)

Hospital billing and reimbursements2

Hospital Billing and Reimbursements

  • Coding system used for hospital procedures (pages 552 – 555)

Hospital billing and reimbursements3

Hospital Billing and Reimbursements

  • Factors affecting the rate Medicare pays for inpatient services (pages 555 – 559)

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