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15. Health Insurance Billing Procedures. Learning Outcomes. 15.1 Define Medicare and Medicaid. 15.2 Discuss TRICARE and CHAMPVA health-care benefits programs. 15.3 Distinguish between HMOs and PPOs. 15.4 Explain how to manage a workers’ compensation case. Learning Outcomes (cont.).

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Health insurance billing procedures


Health Insurance Billing Procedures

Learning outcomes
Learning Outcomes

15.1 Define Medicare and Medicaid.

15.2 Discuss TRICARE and CHAMPVA health-care benefits programs.

15.3 Distinguish between HMOs and PPOs.

15.4 Explain how to manage a workers’ compensation case.

Learning outcomes cont
Learning Outcomes (cont.)

15.5 List the basic steps of the health insurance claim process.

15.6 Describe your role in insurance claims processing.

15.7 Apply rules related to the coordination of benefits.

15.8 Describe the health-care claim preparation process.

Learning outcomes cont1
Learning Outcomes (cont.)

15.9 Explain how payers set fees.

15.10 Complete a Centers for Medicare and Medicaid Service (CMS-1500) claim form.

15.11 Identify three ways to transmit electronic claims.


  • Health care claims = reimbursement

    • Accuracy = maximum appropriate payment

  • Medical assistant

    • Prepare claims

    • Review insurance coverage

    • Explain fees

    • Estimate charges for payers

    • Prepare claims

Basic insurance terminology

Medical insurance – written contract between a policy holder and a health plan

First Party – the patient or policy holder

Premium– the amount of money paid by the policy holder to the insurance carrier

Lifetime maximum benefit – a total sum that the health plan will pay out over the patient’s life

Basic Insurance Terminology

Basic insurance terminology cont
Basic Insurance Terminology (cont.)

  • Second Party–the physician who provides medical services

  • Benefits – payment by the insurance carrier for medical services provided

  • Third-party payer – the health plan that agrees to carry the risk of paying for services

  • Deductible–a fixed dollar amount paid or met once a year before third-party payers begin to cover expenses

Basic insurance terminology cont1
Basic Insurance Terminology(cont.)

  • Coinsurance– a fixed percentage of coverage charges after the deductible is met

  • Copayment– a small fee that is collected at the time of the visit

  • Exclusions– uncovered expenses

  • Formulary–a list of approved drugs

  • Elective procedure – one not required to sustain life

Basic insurance terminology cont2

Pre-authorization – approval in advance of the need for a specific procedure

Pre-certification – determination of whether the proposed procedure is a covered service under the patient’s insurance plan

Liability insurance – covers injuries caused by the insured or on their property

Disability insurance – insurance that is activated when the insured is injured or disabled

Basic Insurance Terminology(cont.)

Apply your knowledge
Apply Your Knowledge

What is the difference between first party, second party, and third-party payer?

ANSWER: The first party is the patient or owner of the policy; the second party is the physician or facility that provides services, and the third-party payer is the insurance company that agrees to carry the risk of paying for approved services.

Good Job!

Types of health plans
Types of Health Plans

  • Insurance companies

    • Rules about benefits and procedures

      • Manuals, printed or online

      • Representatives to assist

  • Sources of health plans

    • Group policies – through employer

    • Individual plans

    • Government plans

Fee for service plans
Fee-for-Service Plans

  • Oldest and most expensive type of plan

  • Covers costs of select medical services

  • Amount charged for services is determined by the physician

  • Amount paid for services is controlled by the insurance carrier

Managed care plans
Managed Care Plans

  • Controls both the financing and delivery of health care to policy holders

  • Both policy holders and physicians (participating physicians) are enrolled by the Managed Care Organizations (MCOs)

  • MCOs pay physicians in two ways

    • Contracted fees

    • Capitated fees – fixed amount per month to provide contracted services to patients enrolled in the plan

Managed care plans cont
Managed Care Plans (cont.)

  • Preferred Provider Organization (PPO)

    • A network of providers to perform services to plan members

    • Physicians in the plan agree to charge discounted fees

  • Health Maintenance Organization (HMO)

    • Physicians who contract with HMOs are often paid a capitated rate

    • Patients pay premiums and a small copayment for each office visit

Government plans
Government Plans

  • Health care

    • Retirees

    • Low-income and disadvantaged

    • Active or retired military personnel and their families

  • Maintain features of managed care plans


  • The largest federal program that provides health care to citizens aged 65 and older

  • Managed by the Centers for Medicare and Medicaid Services (CMS)

  • Part A

    • Hospital insurance available to anyone receiving social security benefits

    • No premium unless ineligible for social security benefits

Medicare cont
Medicare (cont.)

  • Part B

    • Covers physician services, outpatient services, and many other services

    • Available to United States citizens and permanent residents 65 and older

    • Participants must pay a premium

Medicare cont1

Part C – 1997

Provides choices in types of plans

Medicare Advantage plans



Private Fee for Service (PFFS)

Special Needs Plans

Medicare Medical Savings plan (MSA)

Part D –

Passed in 2003

Coverage began in 2006

Prescription drug plan

Medicare (cont.)

Medicare plans

Fee-for-Service: The Original Medicare Plan

Allows the beneficiary to choose any licensed physician certified by Medicare

An annual deductible fee

Medicare pays 80 percent and the patient pays 20 percent

Medigap plan – secondary insurance

Medicare Plans

Medicare advantage plans

Medicare Advantage Plans

Medicare plans cont
Medicare Plans (cont.)

  • Recovery Audit Contractor (RAC) Program

    • Designed to guard the Medicare Trust Fund

    • Identify improper payments




  • A health-benefit program designed for:

    • Low-income

    • Blind

    • Disabled patients

    • Temporary assistance to needy families

    • Foster children

    • Children born with disabilities

  • Not an insurance program

Medicaid cont
Medicaid (cont.)

  • Funded by the federal and state governments

  • Provides assistance such as:

    • Physician services

    • Emergency services

    • Laboratory and x-rays

    • Skilled nursing facility (SNF) care

    • Vaccines

    • Early diagnostic screening and treatment for minors

Medicaid cont1
Medicaid (cont.)


Accepting Assignment


Older or disabled patients unable to pay the difference between the bill and the Medicaid payment may qualify for both Medicaid and Medicare

Physicians agreeing to treat Medicaid patients also agree to the set amount for reimbursements

Medicaid cont2

  • Comply with state guidelines

    • Verify Medicaid eligibility

    • Ensure that the physician signs all claims

    • Authorization must be received in advance for medical services except in an emergency

    • Verify deadlines for claim submissions

    • Treat Medicaid patients with the same professionalism and courtesy that you extend to other patients

Types of health plans1

Department of Defense

Families of uniformed personnel and retirees

TRICARE for Life

Medicare-eligible military retirees 65 and older

Dependent spouses and children of veterans with disabilities

Surviving spouses and dependent children of veterans who died in the line of duty or from service-connected disabilities

Types of Health Plans



Blue cross and blue shield
Blue Cross and Blue Shield

  • A nationwide federation of nonprofit and for-profit service organizations that provide prepaid health-care services to subscribers

  • Specific plans for BCBS can vary greatly because each local organization operates under its own state laws

State children s health plan schip
State Children’s Health Plan (SCHIP)

  • Enacted in 1997 and reauthorized in 2009

  • State-provided health coverage for uninsured children in families that do not qualify for Medicaid

Types of health plans workers compensation
Types of Health Plans:Workers’ Compensation

  • Covers accidents or diseases incurred in the workplace

  • By federal law, employers must purchase a minimum amount of workers’ compensation insurance

Coverage Includes

  • Basic medical treatment

  • Weekly or monthly amount paid to patient while not employed

  • Rehabilitation costs

Verify coverage prior to procedures and treatments.

Apply your knowledge1
Apply Your Knowledge

A 72-year-old disabled patient is being treated at an office that accepts Medicaid. The total office visit is $165, but Medicaid will only reimburse a set fee of $125. In this situation, what is the most likely solution?



  • Bill the patient for the balance due.

  • Expect the balance to be paid at the time of service.

  • This patient probably has a secondary employer health insurance plan.

  • This patient may qualify for the Medi/Medi coverage.

The claims process an overview
The Claims Process: An Overview

  • Obtains patient information

  • Determines diagnosis and fees based on services provided

  • Records patient payments

  • Prepares health-care claims

  • Reviews the insurer’s processing of the claim

Services Provided by the Physician’s Office

The claims process an overview cont
The Claims Process: An Overview(cont.)

  • Gathering and reporting patient information

  • Verifying patient’s insurance coverage

  • Recording procedures and services performed

  • Recording applicable diagnosis and codes for each procedure performed

  • Filing insurance claims and billing patients

  • Reviewing and recording payments

Tasks Supported by Using a Billing Program

Obtaining patient information

Insurance information

Current employer

Employer address and telephone number

Insurance carrier and date of coverage

Insurance group plan

Insurance identification number

Name of subscriber or insured

Personal information


Home address

Telephone number

Date of birth

Social security number

Emergency contact person

Obtaining Patient Information

Obtaining patient information cont
Obtaining Patient Information (cont.)

  • Release signatures

    • Form to release insuranceinformation to insurance carrier

    • Form for assignment of benefits

  • Verify eligibility

    • Check effective date of coverage

Obtaining patient information cont1

Coordination of benefits

Legal clauses to prevent duplication of payment

Primary or main insurance plan pays first

Secondary or supplemental plan pays the deductible and co-payment

The Birthday Rule

Obtaining Patient Information (cont.)

If a husband and wife both have a family insurance plan, the insurance plan of the person born first becomes the primary payer.

Delivering services
Delivering Services

  • Physician’s services

    • Examines patient

    • Documents symptoms, diagnosis, and treatment plan in medical record

  • Medical coding

    • Translates the medical terminology into codes for reimbursement

Delivering services cont

Referrals to other services

The medical assistant

Secures authorization from the insurance company for additional services

Arranges an appointment for referred services

Delivering Services(cont.)

Preparing the health care claim
Preparing the Health-Care Claim

  • Filing the insurance claim

    • Once prepared, the physician reviews the claim

    • Usually transmitted to payer electronically

  • Time limits

    • Vary by company and state

    • Medicare and Medicaid

Insurer s processing and payment
Insurer’s Processing and Payment

Insurance claims are reviewed for:

  • Medical necessity

  • Allowable benefits

  • Payment and remittance advice

Insurer s processing and payment cont
Insurer’s Processing and Payment (cont.)

  • Remittance advice (RA)

    • Sent with payment to patient and physician

    • Also known as explanation of benefits (EOB)

  • Information the RA Form

    • Insured name and identification number

    • Name of beneficiary

    • Claim number

    • Date, place, and type of service

    • Amount billed and amount allowed

    • Amount of copayment and payments made

    • Notation of any services not covered

Reviewing the insurer s ra and payment
Reviewing the Insurer’s RA and Payment

  • Verify all information on the remittance advice (RA) line by line

  • If a claim is rejected, check the diagnosis codes for accuracy

  • Track all unpaid claims using either a follow-up log or computer automation

Apply your knowledge2


Apply Your Knowledge

A patient had two appointments in the same week for different ailments. On Monday, the patient complains of back pain and receives a prescription for a muscle relaxant. On Wednesday, the patient complains of hair loss. When the medical assistant files the claims, she accidentally codes the first visit diagnosis (muscle spasm) with the prescribed treatment for the second visit (hair loss) which was an anti-fungal shampoo. The insurance claim is probably rejected for which of the following reasons:

Allowable benefits


Medical necessity

Very Good!

Fee schedules and charges medicare payment systems rbrvs

The nationally uniform relative value

A geographic adjustment factor

Fee Schedules and Charges: Medicare Payment Systems—RBRVS

  • Resource-based relative value scale (RBRVS)

    • Payment system used byMedicare

Three Parts to an RBRVS Fee:

A nationally uniform conversion factor

The current annual Medicare Fee Schedule (MFS) is published by CMS in the Federal Register

Fee schedules and charges cont





Fee Schedule

Fee Schedules and Charges(cont.)

Payment Methods

Fee schedules and charges cont1
Fee Schedules and Charges (cont.)

  • Allowed charges

    • This represents the most the payer will pay any provider for that work

    • Other equivalent terms

Maximum allowable fee

Maximum charge

Allowed amount

Allowed fee

Allowable charge

Maximum charge

Billing the patient for the difference between the higher usual fee and a lower allowed charge is called balance billing

Fee schedules and charges cont2
Fee Schedules and Charges (cont.)

  • Contracted fee schedule

    • Fixed fee schedules for participating physicians

    • Non-covered services billed to patient

  • Capitation

    • The fixed prepayment for each plan member

    • Non-covered services billed to patient

Fee schedules and charges cont3
Fee Schedules and Charges (cont.)

  • Calculating patient charges

    • Depending on plan, patients may be obligated to pay

      • Premiums and deductibles

      • Copayments and coinsurance

      • Excluded and over-limit services

      • Balance billing

Communication with patients about charges

A practice may require patients to

Sign an assignment of benefits statement


Pay in full for services at the time provided

Remind patients of financial obligation

Ask patients to agree in writing to cost of procedures not covered by plan

Advance Beneficiary Notice of Noncoverage (ABN)

Communication with Patients About Charges

Communication with patients about charges cont
Communication with Patients About Charges(cont.)

  • Financial policy

    • Patient responsibility for payment for services

Unless other prior arrangements are made, payment is expected at the time service is delivered

Unassigned Claims

The patient is responsible for any amounts not covered by the insurance carrier

Assigned Claims

Copayments must be paid before patients leave the office

Managed Care Members

Apply your knowledge3
Apply Your Knowledge

What do you need to consider when calculating patient charges?

ANSWER:You need to consider whether the patient has met thedeductible, if the patient has to pay a copayment, if the service is excluded, or if the patient is over his/her limit for services.

Nice Job!

Preparing and transmitting health care claims

HIPAA claims


X12 837 Health Care Claim- official name

Information entered is called data elements

Data must be entered in CAPS in valid fields

No prefixes or special characters allowed

Preparing and Transmitting Health-Care Claims

Preparing and transmitting health care claims1
Preparing and Transmitting Health-Care Claims

  • Data elements – five major sections

    • Provider section –

      • Billing and rendering provider

      • Taxonomy information

    • Subscriber (insured or policyholder) section

    • Patient (may be the subscriber or another person) and payer section

    • Claim details

    • Services

Preparing and transmitting health care claims cont
Preparing and Transmitting Health-Care Claims(cont.)

  • Paper claims

    • A CMS-1500 paper form is used

    • May be mailed or faxed to the third-party payer

    • Not widely used as a result of HIPAA requirements

    • CMS-1500 requires 33 form indicators

Preparing and transmitting health care claims cont1
Preparing and Transmitting Health-Care Claims(cont.)

Transmission of Electronic Claims

Three major methods of transmitting

claims electronically

Direct transmission

to the payer

Direct data entry

Using a


Internet-based service that loads data elements directly into the health plan’s computer

Offices and payers exchange information directly by electronic data interchange (EDI)

  • Translates nonstandard data into standard format. Clearinghouse cannot create or modify data

Preparing and transmitting health care claims cont2

Generate clean claims by avoiding common errors

or incomplete service facility name, address, and identification for services rendered outside the office or home

Medicare assignment indicator or benefits assignment indicator

part of the name or the identifier of the referring provider

or invalid subscriber’s birth date

information about secondary insurance plans, such as spouse’s payer

payer name and/or payer identifier

Preparing and Transmitting Health-Care Claims(cont.)


Preparing and transmitting health care claims cont3
Preparing and Transmitting Health-Care Claims(cont.)

  • Claims security

    • The HIPAA rules

      • Standards for protecting individually identifiable health information when maintained or transmitted electronically

    • Common security measures

      • Access control, passwords, and log files

      • Backup copies

      • Security policies to handle violations

Apply your knowledge4
Apply Your Knowledge

A medical assistant has two part-time positions, one for a pediatrician and the other for a surgeon. When completing the X12 837, which of the following would be a major difference?



  • Provider information

  • Taxonomy information

  • HIPAA identifiers

The taxonomy information would be very different because the physician preparation and licensing are very different.

In summary

 15.1 Medicare provides health care for citizens aged 65 and over, and certain patients under 65 may also qualify for Medicare. Medicaid is a health benefits program for low-income, blind or disabled patients, needy families, foster children, and children born with birth defects.

15.2 TRICARE is a health insurance plan for families of uniformed personnel and retirees from the uniformed services. CHAMPVA covers the expenses of families of veterans with total, permanent, service-connected disabilities, as well as the surviving spouses and children of veterans in this same category.

In Summary

In summary cont

15.3 HMOs generally seek services from a specific group of providers within their plan. PPOs establish a network of providers to perform services for their plan members.

15.4 Keep medical and financial records of workers’ compensation cases separate from other employee records; verify coverage and maintain confidentiality.

15.5 The claims process consists of obtaining patient information, determining diagnosis and fees, recording charges and codes, preparing the claim, reviewing the processing of the claim and remittance advice, and making sure the payment comes into the office.

In Summary (cont.)

In summary cont1

15.6 Medical assistants gather and record patient information; verify coverage, record procedures and services performed; file claims; bill patients; and review and record payments.

15.7 The rules that determine the coordination of benefits are guidelines for payments from insurance companies.

15.8 Preparing the health-care claim consists of filing the claim, setting time limits for filing the claim, reviewing the claim for medical necessity, reviewing for allowable benefits, payment, and remittance advice.

In Summary (cont.)

In summary cont2

15. 9 Payers set fees based on the amounts that Medicare allows, geographic factors, a uniform conversion factor, practice costs, insurance, and the physician’s work.

15.10 The CMS-1500 form contains numbered items that refer to the patient and the patient’s insurance coverage.

15.11 Three ways to transmit electronic claims are to

Transmit claims directly to the clearinghouse

Use a clearinghouse to prepare and send claims

Use direct data entry using an Internet-based service

In Summary (cont.)

End of chapter 15
End of Chapter 15 allows, geographic factors, a uniform conversion factor, practice costs, insurance, and the physician’s work.

I am always doing that which I can not do, in order that I may learn how to do it.

~ Pablo Picasso