Medical Reimbursement: A Contextualized Method
Edition: 5
Copyright: 2023
Edition: 5
Copyright: 2023
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Medical Reimbursement: A Contextualized Method helps students navigate through the ins and outs of medical billing. An understanding of medical insurance and related terms is essential to the medical billing process. Healthcare is very expensive for a variety of reasons and, to remain profitable, medical providers must manage their “business” with the help of qualified employees who understand insurance benefits and the responsibility of reimbursement. Simply having medical insurance coverage does not necessarily mean that insurance will pay for all, or even part, of healthcare expenses. Some individuals by their own choice or by unforeseen circumstances, do not have insurance and are considered to be self-insured (or self-pay patients) and are, therefore, responsible for the entire cost of their own healthcare expenses.
CHAPTER 1: INTRODUCTION TO MEDICAL INSURANCE
Health Insurance History
Types of Payers
Managed Care
Health Maintenance Organizations
Preferred Provider Organizations
Consumer-Driven Health Plans
Government Payers
Medicare
Medicaid
Tricare
ChampVA
Workers’ Compensation
CHAPTER 2: LAWS AND REGULATORY REQUIREMENTS
Health Insurance Portability and Accountability Act
Federal False Claims Act
Civil Monetary Penalties Law
Patient Protection and Affordable Care Act
No Surprises Billing Act
CHAPTER 3: DOCUMENTING MEDICAL CARE
Patient Encounters
Telehealth Encounters
Preauthorization of Service or Procedure
Medical Coding
Procedures and Services (CPT) Coding
Guidelines for CPT coding
Evaluation and Management Codes
Diagnoses Coding
Guidelines for ICD-10-CM coding
Diagnosis-Related Groups
Procedure 3-1 Patient Encounters
Procedure 3-2 Completing a Preauthorization
Procedure 3-3 Completing a Precertification
Procedure 3-4 Utilizing Medical Necessity Guidelines
CHAPTER 4: PROFESSIONAL FEES AND REIMBURSEMENT
Practice Fee Schedules
Payer Reimbursement
Resource-based Relative Value Scale
Capitation
Discounted Fee-for-Service
Transformation of Health care Reimbursement
Procedure 4-1 Creating a Fee Schedule
CHAPTER 5: PRIVATE PAYERS
Group Health Plans
Managed Care Plans
Procedure 5-1 Interpreting Insurance Information and Verify Elibility for Services
CHAPTER 6: THE HEALTH INSURANCE CLAIM FORM
CMS-1500 Claim Form
Primary Claims
Secondary Payers
Tracking Unpaid Claims
Procedures 6-1, 6-2, 6-3, 6-4 Preparing Primary CMS-1500 Claims
Procedure 6-5 Preparing Secondary CMS-1500 Claim
CHAPTER 7: GOVERNMENT PAYERS AND WORKERS’ COMPENSATION
Medicare
Medicaid
Workers’ Compensation
Tricare
CHAMPVA
Procedure 7-1 Preparing Workers’ Compensation CMS-1500 Claim
Procedure 7-2 Preparing Medicare CMS-1500 Claim
CHAPTER 8: INTRODUCTION TO BOOKKEEPING
Procedure 8-1 Posting Charges to Ledgers
CHAPTER 9: REIMBURSEMENT FOR HEALTH CARE SERVICES
Posting Insurance Payments
Insurance Math Guidelines
Procedure 9-1 Posting Payments to Day Sheet
CHAPTER 10: ACCOUNT BALANCES AND GUARANTOR RESPONSIBILITY
Patient Statements
Precautions for Accepting Payments
Procedure 10-1 Creating Patient Statements
Procedure 10-2 Assist a Patient With an EOB
CHAPTER 11: DELINQUENT ACCOUNTS, COLLECTIONS, AND REFUNDS
Delinquent Accounts
Collection Agency Payments
Nonsufficient Funds Payments
Refunds
Procedure 11-1 Posting Refunds and Delinquent Transactions
CHAPTER 12: BANKING SERVICES
Accounts Receivable
Accounts Payable
Procedure 12-1 Posting to the Disbursement Journal
Procedure 12-2 Completing a Deposit Slip
CHAPTER 13: RECONCILIATION OF ACCOUNTS
Procedure 13-1 Reconciling a Bank Statement
Procedure 13-2 Posting Transactions and Reconciling a Day Sheet
Physicians Healthcare Services
Participating Provider Fee Schedule
Procedure 13-2
CHAPTER 14: MISCELLANEOUS PRACTICE EXPENSES
Petty Cash
Procedure 14-1 Completing Petty Cash Vouchers
Procedure 14-2 Completing Petty Cash Report
Objective: Prepare an Accurate Petty Cash Report
Procedure 14-3 Replenishing Petty Cash
CHAPTER 15: PAYROLL
Payroll Responsibilities
Payroll Processing
Procedure 15-1 Calculating Payroll