Bài giảng Medical Assisting - Chapter 15: Processing Health Care Claims

Objectives 15-1 List the basic steps of the health insurance claim process. 15-2 Describe your role in insurance claims processing. 15-3 Explain how payers set fees. 15-4 Define Medicare and Medicaid. 15-5 Discuss TRICARE and CHAMPVA healthcare benefits programs. 15-6 Distinguish between HMOs and PPOs.

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Medical Assisting Chapter 15PowerPoint® to accompany Second EditionRamutkowski • Booth • Pugh • Thompson • Whicker ChapterCopyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.1Processing Health Care ClaimsObjectives15-1 List the basic steps of the health insurance claim process. 15-2 Describe your role in insurance claims processing.15-3 Explain how payers set fees.15-4 Define Medicare and Medicaid.15-5 Discuss TRICARE and CHAMPVA healthcare benefits programs.15-6 Distinguish between HMOs and PPOs.2 Processing Healthcare Claims Objectives (cont.)15-7 Explain how to manage a workers’ compensation case.15-8 Apply rules related to coordination of benefits.15-9 Describe the healthcare claim preparation process. 15-10 Complete a Centers for Medicare and Medicaid service (CMS-1500) claim form. 15-11 Identify three ways to transmit electronic claims. 3Basic Insurance TerminologyMedical insurance (health insurance) is a written contract policy between a policy holder and a health plan. Terms To KnowpremiumAmount of money paid by the policy holder to the insurance carrier. benefitsMedical services provided.First PartyThe patient policy holder.Second PartyThe physician who provides medical services.Third PartyThe health plan.4Deductible - a fixed dollar amount that must be paid or met once a year before third-party payers begin to cover expenses.Coinsurance - a fixed percentage of coverage charges after the deductible is met.Co-payment - a small fee that is collected at the time of the visit.Exclusions - uncovered expenses.Formulary - an approved list of drugs.Basic Insurance Terminology (cont.)5Liability InsuranceCovers injuries caused by the insured or on their property.Disability InsuranceInsurance that is activated when the insured is injured or disabled.Basic Insurance Terminology (cont.)6Types of Health PlansFee For ServicePlansManaged CarePlans Oldest and most expensive type of plan Covers costs of select medical services Amount services determined by the physicianControls both the financing and delivery of healthcare to policy holders.Both policy holders and physicians (participating physicians) are enrolled by the Managed Care Organizations (MCOs).In a capitated managed care plan, providers are paid a fixed amount regardless of the number of times the patient is seen by the physician.7Preferred 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 co-payment, often $10.Types of Health Plans (cont.)8Medicare is the largest federal program that provides healthcare to citizens aged 65 and older.Managed by the Centers for Medicare and Medicaid Services (CMS)Part AHospital insurance available to anyone receiving social security benefits.Part BCovers physician services, outpatient services, and many other services.Available to persons 65 and older that are US citizensA premium must be paid by all unlike Part A.Types of Health Plans (cont.)9Types of Medicare PlansFee-for-Service: The Original Medicare PlanAllows the beneficiary to choose any licensed physician certified by Medicare.A deductible was charged then Medicare paid 80 percent and the patient paid 20 percent. Medicare + Choice PlansAllows patients to sign up for one of three plans:Medicare Managed Care PlansMedicare Preferred Provider Organization Plans (PPOs)Medicare Private Fee-for-Service PlansTypes of Health Plans (cont.)10Types of Health Plans (cont.)Medicare Managed Care Plans Medical care is managed by a primary care physician (PCP) A small co-payment for each visit is required but no deductibles Some plans allow services from providers outside the networkMedicare Preferred Provider Organization PlanMedicare Private Fee-For-Service Plan Patients do not need a PCP No referrals are required Costs less to use referrals within the networkOperated by a private insurance companyCo-payment may be requiredPhysicians can bill patients for amount not covered by the plan11A health-benefit program designed for: Low-income  Blind  Disabled patients Temporary assistance to needy families Foster children  Children born with disabilitiesNot an insurance programFunded by the federal and state governmentProvides assistance such as:  Physician services  Emergency services  Laboratory and x-rays  SNF care  Vaccines  Early diagnostic screening and treatment for minorsTypes of Health Plans (cont.) Medicaid12Types of Health Plans (cont.) MedicaidMedicaidAccepting AssignmentMedi/MediPhysicians agreeing to treat Medicaid patients also agree to the set reimbursements.Older or disabled patients unable to pay the difference between the bill and the Medicaid payment may qualify for both Medicaid and Medicare.13State GuidelinesMedicaid cards are issued monthly, so always ask the patient for a current card.Ensure that the physician signs all claims.Authorization must be received in advance for medical services.Verify deadlines for claim submissions.Treat Medicaid patients with the same professionalism and courtesy that you extend to other patients.Types of Health Plans (cont.) Medicaid14Types of Health Plans (cont.) Tricare and ChampvaRun by the Defense DepartmentHealthcare benefit for families of uniformed personnel and retireesTRICARE for Life is offered to persons 65 and older that are eligible for both TRICARE and Medicare.Covers the expenses of dependent spouses and children of veterans with disabilitiesAlso covers surviving spouses and dependent children of veterans who died in the line of duty or from service-connected disabilitiesTRICARECHAMPVA15Types of Health Plans (cont.) Blue Cross and Blue Shield A nationwide federation of nonprofit and for-profit service organizations that provide prepaid healthcare services to subscribers.Specific plans for BCBS can vary greatly because each local organization operates under its own state laws.16Apply Your KnowledgeA 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 serviceThis patient more than likely has a secondary employer health insurance plan.This patient may qualify for the Medi/Medi coverage.- Answer17Insurance covering accidents or diseases incurred in the workplace.Federal law requires that employers purchase a minimum amount of workers’ compensation insurance.Coverage Includes Basic medical treatment Weekly or monthly amount paid to patient while not employed Rehabilitation costsWorkers’ Compensation18The Claims Process: An OverviewServices Provided by the Physician’s Office Obtain patient information Determine diagnosis and fees based on services provided Records patient payments Prepares healthcare claims Reviews the insurer’s processing of the claim Tasks Supported by usinga Billing Program Gathering and reporting patient information Verifying patient’s insurance coverage Recording procedures and services performed Filing insurance claims and billing patients Reviewing and recording payments19Obtaining Patient InformationPersonal Information Name Home address Telephone number Date of birth Social security number Emergency contact person Current employer Employer address and telephone number Insurance carrier and date of coverage Insurance group plan Insurance identification number Name of subscriber or insuredRelease SignaturesForm to release insurance information to insurance carrierForm for assignment of benefits20Coordination of BenefitsLegal clauses that prevent duplication of payment.Primary or main insurance plan pays first, and then the secondary or supplemental plan pays the deductible and co-payment.The Birthday RuleIf a husband and wife both have a family insurance plan, the insurance plan of the person born first will become the primary payer. 21Physician’s ServicesThe physician writes the diagnosis and treatment The medical assistant translates the medical terminology into codes for reimbursementReferrals to Other ServicesThe medical assistant may also be requested to secure authorization from the insurance company for additional services.Coordination of Benefits (cont.)22Insurer’s Processing and PaymentInsurance claims are reviewed for: Medical Necessity Allowable Benefits Payment and Explanation of Benefits23Payment and Remittance AdviceInformation found on the Remittance Advice (RA) Form:Insured name and identification numberName of beneficiaryClaim numberDate, place, and type of serviceAmount billed and amount allowedAmount of co-payment and payments madeNotation of any services not covered24Reviewing the Insurer’s Remittance Advice and PaymentVerify 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.25A patient has visited the medical office on two separate occasions within 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 rejected more than likely for which of the following reasons:Medical necessityPaymentsApply Your KnowledgeAllowable benefits- Answer26Fee Schedules and ChargesMedicare Payment System: RBRVSThe payment system used by Medicare is called the resource based relative value scale (RBRVS). Three Parts to an RBRVS Fee:A nationally uniform conversion factorThe nationally uniform relative valueA geographic adjustment factorThe current annual Medicare Fee Schedule (MFS) is published by CMS in the Federal Register.27Fee Schedules and Charges (cont.)Payment MethodsAllowed ChargesContractedFee ScheduleCapitation28Allowed ChargesThis represents the most the payer will pay any provider for that work.Other equivalent terms are:Fee Schedules and Charges (cont.)Maximum allowable feeMaximum chargeAllowed amountMaximum chargeAllowed feeAllowable chargeBilling the patient for the difference between the higher usual fee and a lower allowed charge is called balance billing.29Contracted Fee ScheduleFixed fee schedules are established particularly with PPOs and participating physicians.Participating providers can bill patients for procedures and services not covered by the plan.CapitationThe fixed prepayment for each plan member. Calculating Patient ChargesAll payers require patients to pay for non-covered services. Fee Schedules and Charges (cont.)30Communication with Patients About ChargesSome practices may require that the patient sign an assignment of benefits statement or that they pay in full for services at the time they are rendered.The policies should explain what is required of the patient and when payment is due.Unassigned ClaimsAssigned ClaimsManaged Care MembersUnless other prior arrangements are made, payment is expected at the time service is delivered.The patient is responsible for any amounts not covered by the insurance carrier. Co-payments must be paid before patients leave the office.31Preparing and Transmitting Healthcare ClaimsHIPAA ClaimsElectronic and predominately usedInformation entered is called data elementsX12 837 Health Care Claim is the official name Data must be entered in CAPS in only valid fieldsNo prefixes allowedPaper ClaimsA CMS-1500 paper form is usedMay be mailed or faxed to the third-party payerNot widely used as a result of HIPAA requirementsCMS-1500 require 33 form indicators32Preparing and Transmitting Healthcare Claims (cont.)Transmission of Electronic Claims There are three major methods of transmitting claims electronically:Direct transmission to the payerUsing a clearing houseDirect data entry33Preparing and Transmitting Healthcare Claims (cont.)Missing...Service facility name, address informationMedicare or benefitsassignment indicatorPart of the name or identifier ofthe referring providerOr invalid subscriber’s birth dateInformation about secondaryinsurance plansPayer name and/or identifierGenerating Clean Claims requires preventing common errors such as:34Preparing and Transmitting Healthcare Claims (cont.)Claims SecurityThe HIPAA rules set standards for protecting individually identifiable health information when maintained or transmitted electronically.Common security measures used consists of:Access control, passwords, and log files to keep intruders outBackups (saved copies of files)Security policies to handle violations that do occur35Tips for the Office/Data Elements for HIPAA Electronic ClaimsPay-to provider (the office) Rendering provider (the physician)The billing provider is the entity that transmits the claim to the payer.A taxonomy code is a 10-digit number representing the physician specialty.This code matches the physician’s : license  certification  educationReporting ProviderInformation Taxonomy Information  HIPAA National IdentifiersIdentifiers are numbers of predetermined length and structure like social security numbers. National identifiers must be established for: Employers  Health plans Healthcare providers  Patients36A medical assistant has two part-time positions. One for a pediatrician and the other position is for a surgeon. When completing the X12 837, which of the following would be a major difference:Taxonomy informationHIPAA identifiersApply Your KnowledgeThe taxonomy information would be very different since the physician preparations and licensing is very different.- Answer37End of ChapterEND OF CHAPTER38
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