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Lecture Medical assisting: Administrative and clinical procedures with anatomy and physiology (4/e) – Chapter 15

Chapter 15 - Health insurance billing procedures. Learning objectives of this chapter include: Define Medicare and Medicaid, discuss TRICARE and CHAMPVA health-care benefits programs, distinguish between HMOs and PPOs, explain how to manage a workers’ compensation case, explain how payers set fees, complete a Centers for Medicare and Medicaid Service (CMS-1500) claim form, identify three ways to transmit electronic claims. | 15 Health Insurance Billing Procedures 15- 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. 15- 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. 15- 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. 15- Introduction Health care claims = reimbursement Accuracy = maximum appropriate payment Medical assistant Prepare claims Review insurance coverage Explain fees Estimate charges for payers Prepare claims 15- Basic Insurance . | 15 Health Insurance Billing Procedures 15- 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. 15- 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. 15- 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. 15- Introduction Health care claims = reimbursement Accuracy = maximum appropriate payment Medical assistant Prepare claims Review insurance coverage Explain fees Estimate charges for payers Prepare claims 15- 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 15- 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 15- 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 .