In this chapter you will learn: 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. | 17 Insurance and Billing Learning Outcomes (cont.) Define the basic terms used by the insurance industry. Compare fee-for- service plans, HMOs, and PPOs. Outline the key requirements for coverage by the Medicare, Medicaid, TRICARE and CHAMPVA programs. Describe allowed charge, contracted fee, capitation and formula for RBRVS. Learning Outcomes (cont.) Outline the tasks performed to obtain the information required to produce an insurance claim. Produce a clean CMS-1500 health insurance claim form. Explain the methods used to submit an insurance claim electronically. Recall the information found on every payer’s remittance advice. Introduction Health care claims Reimbursement for services Accuracy = maximum appropriate payment Medical assistant Prepare claims Review insurance coverage Explain fees Estimate charges Understand payment explanation Calculate the patient’s financial responsibility Insurance claims are a critical part of the reimbursement process. It is important that claims be accurate so that medical practices receive the maximum appropriate payment for the services they provide. The medical assistant may: Prepare healthcare claims Review each patient’s insurance coverage Explain the physician’s fees Estimate what services are covered by payers Prepare the claims to be submitted for these charges Understand the payment explanation when it is returned with the payment from the payer Calculate the patient’s financial responsibility for the treatment and care not covered by the insurance carrier. Basic Insurance Terminology Medical insurance Policy holder Premium Benefits Dependents Lifetime maximum benefits Learning Outcome: Define the basic terms used by the insurance industry. Medical insurance, also known as health insurance, is a written contract in the form of a policy between a policyholder and a health plan. Policyholder – the insured, the member, or the subscriber. Premium – the . | 17 Insurance and Billing Learning Outcomes (cont.) Define the basic terms used by the insurance industry. Compare fee-for- service plans, HMOs, and PPOs. Outline the key requirements for coverage by the Medicare, Medicaid, TRICARE and CHAMPVA programs. Describe allowed charge, contracted fee, capitation and formula for RBRVS. Learning Outcomes (cont.) Outline the tasks performed to obtain the information required to produce an insurance claim. Produce a clean CMS-1500 health insurance claim form. Explain the methods used to submit an insurance claim electronically. Recall the information found on every payer’s remittance advice. Introduction Health care claims Reimbursement for services Accuracy = maximum appropriate payment Medical assistant Prepare claims Review insurance coverage Explain fees Estimate charges Understand payment explanation Calculate the patient’s financial responsibility Insurance claims are a critical part of
