Loose Leaf for Insurance in the Medical Office

The seventh edition of Insurance in the Medical Office: From Patient to Payment emphasizes the medical billing cycle—ten steps that clearly identify all the components needed to successfully manage the medical insurance claims process. Studying this cycle shows how administrative medical assistants must first collect accurate patient information and then be familiar with the rules and guidelines of each health plan in order to submit proper documentation and follow up on payments. This ensures that offices receive maximum, appropriate reimbursement for services provided. Without an effective administrative staff, a medical office would have no cash flow! Insurance in the Medical Office is specifically targeted to Medical Assisting students and addresses the role they play in contributing to the financial success of the medical office.

Preface

Acknowledgments

CHAPTER 1 From Patient to Payment: Understanding Medical Insurance

1.1 Working with Medical Insurance

1.2 Paying for Medical Services

1.3 The Medical Billing Cycle

1.4 Using PM/EHRs: The Integrated Medical Documentation and Billing Cycle

1.5 Set for Success

Chapter Review

CHAPTER 2 Electronic Health Records, HIPAA, and HITECH: Sharing and Protecting Patients' Health Information

2.1 Medical Records and the Need for Accurate Documentation

2.2 Health Care Regulations

2.3 HIPAA Privacy Rule

2.4 HIPAA Security Rule and HITECH Breach Notification Rule

2.5 HIPAA Electronic Health Care Transactions and Code Sets

2.6 Avoiding Fraud and Abuse

2.7 Compliance Plans

Chapter Review

CHAPTER 3 Patient Encounters and Billing Information

3.1 New Versus Established Patients

3.2 Information for New Patients

3.3 Information for Established Patients

3.4 Verifying Patient Eligibility for Insurance Benefits

3.5 Determining Preauthorization and Referral Requirements

3.6 Determining the Primary Insurance

3.7 Working with Encounter Forms

3.8 Communications Are Key

Chapter Review

CHAPTER 4 Diagnostic Coding

4.1 ICD-10-CM

4.2 The Alphabetic Index

4.3 The Tabular List

4.4 Using External Cause Codes and Z Codes

4.5 ICD-10-CM Official Guidelines for Coding and Reporting

4.6 Assigning Diagnosis Codes

Chapter Review

CHAPTER 5 Procedural Coding

5.1 Introduction to Procedure Codes in the CPT

5.2 Coding Steps

5.3 Coding Evaluation and Management Services

5.4 Coding Surgical Procedures

5.5 Coding Laboratory Procedures and Immunizations

5.6 HCPCS Codes

Chapter Review

CHAPTER 6 Payment Methods and Checkout Procedures

6.1 Types of Health Plans

6.2 Methods for Setting Fees

6.3 Third-Party Contracts and Guidelines

6.4 Time-of-Service (TOS) Payments

6.5 Calculating TOS Payments

6.6 Checking Out Patients

Chapter Review

CHAPTER 7 Health Care Claim Preparation and Transmission

7.1 Preparing Claims Using Practice Management Programs

7.2 Health Care Claims

7.3 Completing the CMS-1500 02/12 Claim

7.4 The HIPAA Claim

7.5 Health Care Claim Transmission

7.6 Billing Secondary Payers

Chapter Review

CHAPTER 8 Private Payers/BlueCross and BlueShield

8.1 Private Insurance

8.2 Major Private Payers and the BlueCross BlueShield Association

8.3 Billing Guidelines Under Participation Contracts

8.4 Private Payer Claims

8.5 Capitation Management

Chapter Review

CHAPTER 9 Medicare

9.1 Medicare Overview

9.2 Part B Plans and Medigap Plans

9.3 Medicare Charges

9.4 Using the ABN

9.5 Medicare Secondary Payer

9.6 Claim Completion

Chapter Review

CHAPTER 10 Medicaid

10.1 Introduction to Medicaid

10.2 Medicaid Coverage

10.3 Medicaid Eligibility and Plans

10.4 Filing Medicaid Claims

Chapter Review

CHAPTER 11 TRICARE and CHAMPVA

11.1 The TRICARE Program

11.2 Provider Participation and Nonparticipation

11.3 TRICARE Plans

11.4 TRICARE and Other Insurance Plans

11.5 CHAMPVA

11.6 Filing Claims

Chapter Review

CHAPTER 12 Workers' Compensation and Automobile/Disability Insurance

12.1 Federal Workers' Compensation Plans

12.2 State Workers' Compensation Plans

12.3 Workers' Compensation Terminology

12.4 Claim Process

12.5 Automobile Insurance and Disability Compensation Programs

Chapter Review

CHAPTER 13 Claim Processing, Payments, and Collections

13.1 Health Plan Claim Processing by Payers

13.2 Processing the Remittance Advice

13.3 Appeals

13.4 Patient Billing and Adjustments

13.5 Collecting Outstanding Patient Accounts

13.6 Writing Off Uncollectible Accounts

13.7 Terminating the Provider-Patient Relationship

Chapter Review

CHAPTER 14 Hospital Insurance

14.1 Health Care Facilities: Inpatient Versus Outpatient

14.2 Hospital Billing Cycle

14.3 Inpatient (Hospital) Coding

14.4 Payers and Payment Methods

14.5 Claims and Follow Up

Chapter Review

CHAPTER 15 AVAILABLE AT WWW.MCGRAWHILLCREATE.COM

Dental Insurance

15.1 Introduction to Dental Terms

15.2 Dental Insurance

15.3 Processing Dental Claims

Chapter Review

CHAPTER 16 AVAILABLE AT WWW.MCGRAWHILLCREATE.COM

Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM

16.1 ICD-9-CM

16.2 Organization of ICD-9-CM

16.3 The Alphabetic Index

16.4 The Tabular List

16.5 Tabular List of Chapters

16.6 V Codes and E Codes

16.7 Coding Steps

16.8 Official Coding Guidelines

16.9 Introducing ICD-10-CM

Chapter Review

Appendix A Guide to Medisoft

Appendix B Guide to the Interactive Simulated CMS-1500 Form

Appendix C Professional Websites

Appendix D Forms

Abbreviations

Glossary

Index

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Loose Leaf for Insurance in the Medical Office

Summary

Table of Contents

Supplemental Materials

Preface

Acknowledgments

CHAPTER 1

From Patient to Payment: Understanding Medical Insurance

1.1 Working with Medical Insurance

1.2 Paying for Medical Services

1.3 The Medical Billing Cycle

1.4 Using PM/EHRs: The Integrated Medical Documentation and Billing Cycle

1.5 Set for Success

Chapter Review

CHAPTER 2

Electronic Health Records, HIPAA, and HITECH: Sharing and Protecting Patients' Health Information

2.1 Medical Records and the Need for Accurate Documentation

2.2 Health Care Regulations

2.3 HIPAA Privacy Rule

2.4 HIPAA Security Rule and HITECH Breach Notification Rule

2.5 HIPAA Electronic Health Care Transactions and Code Sets

2.6 Avoiding Fraud and Abuse

2.7 Compliance Plans

Chapter Review

CHAPTER 3

Patient Encounters and Billing Information

3.1 New Versus Established Patients

3.2 Information for New Patients

3.3 Information for Established Patients

3.4 Verifying Patient Eligibility for Insurance Benefits

3.5 Determining Preauthorization and Referral Requirements

3.6 Determining the Primary Insurance

3.7 Working with Encounter Forms

3.8 Communications Are Key

Chapter Review

CHAPTER 4

Diagnostic Coding

4.1 ICD-10-CM

4.2 The Alphabetic Index

4.3 The Tabular List

4.4 Using External Cause Codes and Z Codes

4.5 ICD-10-CM Official Guidelines for Coding and Reporting

4.6 Assigning Diagnosis Codes

Chapter Review

CHAPTER 5

Procedural Coding

5.1 Introduction to Procedure Codes in the CPT

5.2 Coding Steps

5.3 Coding Evaluation and Management Services

5.4 Coding Surgical Procedures

5.5 Coding Laboratory Procedures and Immunizations

5.6 HCPCS Codes

Chapter Review

CHAPTER 6

Payment Methods and Checkout Procedures

6.1 Types of Health Plans

6.2 Methods for Setting Fees

6.3 Third-Party Contracts and Guidelines

6.4 Time-of-Service (TOS) Payments

6.5 Calculating TOS Payments

6.6 Checking Out Patients

Chapter Review

CHAPTER 7

Health Care Claim Preparation and Transmission

7.1 Preparing Claims Using Practice Management Programs

7.2 Health Care Claims

7.3 Completing the CMS-1500 02/12 Claim

7.4 The HIPAA Claim

7.5 Health Care Claim Transmission

7.6 Billing Secondary Payers

Chapter Review

CHAPTER 8

Private Payers/BlueCross and BlueShield

8.1 Private Insurance

8.2 Major Private Payers and the BlueCross BlueShield Association

8.3 Billing Guidelines Under Participation Contracts

8.4 Private Payer Claims

8.5 Capitation Management