Medical Insurance: An Integrated Claims

The sixth edition of Medical Insurance: An Integrated Claims Process Approach emphasizes the medical billing cycle—ten steps that clearly identify all the components needed to successfully manage the medical insurance claims process. The cycle shows how administrative medical professionals “follow the money.” Medical insurance specialists must be familiar with the rules and guidelines of each health plan in order to submit proper documentation, which then ensures that offices receive maximum, appropriate reimbursement for services provided. Each part of the book is dedicated to a section of the cycle followed by case studies to apply the skills discussed in each section. These case studies can be completed with the electronic CMS-1500 at www.mhhe.com/valerius6e or using simulated Medisoft exercises in Connect Plus, McGraw-Hill's homework and assessment platform.

Preface

Acknowledgments

Part 1 WORKING WITH MEDICAL INSURANCE AND BILLING

Chapter 1 Introduction to the Medical Billing Cycle

1.1 Working in the Medical Insurance Field

1.2 Medical Insurance Basics

1.3 Health Care Plans

1.4 Health Maintenance Organizations

1.5 Preferred Provider Organizations

1.6 Consumer-Drive Health Plans

1.7 Medical Insurance Payers

1.8 The Medical Billing Cycle

1.9 Achieving Success

1.10 Moving Ahead

Chapter Review

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

2.1 Medical Record Documentation: Electronic Health Records

2.2 Health Care Regulation: HIPAA and HITECH

2.3 Covered Entities and Business Associates

2.4 HIPAA Privacy Rule

2.5 HIPAA Security Rule

2.6 HITECH Breach Notification Rule

2.7 HIPAA Electronic Health Care Transactions and Code Sets

2.8 Fraud and Abuse Regulations

2.9 Enforcement and Penalties

2.10 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 Understanding Time-of-Service (TOS) Payments

3.9 Calculating TOS Payments

Chapter Review

Part 2 CLAIM CODING

Chapter 4 Diagnostic Coding: Introduction to ICD-10-CM

4.1 ICD-10-CM

4.2 Organization of ICD-10-CM

4.3 The Alphabetic Index

4.4 The Tabular List

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

4.6 Overview of ICD-10-CM Chapters

4.7 Coding Steps

4.8 ICD-10-CM and ICD-9-CM

Chapter Review

Chapter 5 Procedural Coding: CPT and HCPCS

5.1 Current Procedural Terminology, Fourth Edition (CPT)

5.2 Organization

5.3 Format and Symbols

5.4 CPT Modifiers

5.5 Coding Steps

5.6 Evaluation and Management Codes

5.7 Anesthesia Codes

5.8 Surgery Codes

5.9 Radiology Codes

5.10 Pathology and Laboratory Codes

5.11 Medicine Codes

5.12 Category II and III Codes

5.13 HCPCS

Chapter Review

Chapter 6 Visit Charges and Compliant Billing

6.1 Compliant Billing

6.2 Knowledge of Billing Rules

6.3 Compliance Errors

6.4 Strategies for Compliance

6.5 Audits

6.6 Physician Fees

6.7 Payer Fee Schedules

6.8 Calculating RBRVS Payments

6.9 Fee-Based Payment Methods

6.10 Capitation

Chapter Review

Part 3 CLAIMS

Chapter 7 Health Care Claim Preparation and Transmission

7.1 Introduction to Health Care Claims

7.2 Completing the CMS-1500 Claim: Patient Information Section

7.3 Types of Providers

7.4 Completing the CMS-1500 Claim: Physician/Supplier Section

7.5 The HIPAA 837P Claim

7.6 Completing the HIPAA 837P Claim

7.7 Checking Claims Before Transmission

7.8 Clearinghouses and Claim Transmission

Chapter Review

Chapter 8 Private Payers/BlueCross BlueShield

8.1 Private Insurance

8.2 Features of Group Health Plans

8.3 Types of Private Payers

8.4 Consumer-Driven Health Plans

8.5 Major Private Payers and the BlueCross BlueShield Association

8.6 Participation Contracts

8.7 Interpreting Compensation and Billing Guidelines

8.8 Private Payer Billing Management: Plan Summary Grids

8.9 Preparing Correct Claims

8.10 Capitation Management

Chapter Review

Chapter 9 Medicare

9.1 Eligibility for Medicare

9.2 The Medicare Program

9.3 Medicare Coverage and Benefits

9.4 Medicare Participating Providers

9.5 Nonparticipating Providers

9.6 Original Medicare Plan

9.7 Medicare Advantage Plans

9.8 Additional Coverage Options

9.9 Medicare Billing and Compliance

9.10 Preparing Primary Medicare Claims

Chapter Review

Chapter 10 Medicaid

10.1 The Medicaid Program

10.2 Eligibility

10.3 State Programs

10.4 Medicaid Enrollment Verification

10.5 Covered and Excluded Services

10.6 Plans and Payments

10.7 Third-Party Liability

10.8 Claim Filing and Completion Guidelines

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 Disability/Automotive Insurance

12.1 Federal Workers' Compensation Plans

12.2 State Workers' Compensation Plans

12.3 Workers' Compensation Terminology

12.4 Claim Process

12.5 Disability Compensation and Automotive Insurance Programs

Chapter Review

Part 4 CLAIM FOLLOW-UP AND PAYMENT PROCESSING

Chapter 13 Payments (RAs), Appeals, and Secondary Claims

13.1 Claim Adjudication

13.2 Monitoring Claim Status

13.3 The Remittance Advice (RA)

13.4 Reviewing RAs

13.5 Procedures for Posting

13.6 Appeals

13.7 Postpayment Audits, Refunds, and Grievances

13.8 Billing Secondary Payers

13.9 The Medicare Secondary Payer (MSP) Program, Claims, and Payments

Chapter Review

Chapter 14 Patient Billing and Collections

14.1 Patient Financial Responsibility

14.2 Working with Patients' Statements

14.3 The Billing Cycle

14.4 Organizing for Effective Collections

14.5 Collection Regulations and Procedures

14.6 Credit Arrangements and Payment Plans

14.7 Collection Agencies and Credit Reporting

14.8 Writing Off Uncollectible Accounts

14.9 Record Retention

Chapter Review

Chapter 15 Primary Case Studies

15.1 Method of Claim Completion

15.2 About the Practice

15.3 Claim Case Studies

Chapter Review

Chapter 16 RA/Secondary Case Studies

16.1 Method of Claim Completion of Secondary Claims

16.2 Handling Denied Claims

16.3 Processing Medicare RAs and Preparing Secondary Claims

16.4 Processing Commercial Payer RAs and Preparing Secondary Claims

16.5 Calculating Patients' BalancesChapter Review

Part 5 HOSPITAL SERVICES

Chapter 17 Hospital Billing and Reimbursement

17.1 Health Care Facilities: Inpatient Versus Outpatient

17.2 Hospital Billing Cycle

17.3 Hospital Diagnosis Coding

17.4 Hospital Procedure Coding

17.5 Payer and Payment Methods

17.6 Claims and Follow-up

Chapter Review

Chapter 18 Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM AVAILABLE AT WWW.MHHE.COM/VALERIUS6E

18.1 ICD-9-CM

18.2 Organization of ICD-9-CM

18.3 The Alphabetic Index

18.4 The Tabular List

18.5 Tabular List of Chapters

18.6 V Codes and E Codes

18.7 Coding Steps

18.8 Official Coding Guidelines

18.9 Introducing ICD-10-CM

Chapter Review

Appendix A Guide to Medisoft

Part 1: Getting Started with Medisoft

Part 2: Overview and Practice

Appendix B Guide to the Interactive Simulated CMS-1500 Form

Appendix C Place of Service Codes

Appendix D Professional Websites

Appendix E Forms

Abbreviations

Glossary

Index

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Medical Insurance: An Integrated Claims Process Approach

Summary

Table of Contents

Supplemental Materials

Preface

Acknowledgments

Part 1 WORKING WITH MEDICAL INSURANCE AND BILLING

Chapter 1

Introduction to the Medical Billing Cycle

1.1 Working in the Medical Insurance Field

1.2 Medical Insurance Basics

1.3 Health Care Plans

1.4 Health Maintenance Organizations

1.5 Preferred Provider Organizations

1.6 Consumer-Drive Health Plans

1.7 Medical Insurance Payers

1.8 The Medical Billing Cycle

1.9 Achieving Success

1.10 Moving Ahead

Chapter Review

Chapter 2

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

2.1 Medical Record Documentation: Electronic Health Records

2.2 Health Care Regulation: HIPAA and HITECH

2.3 Covered Entities and Business Associates

2.4 HIPAA Privacy Rule

2.5 HIPAA Security Rule

2.6 HITECH Breach Notification Rule

2.7 HIPAA Electronic Health Care Transactions and Code Sets

2.8 Fraud and Abuse Regulations

2.9 Enforcement and Penalties

2.10 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 Understanding Time-of-Service (TOS) Payments

3.9 Calculating TOS Payments

Chapter Review

Part 2 CLAIM CODING

Chapter 4

Diagnostic Coding: Introduction to ICD-10-CM

4.1 ICD-10-CM

4.2 Organization of ICD-10-CM

4.3 The Alphabetic Index

4.4 The Tabular List

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

4.6 Overview of ICD-10-CM Chapters

4.7 Coding Steps

4.8 ICD-10-CM and ICD-9-CM

Chapter Review

Chapter 5

Procedural Coding: CPT and HCPCS

5.1 Current Procedural Terminology, Fourth Edition (CPT)

5.2 Organization

5.3 Format and Symbols

5.4 CPT Modifiers

5.5 Coding Steps

5.6 Evaluation and Management Codes

5.7 Anesthesia Codes

5.8 Surgery Codes

5.9 Radiology Codes

5.10 Pathology and Laboratory Codes

5.11 Medicine Codes

5.12 Category II and III Codes

5.13 HCPCS

Chapter Review

Chapter 6

Visit Charges and Compliant Billing

6.1 Compliant Billing

6.2 Knowledge of Billing Rules

6.3 Compliance Errors