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Understanding Health Insurance : A Guide to Billing and Reimbursement,9781401895952

Understanding Health Insurance : A Guide to Billing and Reimbursement

by ;
Edition:
8th
ISBN13:

9781401895952

ISBN10:
1401895956
Format:
Paperback
Pub. Date:
8/25/2005
Publisher(s):
CENGAGE Delmar Learning
List Price: $117.66

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Summary

Understanding Health Insurance: A Guide to Billing and Reimbursement, 8th Edition is a comprehensive source for teaching the subject of health insurance and reimbursement. The book contains chapters on introductory information on the health insurance field, managed health care, legal and regulatory issues, coding systems, reimbursement methodologies, coding for medical necessity, and common health insurance plans. Each chapter contains exercises to illustrate content and reinforce learning. Numerous opportunities are provided throughout the book for manual completion of CMS-1500 claims. A CD-ROM at the back of the book allows for electronic data entry of CMS-1500 claim form information. End of chapter review questions in objective format (e.g., multiple choice) test learners on their understanding of book content. Appendices I and II provide case studies that are also included on the Student Practice CD-ROM. Additional appendices provide instruction in dental claims processing and completion of the UB-92 (claim used for inpatient and outpatient hospital claims). The accompanying workbook provides application based assignments for each chapter, additional content review (multiple choice questions), and additional case studies for practice in completing CMS-1500 claims. This edition of the book contains the most up to date information regarding health insurance claims processing and coding and reimbursement issues.

Table of Contents

List of Tables
xi
Preface xiii
How to Use This Text xix
How to Use the Student Practice CD-ROM xxi
Health Insurance Specialist Career
1(12)
Health Insurance Overview
2(2)
Education and Training
4(1)
Job Responsibilities
5(4)
Professional Credentials
9(4)
Introduction to Health Insurance
13(16)
What Is Health Insurance?
15(1)
Automobile, Disability, and Liability Insurance
15(3)
Major Developments in Health Insurance
18(1)
Health Insurance Coverage Statistics
18(11)
Managed Health Care
29(18)
History of Managed Health Care
30(4)
Managed Care Organizations
34(4)
Six Managed Care Models
38(3)
Consumer-Directed Health Plans
41(1)
Accreditation of Managed Care Organizations
41(2)
Effects of Managed Care on a Physician's Practice
43(4)
Life Cycle of an Insurance Claim
47(40)
Insurance Claim Life Cycle
48(12)
Managing New Patients
60(8)
Managing Established Patients
68(1)
Managing Office Finances
68(4)
Maintaining Insurance Claim Files
72(3)
Credit and Collections
75(12)
Legal and Regulatory Issues
87(36)
Introduction to Legal and Regulatory Considerations
88(5)
Federal Laws and Events That Affect Health Care
93(7)
Retention of Records
100(1)
Medical Necessity
100(1)
Health Insurance Portability and Accountability Act
100(23)
ICD-9-CM Coding
123(62)
Overview of ICD-9-CM
125(2)
Outpatient Coding Guidelines
127(4)
ICD-9-CM Coding System
131(4)
ICD-9-CM Index to Diseases
135(5)
ICD-9-CM Tabular List (Diseases)
140(8)
Index to Procedures and Tabular List
148(1)
ICD-9-CM Index to Diseases Tables
149(11)
Supplementary Classifications
160(3)
Coding Special Disorders
163(4)
Considerations to Ensure Accurate ICD-9-CM Coding
167(1)
ICD-10-CM: Diagnostic Coding for the Future
168(17)
CPT Coding
185(62)
Overview of CPT
186(6)
CPT Categories, Subcategories, and Headings
192(3)
CPT Index
195(3)
CPT Modifiers
198(10)
Coding Procedures and Services
208(2)
Surgery Section
210(9)
Medicine Section
219(1)
Radiology Section
220(2)
Pathology/Laboratory Section
222(3)
Evaluation and Management Section
225(9)
Evaluation and Management Subsections
234(13)
HCPCS Coding
247(12)
Overview of HCPCS
248(1)
HCPCS Level II National Codes
249(6)
Determining Payer Responsibility
255(1)
Assigning HCPCS Level II Codes
256(3)
CMS Reimbursement Methodologies
259(24)
Historical Perspective of CMS Reimbursement Systems
260(1)
CMS Payment Systems
260(1)
Ambulance Fee Schedule
261(1)
Ambulatory Surgical Center Rates
262(1)
Clinical Laboratory Fee Schedule
263(1)
Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule
264(1)
Home Health Prospective Payment System
265(1)
Hospital Inpatient Prospective Payment System
265(3)
Hospital Outpatient Prospective Payment System
268(1)
Inpatient Psychiatric Facility Prospective Payment System
269(1)
Inpatient Rehabilitation Facility Prospective Payment System
269(2)
Long-Term Care Hospital Prospective Payment System
271(1)
Skilled Nursing Facility Prospective Payment System
272(1)
Medicare Physician Fee Schedule
273(10)
Coding for Medical Necessity
283(30)
Coding and Billing Considerations
288(3)
Coding from Case Scenarios
291(3)
Coding from Patient Records
294(19)
Essential CMS-1500 Claim Instructions
313(24)
Insurance Billing Guidelines
317(2)
Optical Scanning Guidelines
319(3)
Recovery of Funds from Responsible Payers
322(1)
Provider Identification Numbers
323(1)
Assignment of Benefits versus Accept Assignment
324(1)
Reporting Diagnoses: ICD-9-CM Codes
324(1)
Reporting Procedures and Services: HCPCS/CPT
325(3)
National Standard Employer Identifier Number
328(1)
Reporting the Billing Entity
329(1)
Processing Secondary Claims
330(1)
Common Errors That Delay Processing
331(1)
Final Steps in Processing Claims
332(1)
Maintaining Insurance Claim Files for the Practice
332(5)
Commercial Insurance
337(18)
Commercial Claims
338(1)
Claims Instructions
339(10)
Commercial Secondary Coverage
349(6)
Blue Cross and Blue Shield Plans
355(28)
History of Blue Cross and Blue Shield
356(4)
Blue Cross/Blue Shield Plans
360(4)
Billing Information Summary
364(2)
Claims Instructions
366(8)
BCBS Secondary Coverage
374(9)
Medicare
383(46)
Medicare Eligibility
385(1)
Medicare Enrollment
386(2)
Original Medicare Plan
388(2)
Medicare Part C
390(1)
Medicare Part D
391(1)
Medigap
392(1)
Participating Providers
393(1)
Nonparticipating Provider Restrictions
394(2)
Surgical Disclosure Notice
396(1)
Mandatory Claims Submission
397(1)
Private Contracting
398(1)
Advance Beneficiary Notice
398(2)
Experimental and Investigational Procedures
400(1)
Medicare as a Secondary Payer
400(4)
Medicare Summary Notice
404(1)
Billing Notes
404(3)
Claims Instructions
407(9)
Medicare with Medigap Claims
416(1)
Medicare-Medicaid Crossover Claims
417(1)
Medicare Secondary Payer Claims
418(3)
Roster Billing for Mass Vaccination Programs
421(8)
Medicaid
429(26)
Medicaid Eligibility
430(4)
Medicaid Covered Services
434(2)
Payment for Medicaid Services
436(4)
Billing Information Notes
440(2)
CMS-1500 Claims Instructions
442(7)
Medicaid as Secondary Claims
449(1)
Mother/Baby Claims
450(5)
Tricare
455(30)
Tricare Background
456(3)
Tricare Administration
459(1)
Champva
460(1)
Tricare Options
461(4)
Tricare Programs and Demonstration Projects
465(1)
Tricare Supplemental Plans
466(1)
Tricare Billing Information
467(3)
Claims Instructions
470(8)
Primary Tricare with a Supplemental Policy
478(1)
Tricare as Secondary Payer
478(7)
Workers' Compensation
485(152)
Federal Workers' Compensation Programs
486(2)
State Workers' Compensation Program
488(1)
Eligibility for Coverage
489(1)
Classification of Workers' Compensation Cases
489(1)
Special Handling of Workers' Compensation Cases
490(1)
Workers' Compensation and Managed Care
491(1)
First Report of Injury
491(3)
Progress Reports
494(2)
Appeals and Adjudication
496(1)
Fraud and Abuse
496(1)
Billing Notes
496(2)
Claims Instructions
498(11)
Appendices
Appendix I Case Studies: Set One
509(22)
Appendix II Case Studies: Set Two
531(48)
Appendix III Forms
579(8)
CMS-1500 Claim
580(1)
Coding Case Study Form
581(1)
Insurance Plan Comparison Chart
582(1)
E/M Codebuilder
583(4)
Appendix IV Answers to Coding Exercises
587(12)
Answers to ICD-9-CM Coding Exercises (Chapter 6)
587(3)
Answers to CPT Coding Exercises (Chapter 7)
590(3)
Answers to HCPCS Coding Exercises (Chapter 8)
593(1)
Answers to Coding for Medical Necessity Exercises (Chapter 10)
594(5)
Appendix V UB-92
599(18)
Appendix VI Dental Claims Processing
617(10)
Appendix VII Abbreviations
627(4)
Appendix VIII Common Medical Terminology: Prefixes, Suffixes, and Combining Forms
631(2)
Appendix IX Web Sites
633(4)
Bibliography 637(4)
Glossary 641(22)
Index 663(30)
Using the Student Practice CD-ROM 693


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