Glencoe Medical Insurance, Student Textbook

by Bayes, Nenna L.; Keller, Cindy; Valerius, Joanne

• ISBN13: 9780028048796
• ISBN10: 0028048792
• Format: Paperback
• Copyright: 2000-11-15
• Publisher: McGraw-Hill Science/Engineering/Math

Summary

Glencoe Medical Insurance provides focused coverage of the knowledge and skills necessary for successful medical insurance processing, including in-depth coverage of medical insurance, the claims process, HCFA 1500, and UB-92. It covers all types of medical insurance including Blue Cross, Blue Shield, HMOs, PPOs, Medicare, Medicaid, and other plans. Managed care is integrated throughout the text, including discussion of contract law as it relates to managed care. There is an emphasis on practice management and patient finance. Optional exploratory computer activities use MediSoft for Windows Advanced. The focus in the text is on electronic claims filing but paper claims are covered as well. Unique to this text is an entire chapter emphasizing how crucial correct coding is to reimbursement and compliance with federal regulations.

Table of Contents

Preface	ix
PART 1 THE HEALTH CARE ENVIRONMENT	1	(102)
Introduction to Managed Care and Medical Insurance	2	(36)
The Health Care Industry	3	(3)
Insurance Basics	6	(2)
Medical Insurance Reimbursement	8	(2)
Medical Insurance Plans	10	(8)
Medical Insurance Payers	18	(2)
Regulations and Accreditation in Medical Insurance	20	(2)
Employment as a Medical Insurance Specialist	22	(9)
Chapter Review	31	(7)
Introduction to Claims Processing	38	(41)
Patient Medical Records	39	(9)
Overview of the Claim-Processing Sequence	48	(2)
Collection of Patient Information	50	(5)
Insurance Verification	55	(5)
Encounter Form Preparation and Coding	60	(3)
Linkage and Compliance Review	63	(1)
Provider Payment Calculations	64	(1)
Claims Preparation	65	(2)
Claims Transmission	67	(1)
Third-Party Payer Adjudication	67	(1)
Reimbursement Follow-up and Record Retention	68	(3)
Chapter Review	71	(8)
The Legal Environment	79	(24)
The Legal Medical Record	79	(2)
Safeguarding Confidential Information	81	(9)
Insurance Fraud and Abuse	90	(2)
Fraud and Abuse Prevention	92	(1)
Medical Professional Liability	93	(2)
Chapter Review	95	(8)
PART 2 PHYSICIAN CODING GUIDELINES	103	(112)
Diagnostic Coding: Introduction to ICD-9-CM	104	(34)
Introduction to Diagnostic Coding	104	(1)
The ICD-9-CM	105	(2)
Organization of the ICD-9-CM	107	(1)
The Alphabetic Index	107	(4)
The Tabular List	111	(5)
Supplementary Classifications	116	(2)
Coding Steps	118	(1)
Key Coding Guidelines	119	(5)
Codes for Circulatory Diseases, Neoplasms, Burns, and Fractures	124	(5)
Chapter Review	129	(9)
Procedural Coding: Introduction to CPT-4 and HCPCS	138	(47)
Introduction to Procedural Coding	138	(1)
Current Procedural Terminology, Fourth Edition (CPT-4)	139	(2)
The Index	141	(2)
The Main Text	143	(4)
CPT-4 Modifiers	147	(2)
The Appendixes	149	(1)
Coding Steps	150	(1)
Evaluation and Management Codes	151	(9)
Anesthesia Codes	160	(2)
Surgery Codes	162	(4)
Radiology Codes	166	(2)
Pathology and Laboratory Codes	168	(1)
Medicine Codes	169	(1)
HCPCS Codes	170	(4)
Chapter Review	174	(11)
Coding Linkage and Compliance	185	(30)
Introduction	185	(2)
Compliance Regulations	187	(6)
Fraudulent Actions and Compliance Errors	193	(3)
Strategies for Compliance: The Compliance Plan	196	(5)
Audits	201	(6)
Chapter Review	207	(8)
PART 3 CLAIMS PROCESSING	215	(92)
Provider Charges and Payment Methods	216	(30)
Introduction	216	(1)
Fee Structures	217	(6)
Payment Methods	223	(5)
Calculations of Patient Charges	228	(8)
Chapter Review	236	(10)
The Universal Health Insurance Claim Form: HCFA-1500	246	(31)
The Universal Claim Form	246	(1)
Completing the HCFA-1500	247	(11)
Claims Transmission	258	(6)
Electronic Claims and Administrative Simplification	264	(4)
Chapter Review	268	(9)
Claim Adjudication, Reimbursement Follow-up, and Record Retention	277	(30)
Introduction	277	(1)
Claim Adjudication	278	(4)
Claim Monitoring and Follow-up	282	(3)
Electronic Remittance Advice (ERA) Processing	285	(5)
Appeals, Postpayment Audits, and Refunds	290	(1)
Patient Billing and Collections	291	(6)
Record Retention	297	(2)
Chapter Review	299	(8)
PART 4 HEALTH CARE PAYERS	307	(216)
Managed Care Contracts and Private Payers	308	(35)
Introduction	308	(4)
Participation Contracts	312	(10)
Fee-for-Service Claim Management	322	(4)
Capitation Management	326	(1)
Private Payer Claim Completion	327	(5)
Chapter Review	332	(11)
Medicare	343	(56)
Introduction	343	(1)
Medicare Programs	344	(4)
Medicare Participation	348	(1)
Nonparticipating Providers	349	(3)
Types of Medicare Plans	352	(4)
Medigap and Supplemental Insurance	356	(4)
Medicare as the Secondary Payer	360	(2)
Filing Guidelines	362	(1)
Preparing Medicare Claims	363	(14)
Part B Appeals	377	(1)
Audits, Fraud, and Abuse	377	(5)
Chapter Review	382	(17)
Medicaid	399	(23)
Introduction	399	(1)
Federal Eligibility	400	(3)
State Programs	403	(2)
Medicaid Enrollment Verification	405	(1)
Covered and Excluded Services	405	(4)
Types of Plans	409	(1)
Payment for Services	410	(1)
Third-Party Liability	411	(1)
Claim Filing Guidelines	412	(1)
Medicaid Claim Completion	413	(2)
Chapter Review	415	(7)
Tricare and Champva	422	(27)
Introduction	422	(1)
Eligibility	423	(1)
Provider Participation and Nonparticipation	424	(1)
Tricare Standard	425	(3)
Tricare Prime	428	(1)
Tricare Extra	428	(1)
Tricare and Other Insurance Plans	429	(1)
Filing Claims	429	(8)
Fraud and Abuse	437	(1)
Champva	437	(4)
Chapter Review	441	(8)
Blue Cross and Blue Shield	449	(24)
Introduction	449	(1)
Eligibility	450	(1)
Blue Cross and Blue Shield Member Plans	450	(4)
BlueCard Program	454	(1)
Nationwide Accounts	454	(1)
Federal Employee Health Benefits Plan	455	(1)
Provider Participation and Nonparticipation	455	(3)
Coordination of Benefits	458	(1)
Claim Filing Guidelines	458	(7)
Chapter Review	465	(8)
Workers' Compensation and Disability	473	(24)
Introduction	473	(1)
Occupational Health and Safety Administration	474	(1)
Federal Workers' Compensation Plans	474	(1)
State Workers' Compensation Plans	474	(3)
Classification of Injuries	477	(1)
Workers' Compensation Terminology	478	(1)
Claims Process	479	(4)
Special Billing Notes	483	(1)
Disability Compensation Programs	484	(1)
Government Programs	484	(2)
Preparing Disability Reports	486	(1)
Chapter Review	487	(10)
Hospital Billing: The UB-92 Claim Form	497	(26)
Introduction	497	(1)
Health Care Facilities: Inpatient versus Outpatient	498	(2)
Hospital Claims Processing	500	(6)
Inpatient (Hospital) Coding	506	(2)
Payers and Payment Methods	508	(3)
Claims and Follow-up	511	(7)
Chapter Review	518	(5)
Appendix: Guide to MediSoft	523	(16)
References	539	(2)
Abbreviations	541	(1)
Glossary	542	(9)
Index	551