Insurance Handbook for the Medical Office

by Fordney, Marilyn Takahashi

• ISBN13: 9780721678863
• ISBN10: 0721678866
• Edition: 6th
• Format: Paperback
• Copyright: 1999-04-01
• Publisher: Elsevier Science Health Science div

Summary

-- The 25th Silver Anniversary Edition.
-- Updated to reflect all insurance changes important to those responsible for billing in the medical office.

This text is key for those who wish to become insurance billing specialists, claims assistance professionals, or electronic claims processors for physicians' practices and hospital outpatient clinics. Those already practicing in this area will also find this text beneficial, as would health claims examiner programs. Its goals are to increase efficiency and streamline administrative procedures for the most exasperating aspect of the doctor's office routine: insurance billing.
-- A free CD-ROM featuring the HCFA-1500 claim form is now included with the book.
-- The CD-ROM contains 10 scored patient case studies with related insurance information so that the student can practice completing the HCFA-1500 claim form in a fun, interactive format.
-- Offers guidance for all aspects of submitting, tracing, appealing, and transmitting claims for today's full range of health plans.
-- Important coverage of

Table of Contents

UNIT ONE CAREER ROLE AND RESPONSIBILITIES
A Career as an Insurance Billing Specialist	2	(18)
Role of the Insurance Billing Specialist	3	(2)
Educational and Training Requirements	5	(1)
Career Advantages	5	(1)
Personal Qualifications	6	(1)
Medical Etiquette	6	(3)
Medical Ethics	9	(6)
Confidentiality	13	(2)
Professionalism	15	(3)
Behavior	15	(1)
Qualifications	15	(1)
Personal Image	15	(1)
Certification	16	(2)
Keeping Current	18	(2)
Legal Issues Affecting Insurance Claims and Medical Records	20	(26)
Professional Liability	21	(1)
Employer Liability	22	(1)
Insurance Policies (Contracts)	22	(1)
Patient/Physician Contracts and Financial Responsibility	23	(1)
Physician and Managed Care Contracts	23	(1)
Confidentiality	23	(7)
Medical Records	23	(4)
Principles for Release of Information	27	(2)
Retention of Records	29	(1)
Subpoena	30	(3)
Insurance Claims	33	(3)
Guarantor	33	(1)
Assignment	33	(1)
Time Limits	33	(1)
Signature Authorization	33	(3)
Insurance Claim Fraud and Abuse	36	(1)
Fraud	36	(1)
Medicaid Fraud Control	37	(2)
Abuse	37	(1)
Federal False Claims Amendments Act	37	(1)
Health Insurance Portability and Accountability Act	38	(1)
Forgery	38	(1)
Claim Audits and Review	38	(1)
Embezzlement	39	(1)
Credit and Collection Laws	40	(1)
Appeals	40	(1)
Statute of Limitations	41	(1)
Medical Professional Liability Prevention	41	(3)
Prevention Commandments of American Medical Association Committee on Medicolegal Problems	41	(2)
Physician/Patient Agreement	43	(1)
Termination of a Case	43	(1)
Medicolegal References	44	(1)
Insurance Commissioners	44	(1)
State Board of Medical Examiners	44	(2)
UNIT TWO THE CLAIMS PROCESS
Basics of Health Insurance	46	(22)
Beginning Insurance Principles and Chapter Focus	47	(1)
History	47	(1)
The Insurance Policy	48	(4)
Policy Application	48	(1)
Policy Provisions	48	(1)
Coordination of Benefits	49	(1)
General Policy Limitations	49	(3)
Choice of Health Insurance	52	(1)
Group Contract	52	(1)
Individual Contract	52	(1)
Prepaid Health Plan	53	(1)
Types of Health Insurance Coverage	53	(2)
Examples of Insurance Billing	55	(1)
Basic Steps in Processing an Insurance Claim	56	(4)
Handling Insurance Claims	60	(6)
First Visit: Preregistration	60	(1)
Patient Registration Form	60	(3)
Insurance Identification Cards	63	(1)
Assignment of Benefits	64	(1)
Submitting and Tracing the Claim	65	(1)
Insurance Claims Register	65	(1)
Keeping Up-to-Date	66	(2)
Diagnostic Coding	68	(18)
Use of Coding System	69	(1)
Coding of Diseases	70	(2)
History	70	(1)
ICD-9-CM	70	(1)
ICD-10	71	(1)
ICD-9-CM Contents	71	(1)
How to Use the Diagnostic Code Books Properly	72	(6)
Coding Instructions	72	(1)
Basic Steps in Coding	73	(1)
Special Points to Remember in Volume 1	74	(1)
Special Points to Remember in Volume 2	75	(1)
Handy Hints in Diagnostic Coding	75	(1)
E Codes	75	(2)
V Codes	77	(1)
Rules for Coding Signs, Symptoms, and III-Defined Conditions	78	(5)
Rules for Coding Sterilization	78	(1)
Rules for Coding Neoplasms	79	(1)
Rules for Coding Circulatory System Conditions	80	(1)
Rules for Coding Diabetes Mellitus	81	(1)
Rules for Coding Pregnancy, Delivery, or Abortion	82	(1)
Rules for Coding Admitting Diagnoses	82	(1)
Rules for Coding Burns	82	(1)
Rules for Coding Injuries and Late Effects	82	(1)
Diagnostic Coding and the Physician's Fee Profile	83	(3)
Procedural Coding	86	(38)
Understanding the Importance of Procedural Coding Skills	87	(1)
Coding of Procedures	88	(1)
Current Procedural Terminology (CPT)	88	(1)
Relative Value Studies (RVS)	89	(1)
Methods of Payment	89	(1)
Vocabulary Used in Coding	90	(1)
Evaluation and Management Section	91	(5)
Unlisted Procedures	95	(1)
Basic Life and/or Disability Evaluation Services	96	(1)
Documentation	96	(6)
Documentation Guidelines for Evaluation and Management Services	96	(1)
General Principles of Medical Record Documentation	97	(1)
Documentation of History	97	(2)
Internal Audit	99	(2)
Cover Letter	101	(1)
Crib Sheets	101	(1)
Surgery Section	102	(1)
How to Use the CPT Code Book	102	(12)
Code Book Symbols	103	(1)
Code Modifiers	103	(2)
How to Code Effectively	105	(1)
Coding Tips	106	(8)
Relative Value Studies Variances	114	(2)
Determining Relative Value Studies Conversion Factors	115	(1)
Comprehensive List of Modifier Codes	116	(7)
Medicare Coding	123	(1)
Laboratory Abbreviations	123	(1)
The Health Insurance Claim Form	124	(36)
History	125	(3)
Types of Claims	128	(1)
Abstracting from Medical Records	128	(3)
Medical and Diagnostic Terminology	131	(7)
Procedures for Use of the Health Insurance Claim Form, HCFA-1500	138	(3)
General Guidelines	138	(3)
Common Reasons Why Claim Forms Are Rejected or Delayed	141	(2)
Completing an Optically Scanned Form	143	(1)
Optical Character Recognition	143	(1)
Optical Character Recognition or Intelligent Character Recognition Guidelines	143	(1)
Completing the Health Insurance Claim Form (HFCA-1500)	144	(13)
Explanation of Benefits	157	(3)
Electronic Data Interchange (EDI)	160	(16)
Background	161	(1)
Computer	162	(1)
Computer Claims Systems	163	(2)
Carrier-Direct	163	(1)
Clearinghouse	163	(1)
Electronic Claims Processor	164	(1)
Electronic Data-Interchange	165	(6)
Carrier Agreements	165	(1)
Signature Requirements	165	(1)
Workers' Compensation	165	(1)
Multipurpose Billing Forms	166	(1)
Crib Sheets	167	(1)
Eligibility Verification	167	(1)
Keying Insurance Data	167	(1)
Electronically Completing the Claim	167	(2)
Electronic Inquiry or Claims Status Review	169	(1)
Remittance Advice	170	(1)
Statements	170	(1)
Computer Confidentiality	171	(3)
Confidentiality Statement	171	(1)
Prevention Measures	171	(3)
Records Management	174	(2)
Data Storage	174	(2)
Tracing Delinquent Claims and Insurance Problem Solving	176	(24)
Claims Provisions	177	(1)
State Insurance Commissioner	177	(2)
Commission Objectives	177	(1)
Types of Problems	178	(1)
Commission Inquiries	178	(1)
Claim Management Techniques	179	(1)
Insurance Claims Register	179	(1)
Insurance Company Payment History	180	(1)
Tickler File	180	(1)
Problem Claims	180	(7)
Types of Problems	180	(1)
Delinquent, Pending, or Suspense	180	(3)
Lost Claims	183	(1)
Rejected Claims	183	(1)
Denied Claims	184	(1)
Downcoding	185	(1)
Partial Payment	186	(1)
Payment Paid to the Patient	186	(1)
Two-Party Check	186	(1)
Overpayment	186	(1)
Rebilling	187	(1)
Claim Inquiries	187	(1)
Review and Appeal Process	187	(13)
Blue Cross and Blue Shield Review and Appeal Process	189	(1)
TRICARE Review and Appeal Process	189	(2)
Federal Employees Appeal Process	191	(1)
Medicare Review and Appeal Process	191	(8)
Medigap	199	(1)
Office and Insurance Collections Strategies	200	(38)
Linda French, CMA-C Cash Flow Cycle	201	(2)
Accounts Receivable	202	(1)
Patient Education	202	(1)
Patient Registration Form	202	(1)
Fees	203	(10)
Fee Schedule	203	(1)
Fee Adjustments	204	(2)
Communicating Fees	206	(1)
Collecting Fees	207	(6)
Credit Arrangements	213	(2)
Payment Options	213	(2)
Credit and Collection Laws	215	(3)
Statute of Limitations	215	(1)
Equal Credit Opportunity Act	215	(2)
Fair Credit Reporting Act	217	(1)
Fair Credit Billing Act	217	(1)
Truth in Lending Act	217	(1)
Truth in Lending Consumer Credit Cost Disclosure	217	(1)
Fair Debt Collection Practices Act	218	(1)
The Collection Process	218	(20)
Office Collection Techniques	218	(4)
Insurance Collections	222	(4)
Collection Agencies	226	(1)
Credit Bureaus	227	(1)
Credit Counseling	227	(1)
Small Claims Court	228	(1)
Office Collection Problem Solving	229	(3)
Special Collection Issues	232	(6)
UNIT THREE HEALTH CARE PAYERS
Managed Care Systems and Special Plans	238	(22)
History	239	(2)
Prepaid Group Practice Health Plans	239	(2)
Health Care Reform	241	(1)
Managed Care Systems	241	(5)
Health Maintenance Organizations	241	(1)
Exclusive Provider Organization	242	(1)
Preferred Provider Organizations	242	(1)
TRICARE and Managed Care Programs	243	(2)
Medicare and Managed Care Programs	245	(1)
Medicaid and Managed Care Programs	245	(1)
Point of Service Plans	245	(1)
Physician Provider Groups	246	(1)
Triple Option Health Plan	246	(1)
Foundations for Medical Care	246	(1)
Medical Review	246	(1)
Professional Review Organizations	246	(1)
Utilization Review or Management	247	(1)
Management of Plans	247	(7)
Contacts	247	(1)
Preauthorization or Prior Approval	247	(3)
Laboratory and X-ray Tests	250	(1)
Managed Care Guide	250	(1)
Plan Administration	250	(4)
Financial Management	254	(2)
Statement of Remittance	254	(1)
Accounting	254	(1)
Fee of Service	254	(1)
Capitation and Year-End Evaluation	254	(2)
Bankruptcy	256	(2)
Special Plans	258	(2)
Individual Responsibility Plan	258	(1)
Optometric Service Plans	258	(2)
Private Insurance Plans	260	(20)
History of Insurance in the United States	261	(1)
Blue Cross	262	(1)
Blue Shield	262	(1)
Types of Coverage	262	(1)
Submission of Claims to Private Payers	262	(1)
Claims Submission to Self-Insured Employers	263	(1)
The Blue Plans	263	(17)
History and Purpose	263	(1)
Provider Relations Representatives	263	(1)
Special Clauses and Benefits	264	(1)
Types of Blue Cross and Blue Shield Contracts	264	(1)
Methods of Payment	264	(2)
Physician Participation Concept	266	(1)
BlueCard Program	266	(1)
Central Certification and Central Site Processing	266	(1)
Identifying Information	266	(2)
Blue Cross/Blue Shield and Medicare Claims	268	(1)
Managed Care	268	(1)
Medical Necessity Program	268	(1)
Technology Assessment	268	(1)
Preadmission Testing, Ambulatory Surgery, and Second Opinions	268	(1)
Standard Blue Plans Claims Procedure	269	(3)
Explanation of Benefits	272	(1)
Provider Number	273	(1)
Federal Employee Health Benefits Program	274	(6)
Medicaid and Other State Programs	280	(12)
History	281	(1)
Medicaid Qualified Medicare Beneficiaries Program	282	(1)
Medicaid Reform	282	(1)
Medicaid Eligibility	282	(2)
Benefits	284	(1)
Claim Procedure	284	(5)
Identification Card	284	(1)
Copayment	284	(1)
Prior Approval	285	(1)
Time Limit	285	(1)
Reciprocity	285	(1)
Claim Form	285	(1)
Remittance Advice	285	(1)
Appeals	285	(3)
Third Party Liability	288	(1)
Medicaid and Managed Care Plans	288	(1)
Medicaid TRICARE, and CHAMPVA	289	(1)
Medicaid and Medicare	289	(1)
Medicaid and Aliens	289	(1)
Helpful Hints	289	(1)
Maternal and Child Health Program (MCHP)	289	(3)
Eligibility	290	(1)
Claims Procedure	290	(2)
Medicare	292	(36)
Chartrand's Medicare Laws	293	(1)
Medicare Program	294	(6)
Eligibility Requirements	294	(1)
Fiscal Intermediaries and Fiscal Agents	294	(6)
Aliens on Medicare	300	(1)
Beneficiary Representative/Representative Payee	300	(1)
Medicare Payments	300	(3)
Civil Monetary Penalties Law	302	(1)
Medicare Health Insurance Card	302	(1)
Coverage	303	(5)
Hospital Benefits	303	(1)
Medical Benefits	304	(1)
Railroad Retirement Benefits	304	(1)
Physician Self-Referrals	304	(1)
Employed Elderly Health Care Coverage	305	(3)
Medicare Supplemental Insurance	308	(3)
Medigap	308	(1)
Medicare Secondary Payer (MSP)	309	(1)
Medigap and MSP Guidelines	309	(1)
Medigap and MSP Claims	309	(2)
Medicare and Prepayment Plans	311	(4)
Health Maintenance Organizations	311	(3)
Copayments	314	(1)
Carrier-Dealing Prepayment Organization	315	(1)
Automobile or Liability Insurance Coverage	315	(1)
Billing for a Deceased Patient	315	(1)
Medicare/Medicaid (Medi-Medi)	315	(6)
Benefits	315	(1)
Claim Procedure	315	(6)
Utilization and Quality Control	321	(1)
Peer Review Organization Program	321	(1)
Prior Authorization	321	(1)
Medicare Coding Tips	322	(6)
Medicare Claim Form	322	(3)
Electronic Claims Submission	325	(1)
Medicare Fraud and Abuse	325	(1)
Medicare Review and Appeal Process	325	(1)
Posting Medicare Payments	325	(3)
Tricare and Champva	328	(28)
Background	329	(9)
TRICARE	329	(1)
Defense Enrollment Eligibility Reporting System	330	(1)
Identification Cards	330	(6)
TRICARE Prime	336	(1)
TRICARE Extra	337	(1)
CHAMPVA Program	337	(1)
Privacy Act of 1974	338	(1)
Nonavailability Statement	338	(1)
Claims Procedure	339	(17)
TRICARE Standard and CHAMPVA	339	(3)
TRICARE Prime and TRICARE Extra	342	(1)
Claims Offices	342	(1)
Participating Providers	342	(1)
Nonparticipating Providers	342	(1)
Instructions for Completing a CHAMPVA Claim Form	343	(3)
Summary Payment Voucher	346	(1)
TRICARE/CHAMPVA and Other Insurance	346	(1)
Claim Submission	346	(2)
Dual or Double Coverage	348	(1)
Medicaid or Medigap	348	(1)
TRICARE and Medicare	348	(1)
CHAMPVA and Medicare	348	(1)
Third Party Liability	348	(1)
Workers' Compensation	348	(1)
Claims Inquiries and Appeals	348	(1)
Additional Information	348	(6)
Quality Assurance	354	(2)
Workers' Compensation	356	(38)
History	357	(3)
Benefits	358	(1)
Purposes of Workers' Compensation Laws	358	(1)
Workers' Compensation Reform	359	(1)
Self-Insurance	359	(1)
Managed Care	359	(1)
Coverage of Federal Laws	360	(1)
Coverage of State Laws	360	(3)
Funding	360	(2)
Minimum Number of Employees	362	(1)
Waiting Periods	363	(1)
Types of State Compensation Benefits	363	(1)
Types of State Claims	363	(6)
Nondisability Claim	363	(3)
Temporary Disability Claim	366	(2)
Permanent Disability Claim	368	(1)
Rating	368	(1)
Fraud and Abuse	369	(2)
Employee	369	(1)
Employer	369	(2)
Insurer	371	(1)
Medical Provider	371	(1)
Lawyer	371	(1)
Occupational Safety and Health Administration (OSHA) Act of 1970	371	(1)
Background	371	(1)
Coverage	371	(1)
Regulations	371	(1)
Filing a Complaint	371	(1)
Inspection	372	(1)
Recordkeeping, Posting, and Reporting	372	(1)
Special Circumstances	372	(4)
Third Party Subrogation	372	(1)
Medical Testimony	372	(1)
Independent Medical Examination	373	(1)
Depositions	373	(1)
Liens	374	(1)
Second-Injury Fund (Subsequent Injury Fund)	375	(1)
Unemployment Compensation Disability and Workers Compensation	376	(1)
Medical Reports	376	(6)
Confidentiality	376	(1)
Documentation	376	(1)
Recordkeeping	376	(1)
Terminology	376	(5)
Information to Be Included in Detailed Progress or Re-Examination Reports	381	(1)
Billing Claims	382	(6)
Financial Responsibility	382	(4)
Fee Schedules	386	(1)
Helpful Billing Tips	387	(1)
Electronic Claims Submission	388	(1)
Out-of-State Claims	388	(1)
Instructions for Completing the Doctor's First Report of Occupational Injury or Illness	388	(6)
Delinquent Claims	392	(2)
Disability Income Insurance and Disability Benefit Programs	394	(20)
Disability Claims	395	(1)
History	396	(1)
Disability Income Insurance	396	(2)
Individual	396	(1)
Group	397	(1)
Federal Disability Programs	398	(3)
Workers' Compensation	398	(1)
Disability Benefit Program	398	(3)
State Disability Insurance	401	(4)
Background	401	(1)
Funding	401	(2)
Eligibility	403	(1)
Benefits	403	(1)
Time Limits	404	(1)
Medical Examinations	404	(1)
Limitations	404	(1)
Voluntary Disability Insurance Plan	404	(1)
Instructions and Procedures for Claims Submission	405	(6)
Disability Income Claims	405	(1)
Federal Disability Claims	405	(3)
Veterans Affairs Disability Outpatient Clinic Claims	408	(3)
Administrative Guidelines for Disability Claim Procedures	411	(3)
State Disability Claims	411	(3)
UNIT FOUR INPATIENT AND OUTPATIENT BILLING
Hospital Billing	414	(30)
Patient Service Representative	415	(1)
Primary Functions	415	(1)
Principal Responsibilities	416	(1)
Medicolegal	416	(4)
Confidentiality	416	(2)
Reimbursement Methods	418	(2)
Appropriateness Evaluation Protocols	420	(1)
Utilization Review	420	(1)
Peer Review Organization	420	(1)
Inpatient Insurance Claims	421	(1)
Blue Plans	421	(1)
TRICARE and CHAMPVA	421	(1)
Managed Care	421	(1)
Medicaid	422	(1)
Medicare	422	(1)
Private Insurance (Group or Individual)	422	(1)
Workers' Compensation	422	(1)
Coding Procedures Using ICD-9-CM	422	(2)
ICD-9-CM Volume 3 Procedures: Tabular List and Alphabetic Index	422	(1)
Tabular List---Procedure Codes	422	(1)
Alphabetic Index	423	(1)
Special Points to Remember in Volume 3	423	(1)
Helpful Hints	423	(1)
Coding Procedures Using CPT	424	(1)
Current Procedural Terminology	424	(1)
Helpful Hints	424	(1)
Health Care Finance Administration Common Procedure Coding System	424	(1)
Hospital Billing Process	424	(1)
Admitting Clerk	424	(1)
Preadmission Testing	424	(1)
Attending Physician and Nursing Staff	424	(1)
Billing Charges and UB-92 Claim Form	424	(1)
Electronic Data Interchange	425	(1)
Payments	425	(1)
Outpatient Insurance Claims	425	(1)
Billing Problems	426	(1)
Billing Errors	426	(1)
Duplicate Statements	426	(1)
Double Billing	426	(1)
Phantom Charges	427	(1)
Posting Errors	427	(1)
Hospital Billing Claim Form	427	(10)
Uniform Bill Inpatient and Outpatient Claim Form	427	(1)
Instructions for Completing the UB-92 Claim Form	427	(10)
Diagnostic-Related Groups	437	(7)
History	437	(1)
The Diagnosis-Related Groups System	437	(2)
Diagnosis-Related Groups and the Medical Assistant/Insurance Billing Specialist	439	(1)
Helpful Handy Hints for the Physician's Practice	439	(2)
Diagnosis-Related Groups and Medical Records	441	(1)
Outpatient Classifications	442	(2)
UNIT FIVE EMPLOYMENT
Seeking a Position as an Insurance Billing Specialist	444	(109)
Employment Opportunities	445	(9)
Job Search	454	(7)
Insurance Billing Specialist	454	(1)
On-Line Job Search	454	(1)
Electronic Resume	455	(1)
Claims Assistance Professional	455	(3)
Application	458	(1)
Letter of Introduction	458	(1)
Resume	458	(3)
Interview	461	(1)
Self-Employment or Free-Lancing	461	(9)
Setting Up an Office	461	(4)
Finances	465	(1)
Equipment	465	(1)
Insurance	465	(1)
Marketing Advertising, Promotion, and Public Relations	465	(2)
Contracts or Agreements	467	(1)
Documentation	467	(1)
Statements and Pricing	467	(1)
Networking	467	(3)
APPENDICES
Appendix A: Addresses for Submitting Claims and Other Information	470	(46)
Appendix B: Reference List of Audiotapes, Books, Newsletters, Periodicals, Software, and Videotapes	516	(16)
Appendix C: Medi-Cal	532	(21)
Glossary	553	(18)
Index	571	(16)
How to Use the Student Software Challenge	587