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Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
Survey of Medical Insurance pp ch01
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Survey of Medical Insurance pp ch01

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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 1.1 Explain the reason that employment opportunities for medical insurance specialists in physician practices are increasing rapidly. Pages: 4-6 Teaching Notes:   Ask students to describe, in their own words, the reasons why job opportunities are growing in the health care field. Highlight some examples of the employment positions that are in high-demand in the health care field for your students. (Such as health information technicians, medical assistants, and medical administrative support personnel.)
  • Learning Outcome: 1.2 Describe covered services and noncovered services under medical insurance policies. Pages: 6-8 Teaching Notes:   Have students identify the different parties involved in a medical insurance agreement, and explain their roles. (Such as the policyholder, health plan, payer, third-party payers, etc.)
  • Learning Outcome: 1.2 Describe covered services and noncovered services under medical insurance policies. Pages: 6-8 Teaching Notes:   Ask students to explain the reason that medical insurance companies use a schedule of benefits and require medical necessity to be demonstrated.
  • Learning Outcome: 1.2 Describe covered services and noncovered services under medical insurance policies. Pages: 6-8 Teaching Notes:   List some examples of commonly covered and noncovered services.
  • Learning Outcome: 1.2 Describe covered services and noncovered services under medical insurance policies. Pages: 6-8 Teaching Notes:   List some examples of commonly covered and noncovered services.
  • Learning Outcome: 1.3 Compare indemnity and managed care approaches to health plan organization. Pages: 8-10 Teaching Notes:   Ask students to explain the four conditions that must be met before an insurance company makes a payment. ((1) The charge is covered; (2) The patient’s premium is current; (3) The deductible has been met; (4) Coinsurance is taken into account.)
  • Learning Outcome: 1.3 Compare indemnity and managed care approaches to health plan organization. Pages: 8-10 Teaching Notes:   Ask students to explain the four conditions that must be met before an insurance company makes a payment. ((1) The charge is covered; (2) The patient’s premium is current; (3) The deductible has been met; (4) Coinsurance is taken into account.) Perform some examples, in class, showing how payments are calculated using coinsurance and deductibles. Use Figure 1.2 to help explain the process of making a payment under a fee-for-service agreement.
  • Learning Outcome: 1.3 Compare indemnity and managed care approaches to health plan organization. Pages: 8-10 Teaching Notes:   Ask students to explain, in their own words, why managed care has become the most common type of health insurance.
  • Learning Outcome: 1.4 Cite three examples of cost containment under health maintenance organizations. Pages: 10-14 Teaching Notes:   Demonstrate an example of a capitation payment arrangement in class. Use Figure 1.3 to help explain the process of making a payment under a capitation agreement.
  • Learning Outcome: 1.4 Cite three examples of cost containment under health maintenance organizations. Pages: 10-14 Teaching Notes:   Highlight the cost-containment methods that are implemented by HMOs. (Such as restricting patients’ choice of providers, requiring preauthorization for services, controlling the use of services, controlling drugs costs, and cost-sharing.)
  • Learning Outcome: 1.4 Cite three examples of cost containment under health maintenance organizations. Pages: 10-14 Teaching Notes:   Ask students to explain, in their own words, the reasons that some patients elect to use a POS plan rather than an HMO.
  • Learning Outcome: 1.5 Define a preferred provider organization. Pages: 14-16 Teaching Notes:   Have students explain the reasons why they think PPOs are the most popular type of insurance coverage.
  • Learning Outcome: 1.6 State the two elements that are combined in a consumer-driven health plan. Pages: 16-17 Teaching Notes:   Have students debate the advantages and disadvantages that CDHPs offer for the people they cover, as well as for the health plan and employers.
  • Learning Outcome: 1.7 Recognize the three major types of medical insurance payers. Pages: 17-18 Teaching Notes:   Have students investigate the services offered by some of the largest, private insurance companies. Use Figure 1.5 to show students the breakdown of insurance coverage.
  • Learning Outcome: 1.8 List the ten steps in the medical billing cycle. Pages: 18-26 Teaching Notes:   Ask students to identify the role(s) that they think a medical insurance specialist can play in each step of the medical billing cycle.
  • Learning Outcome: 1.8 List the ten steps in the medical billing cycle. Pages: 18-26 Teaching Notes:   Ask students to identify the role(s) that they think a medical insurance specialist can play in each step of the medical billing cycle.
  • Learning Outcome: 1.8 List the ten steps in the medical billing cycle. Pages: 18-26 Teaching Notes:   Ask students to identify the role(s) that they think a medical insurance specialist can play in each step of the medical billing cycle.
  • Learning Outcome: 1.8 List the ten steps in the medical billing cycle. Pages: 18-26 Teaching Notes:   Ask students to identify the role(s) that they think a medical insurance specialist can play in each step of the medical billing cycle.
  • Learning Outcome: 1.9 Define professionalism. Pages: 26-30 Teaching Notes:   In their own words, have students explain the roles that professionalism, ethics, and etiquette play in the medical office.
  • Learning Outcome: 1.10 Explain the purpose of certification. Pages: 30-32 Teaching Notes:   Examine the different certifications offered by the AHIMA with the class. Ask students to explain, in their own words, the reasons why certification is an important part of a career in the health care field.
  • Transcript

    • 1. 1 Introduction to the Medical Billing Cycle
    • 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>1.1 Explain the reason that employment opportunities for medical insurance specialists in physician practices are increasing rapidly. </li></ul><ul><li>1.2 Describe covered services and noncovered services under medical insurance policies. </li></ul><ul><li>1.3 Compare indemnity and managed care approaches to health plan organization. </li></ul><ul><li>1.4 Cite three examples of cost containment under health maintenance organizations. </li></ul><ul><li>1.5 Define a preferred provider organization. </li></ul>1-2
    • 3. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>1.6 State the two elements that are combined in a consumer-driven health plan. </li></ul><ul><li>1.7 Recognize the three major types of medical insurance payers. </li></ul><ul><li>1.8 List the ten steps in the medical billing cycle. </li></ul><ul><li>1.9 Define professionalism. </li></ul><ul><li>1.10 Explain the purpose of certification. </li></ul>1-3
    • 4. Key Terms <ul><li>accounts receivable (A/R) </li></ul><ul><li>adjudication </li></ul><ul><li>benefits </li></ul><ul><li>capitation </li></ul><ul><li>coinsurance </li></ul><ul><li>compliance </li></ul><ul><li>consumer-driven health plan (CDHP) </li></ul><ul><li>copayment </li></ul><ul><li>covered services </li></ul>1-4 <ul><li>deductible </li></ul><ul><li>diagnosis code </li></ul><ul><li>ethics </li></ul><ul><li>etiquette </li></ul><ul><li>excluded services </li></ul><ul><li>fee-for-service </li></ul><ul><li>health care claim </li></ul><ul><li>health maintenance organization (HMO) </li></ul><ul><li>health plan </li></ul><ul><li>indemnity plan </li></ul><ul><li>managed care </li></ul>
    • 5. Key Terms (Continued) <ul><li>managed care organization (MCO) </li></ul><ul><li>medical coder </li></ul><ul><li>medical insurance </li></ul><ul><li>medical insurance specialist </li></ul><ul><li>medical necessity </li></ul><ul><li>network </li></ul><ul><li>noncovered services </li></ul><ul><li>open-access plan </li></ul><ul><li>out-of-network </li></ul><ul><li>out-of-pocket </li></ul>1-5 <ul><li>participation </li></ul><ul><li>patient ledger </li></ul><ul><li>Patient Protection and Affordable Care Act (PPACA) </li></ul><ul><li>payer </li></ul><ul><li>per member per month (PMPM) </li></ul><ul><li>point-of-service (POS) plan </li></ul><ul><li>policyholder </li></ul><ul><li>practice management program (PMP) </li></ul>
    • 6. Key Terms (Continued) <ul><li>preauthorization </li></ul><ul><li>preexisting condition </li></ul><ul><li>preferred provider organization (PPO) </li></ul><ul><li>premium </li></ul><ul><li>preventive medical services </li></ul><ul><li>primary care physician (PCP) </li></ul><ul><li>procedure code </li></ul><ul><li>professionalism </li></ul><ul><li>provider </li></ul>1-6 <ul><li>referral </li></ul><ul><li>schedule of benefits </li></ul><ul><li>self-funded (self-insured) health plan </li></ul><ul><li>third-party payer </li></ul>
    • 7. 1.1 The Medical Insurance Field <ul><li>Spending on health care in the United States is rising due to the cost of advances in medical technology and an aging population </li></ul><ul><li>There are many job opportunities in the health care field as a result </li></ul>1-7
    • 8. 1.2 Medical Insurance Terms <ul><li>Medical insurance is a written policy that states the terms of an agreement between a policyholder (an individual) and a health plan (an insurance company) </li></ul><ul><li>Health plans provide benefits (payments for medical services) </li></ul><ul><li>Health plans are often referred to as payers </li></ul><ul><li>A third-party payer is a private or government organization that insures or pays for health care on behalf of beneficiaries </li></ul>1-8
    • 9. 1.2 Medical Insurance Terms (Continued) <ul><li>Insurance policies contain a schedule of benefits that summarizes payments that may be made for medical services </li></ul><ul><li>Payer’s definition of medical necessity determines coverage and payment </li></ul><ul><li>A provider must meet the payer’s professional standards </li></ul><ul><ul><li>Providers include physicians, nurse-practitioners, physician assistants, therapists, hospitals, laboratories, long-term care facilities, and suppliers such as pharmacies and medical supply companies </li></ul></ul>1-9
    • 10. 1.2 Medical Insurance Terms (Continued) <ul><li>Covered services may include primary care, emergency care, medical specialists’ services, and surgery </li></ul><ul><li>Preventive medical services include physical examinations, pediatric and adolescent immunizations, prenatal care, and routine screening procedures </li></ul>1-10
    • 11. 1.2 Medical Insurance Terms (Continued) <ul><li>Noncovered services are those not paid for by a health plan </li></ul><ul><li>Excluded services may include: </li></ul><ul><ul><li>Dental services, eye care, employment-related injuries, cosmetic procedures, or experimental procedures </li></ul></ul><ul><ul><li>Some other specific items </li></ul></ul><ul><ul><li>A preexisting condition— a medical condition diagnosed before the policy took effect </li></ul></ul>1-11
    • 12. 1.3 Health Care Plans <ul><li>An indemnity plan provides protection against loss </li></ul><ul><li>Physicians send the health care claim —a formal insurance claim that reports data about the patient and the services provided—to the payer on behalf of the patient </li></ul><ul><li>Patients pay a premium —the periodic payment they are required to make to keep a policy in effect </li></ul>1-12
    • 13. 1.3 Health Care Plans (Continued) <ul><li>Most policies have a deductible —the amount that the insured pays on covered services before benefits begin </li></ul><ul><li>Coinsurance is the percentage of each claim that the insured pays </li></ul><ul><li>Some patients must pay out-of-pocket expenses prior to benefits </li></ul><ul><li>Fee-for-service is a charging method based on each service performed </li></ul>1-13
    • 14. 1.3 Health Care Plans (Continued) <ul><li>Managed care offers a more restricted choice of providers and treatments in exchange for lower premiums, deductibles, and other charges </li></ul><ul><li>Managed care organizations (MCOs) establish links between provider, patient, and payer </li></ul>1-14
    • 15. 1.4 Health Maintenance Organizations <ul><li>A health maintenance organization (HMO) combines coverage of medical costs and delivery of health care for a prepaid premium </li></ul><ul><li>Participation means that a provider has contracted with a health plan to provide services to the plan’s beneficiaries </li></ul><ul><li>Capitation is a fixed prepayment to a provider for all necessary contracted services provided to each plan member </li></ul><ul><ul><li>Per member per month (PMPM) is the capitated rate </li></ul></ul>1-15
    • 16. 1.4 Health Maintenance Organizations (Continued) <ul><li>A network is a group of providers having participation agreements with a health plan </li></ul><ul><ul><li>Visits to out of-network providers are not covered </li></ul></ul><ul><li>HMOs often require preauthorization before the patient receives many types of services </li></ul><ul><li>When HMO members see a provider, they pay a specified charge called a copayment </li></ul><ul><li>HMO members choose a primary care physician (PCP) , who directs all aspects of their care </li></ul>1-16
    • 17. 1.4 Health Maintenance Organizations (Continued) <ul><li>Open-access plans are those HMOs that allow visits to specialists in the plan’s network without a referral </li></ul><ul><li>A point-of-service (POS) plan permits patients to receive medical services from non-network providers </li></ul>1-17
    • 18. 1.5 Preferred Provider Organizations <ul><li>A preferred provider organization (PPO) is an MCO where a network of providers supply discounted treatment for plan members </li></ul><ul><ul><li>Most popular type of health plan </li></ul></ul><ul><ul><li>Creates a network of physicians, hospitals, and other providers with negotiated discounts </li></ul></ul><ul><ul><li>Requires payment of a premium and often of a copayment for visits </li></ul></ul>1-18
    • 19. 1.6 Consumer-Driven Health Plans <ul><li>A consumer-driven health plan (CDHP) combines a high-deductible health plan with a medical savings plan </li></ul><ul><ul><li>The health plan is usually a PPO with a high deductible and low premiums </li></ul></ul><ul><ul><li>The savings account is used to pay medical bills before the deductible has been met </li></ul></ul>1-19
    • 20. 1.7 Medical Insurance Payers <ul><li>Three major types of medical insurance payers: </li></ul><ul><ul><li>Private payers—dominated by large insurance companies </li></ul></ul><ul><ul><li>Self-funded (self-insured) health plans— organizations that pay for health insurance directly and set up a fund from which to pay </li></ul></ul><ul><ul><li>Government-sponsored health care programs—includes Medicare, Medicaid, TRICARE, and CHAMPVA </li></ul></ul><ul><li>The Patient Protection and Affordable Care Act (PPACA) is health system reform legislation that introduced significant benefits for patients </li></ul>1-20
    • 21. 1.8 The Medical Billing Cycle <ul><li>A medical insurance specialist is a staff member who handles billing, checks insurance, and processes payments </li></ul><ul><li>To complete their duties, medical insurance specialists follow a 10-step medical billing cycle </li></ul><ul><ul><li>This cycle is a series of steps that leads to maximum, appropriate, timely payment </li></ul></ul>1-21
    • 22. 1.8 The Medical Billing Cycle (Continued) <ul><li>Step 1 – Preregister patients </li></ul><ul><li>Step 2 – Establish financial responsibility for visits </li></ul><ul><li>Step 3 – Check in patients </li></ul><ul><li>Step 4 – Check out patients </li></ul><ul><ul><li>A medical coder is a staff member with specialized training who handles diagnostic and procedural coding </li></ul></ul><ul><ul><li>The patient’s primary illness is assigned a diagnosis code </li></ul></ul>1-22
    • 23. 1.8 The Medical Billing Cycle (Continued) <ul><li>Step 4 – Check out patients (continued) </li></ul><ul><ul><li>Each procedure the physician performs is assigned a procedure code </li></ul></ul><ul><ul><li>Transactions are entered in a patient ledger —a record of a patient’s financial transactions </li></ul></ul><ul><li>Step 5 – Review coding compliance </li></ul><ul><ul><li>Compliance means actions that satisfy official requirements </li></ul></ul><ul><li>Step 6 – Check billing compliance </li></ul><ul><li>Step 7 – Prepare and transmit claims </li></ul>1-23
    • 24. 1.8 The Medical Billing Cycle (Continued) <ul><li>Step 8 – Monitor payer adjudication </li></ul><ul><ul><li>Accounts receivable (A/R) is the monies owed to a medical practice </li></ul></ul><ul><ul><li>Adjudication is the process of examining claims and determining benefits </li></ul></ul><ul><li>Step 9 – Generate patient statements </li></ul><ul><li>Step 10 – Follow up patient payments and handle collections </li></ul><ul><li>A practice management program (PMP) is business software that organizes and stores a medical practice’s financial information </li></ul>1-24
    • 25. 1.9 Working Successfully <ul><li>Professionalism is acting for the good of the public and the medical practice </li></ul><ul><li>Medical ethics are standards of behavior requiring truthfulness, honesty, and integrity </li></ul><ul><li>Etiquette is comprised of the standards of professional behavior </li></ul>1-25
    • 26. 1.10 Moving Ahead <ul><li>Certification is the recognition of a superior level of skill by an official organization </li></ul><ul><ul><li>Provides evidence to prospective employers that the applicant has demonstrated a superior level of skill on a national test </li></ul></ul>1-26

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