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Review Figure 10.1 on p. 239 and the Billing Workflow section on pp. 238-239 of Health Information and Technology Management . Write a 150- to 350-word response to the following: Discuss at least two components described in the Billing Workflow section in Ch. 10 of Health Information and Technology Management . How do these components affect health care reimbursement? Billing Workflow 1. Providers of all types verify patient insurance eligibility with the health plan, either prior to or during the admission or visit. Medical offices collect and post copays at the visit. 2. The patient is treated and discharged or checked out. 3. As you learned in Chapter 9 , the provider usually needs to bill a third party, the insurance plan, in order to receive payment. The insurance bill is called a claim . The first step in preparing the claim is to assign procedure codes for the services rendered and the supplies used and diagnosis codes representing the disease or medical condition. 4. Using these codes and the patient registration information, a computer program generates a paper or electronic claim to be sent to the insurance plan.Before the claim is sent to the insurance plan, an insurance or claim specialist reviews the claim to make sure there are no errors. Because of the volume of claims, a computer program is used to examine the claim data and identify problems. Once the claim is correct, it is sent to the insurance plan (usually electronically). 5. When the claim is received by the insurance plan, it is adjudicated. If the claim is correct, a payment is sent to the provider; this is called the remittance . A paper or electronic document is generated that explains the amounts that were paid. This is called the remittance advice or explanation of benefits (EOB). 6. When the remittance is received by the provider, the payment amount is recorded in the patient accounts system. Frequently, the amount billed does not equal the amount paid. This may be the result of a contractual agreement that stipulates that the provider will accept a discounted payment and/or that a portion of the charges is the patient’s obligation. An accounting entry called a write-down adjustment is posted to adjust the charge. 7. If the patient has a secondary insurance plan, a claim is next sent to the second plan. In certain cases the first plan will automatically forward the claim to the second plan. This is called a “piggyback” claim or coordination of benefit (COB) claim. For example, when a Medicare patient has a supplemental insurance policy with the fiscal intermediary who processes the Medicare claims, the company will sometimes process the secondary claim automatically. This eliminates the need for the provider to file a second claim. These are also known as crossover claims. 8. Most health plans require the patient to pay a portion of the medical bill. These payments are referred to as the copay, coinsurance, and deductible amou ...
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Tynisa Anderson Week 2 Discussion COLLAPSE The life cycle of an insurance claim has four stages: Claims submission and electronic data intechange (EDI) Claims processing Claims adjudication Payment The life cycle of an insurance claim begins in the providers office when the claims department completes an CMS-1500 claims using medical management software. In most offices claims are submitted electronically to payers or clearinghouse for processing. Electric data interchange is the transfer of data from computer to computer between providers and third-party payers in a data format agreed upon by sending and receiving parties. What is a clearinghouse? A clearinghouse is a public or private entity that processes or facilitates the processing of nonstandard data elements into standard data elements. Claims processing involves sorting claims upon submission to collect and verify information about the patient and provider. After the claim has been approved by the payer's claims examiner it then goes through what we call the claims adjudication process. In this part of the process the claim is now compared to payer edits and the patients health plan benefits to verify that everything checks out to be accurate. After the adjudication process has been finalized, the claim will be either denied or approved for payment. The provider recieves a remittance advice and an EOB (explanation of benefits) is normally sent to the patient explaining the payment from their insurance and what the patient is responsible for if anything at all. Refernces: Understanding Health Insurance 13th Edition 2nd post Caron Passley Week 2 Discussion Post 1 COLLAPSE A few key terms to understand before going into how and whys of the life cycle of an insurance claim beginning with CMS1500- a form used to submit Medicare claims previously called the HCFA-1500 (Steiner, J., Pozgar, G. Pg. 730)., claims submission is the electronic or manual transmission of claims data to payers or clearinghouse(a public or private entity that processes or facilitates the processing of nonstandard data elements in to standard data elements and visa versa )for processing; a value-added network (VAN) is clearinghouse that involves value-added vendors, such as banks in the processing of claim; electronic data exchange (EDI) is the computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties (Steiner, J., Pozgar, G. Pg. 80-81).. This life cycle starts with the healthcare specialist completing a CMS-1500 using medical management software the submission of a claim to the payer or clearinghouse for processing (this the back and forth of whether a claim is correct, was a procedure authorized, etc )which is where the EDI takes place (the conversion of data from one form to another paper to electronic one electronic format to another) sometimes through VAN cl ...
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Helathcare IT - AR Days Reduction
Medics rcm.serviceagreement.v11 (1)
Medics rcm.serviceagreement.v11 (1)
Easy Steps To Follow In Medical Billing Process.pptx
Easy Steps To Follow In Medical Billing Process.pptx
Easy Steps To Follow In Medical Billing Process.pdf
Easy Steps To Follow In Medical Billing Process.pdf
Medical Bill Review and Audit
Medical Bill Review and Audit
Auto Injury Claim Tips for Urgent Care
Auto Injury Claim Tips for Urgent Care
Revenue cycle management
Revenue cycle management
Religare Health Insurance Leadership Talk Mr. Anuj Gulati - Claim Process
Religare Health Insurance Leadership Talk Mr. Anuj Gulati - Claim Process
Candance Resume 2016 new
Candance Resume 2016 new
Insurance Eligibility Verification – A Critical Component of Revenue Cycle Ma...
Insurance Eligibility Verification – A Critical Component of Revenue Cycle Ma...
Más de Sandy Thunell
Pics taken during March 2015 OAT Trip "Heart of India" including Old and New Delhi, Jaipur, Agra, Ranthumbhore, Erotic Temples, and Varanasi
George and Sandy's Best of OAT Trip Heart of India March 2015
George and Sandy's Best of OAT Trip Heart of India March 2015
Sandy Thunell
Chapter 14 medicare
Chapter 14 medicare
Sandy Thunell
Chapter 12 scarce allocation
Chapter 12 scarce allocation
Sandy Thunell
Chapters 6 public duties
Chapters 6 public duties
Sandy Thunell
Chapter 7
Chapter 7
Sandy Thunell
Chapter 11
Chapter 11
Sandy Thunell
Chapter 6
Chapter 6
Sandy Thunell
Chapter 7
Chapter 7
Sandy Thunell
Chapter 5
Chapter 5
Sandy Thunell
Week 2 chapter 4
Week 2 chapter 4
Sandy Thunell
Chapter 2 & 3
Chapter 2 & 3
Sandy Thunell
Chapter 2, 3
Chapter 2, 3
Sandy Thunell
Chapter 1
Chapter 1
Sandy Thunell
Intro to LEB
C:\Fakepath\Chapter 1 & Professionalism
C:\Fakepath\Chapter 1 & Professionalism
Sandy Thunell
Male reproductive system
Male reproductive system
Sandy Thunell
Urology
Urology
Sandy Thunell
Neurology
Neurology
Sandy Thunell
Orthopedics
Orthopedics
Sandy Thunell
Orthopedics
Orthopedics
Sandy Thunell
Dermatology
Dermatology
Sandy Thunell
Más de Sandy Thunell
(20)
George and Sandy's Best of OAT Trip Heart of India March 2015
George and Sandy's Best of OAT Trip Heart of India March 2015
Chapter 14 medicare
Chapter 14 medicare
Chapter 12 scarce allocation
Chapter 12 scarce allocation
Chapters 6 public duties
Chapters 6 public duties
Chapter 7
Chapter 7
Chapter 11
Chapter 11
Chapter 6
Chapter 6
Chapter 7
Chapter 7
Chapter 5
Chapter 5
Week 2 chapter 4
Week 2 chapter 4
Chapter 2 & 3
Chapter 2 & 3
Chapter 2, 3
Chapter 2, 3
Chapter 1
Chapter 1
C:\Fakepath\Chapter 1 & Professionalism
C:\Fakepath\Chapter 1 & Professionalism
Male reproductive system
Male reproductive system
Urology
Urology
Neurology
Neurology
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Dermatology
Dermatology
Chapter 4
1.
Life Cycle
of an Insurance Claim Chapter 4
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10.
11.
Life Cycle
of an Insurance Claim
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