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Contents
UNIT 1 BUILDING A FOUNDATION
Chapter 1 MEDICAL INSURANCE: WHERE DID IT COME FROM?
What Is Insurance?, 4
History, 5
Metamorphosis of Medical Insurance, 6
Key Health Insurance Issues, 9
How Do People Get Health Insurance?, 10
Access to Health Insurance, 10
Why Do Healthcare and Medical Insurance Cost So Much?, 11
Cost Sharing, 12
Reasons for Health Insurance, 12
Medical Insurance Plans, 13
Chapter 2 TOOLS OF THE TRADE: A CAREER AS A HEALTH (MEDICAL)
INSURANCE PROFESSIONAL
Your Future as a Health Insurance Professional {COMP: Pls. add commas and page numbers
for Ch. 2+ entries}
Required Skills and Interests
Job Duties and Responsibilities
Career Prospects
Opportunities
Rewards
Certification Possibilities
Chapter 3 THE LEGAL AND ETHICAL SIDE OF MEDICAL INSURANCE
Medical Law and Liability
Employer Liability
Employee Liability
Insurance and Contract Law
Elements of a Legal Contract
Termination of Contracts
Medical Law and Ethics Applicable to Health Insurance
Important Legislation Affecting Health Insurance
Federal Privacy Act of 1974
Federal Omnibus Budget Reconciliation Act of 1980
Tax Equity and Fiscal Responsibility Act of 1982
Consolidated Omnibus Budget Reconciliation Act of 1986
Federal False Claim Amendments Act of 1986
Fraud and Abuse Act
Federal Omnibus Budget Reconciliation Act of 1987
Medical Ethics and Medical Etiquette
Medical Ethics
Medical Etiquette
Documentation of Patient Medical Record
Health Insurance Portability and Accountability Act and Compliance
Impact of Health Insurance Portability and Accountability Act
Enforcement of Confidentiality Regulations of Health Insurance Portability and
Accountability Act
Developing a Compliance Plan
The Medical Record
Purposes of a Medical Record
Complete Medical Record
Who Owns Medical Records?
Retention of Medical Records
Access to Medical Records
Releasing Medical Record Information
Confidentiality and Privacy
Confidentiality
Privacy
Security
Exceptions to Confidentiality
Authorization to Release Information
Exceptions for Signed Release of Information for Insurance Claims Submission
Breach of Confidentiality
Healthcare Fraud and Abuse
Defining Fraud and Abuse
Preventing Fraud and Abuse
Chapter 4 TYPES AND SOURCES OF HEALTH INSURANCE
Types of Health Insurance
Indemnity (Fee-for-Service)
Managed Care
Sources of Health Insurance
Group Contract
Individual Policies
Medicare
Medicaid
TRICARE/CHAMPVA
Disability Insurance
Medical Savings Account (MSA)
Flexible Spending Account (FSA)
Long-Term Care Insurance
Consolidated Omnibus Budget Reconciliation Act
Other Terms Common to Third-Party Carriers
Birthday Rule
Coordination of Benefits
Medical Necessity
Usual, Reasonable, and Customary
Participating versus Nonparticipating Providers
UNIT 2 HEALTH INSURANCE BASICS
Chapter 5 THE ¿UNIVERSAL¿ CLAIM FORM: CMS-1500
Universal Insurance Claim Form
CMS-1500 Paper Form
Who Uses the Paper CMS-1500 Form
Documents Needed when Completing the CMS-1500 Claim Form
Patient Information Form
Patient Insurance Identification Card
Patient Health Record
Encounter Form
Patient Ledger Card
Completing the CMS-1500 Paper Form
Patient/Insured Section
Physician/Supplier Section
Preparing the Claim Form for Submission
Proofreading
Claim Attachments
Tracking Claims
Generating Claims Electronically
Claims Clearinghouses
Using a Clearinghouse
Direct Claims
Clearinghouses versus Direct
Chapter 6 TRADITIONAL FEE-FOR-SERVICE/PRIVATE PLANS
Traditional Fee-For-Service/Indemnity Insurance
How a Fee-for-Service Plan Works
Commercial or Private Health Insurance
What Is Commercial Insurance?
Who Pays for Commercial Insurance?
What Is Self-Insurance?
Blue Cross and Blue Shield
Overview
History of Blue Cross
History of Blue Shield
Blue Cross and Blue Shield Programs
Participating versus Nonparticipating Providers
Completing the CMS-1500 Form for a Commercial Plan
Submitting Commercial Claims
Timely Filing
Filing Commercial Paper and Electronic Claims
Commercial Claims Involving Secondary Coverage
Chapter 7 UNRAVELING THE MYSTERIES OF MANAGED CARE
What Is Managed Care?
Common Types of Managed Care Organizations
Preferred Provider Organization
Health Maintenance Organization
Advantages and Disadvantages of Managed Care
Advantages
Disadvantages
Managed Care Certification and Regulation
National Committee on Quality Assurance
National Committee on Quality Assurance and Health Insurance Portability and
Accountability Act
The Joint Commission
Utilization Review
Complaint Management
Preauthorization, Precertification, and Referrals
Preauthorization
Precertification
Referrals
Health Insurance Portability and Accountability Act and Managed Care
Impact of Managed Care
Impact of Managed Care on the Physician-Patient Relationship
Impact of Managed Care on Healthcare Providers
Future of Managed Care
Chapter 8 UNDERSTANDING MEDICAID
What Is Medicaid?
Evolution of Medicaid
Structure of Medicaid
Federal Government¿s Role
States¿ Options
Mandated Services
Optional Services
State Children¿s Health Insurance Program
Fiscal Intermediaries
Who Qualifies for Medicaid Coverage?
Categorically Needy
Medically Needy
Early and Periodic Screening, Diagnosis, and Treatment Program
Program for All-Inclusive Care for the Elderly
Payment for Medicaid Services
Medically Necessary
Prescription Drug Coverage
Accepting Medicaid Patients
Participating Providers
Verifying Medicaid Eligibility
Medicaid Identification Card
Automated Voice Response System
Electronic Data Interchange
Point-of-Sale Device
Computer Software Program
Benefits of the Eligibility Verification System
Medicare/Medicaid Relationship
Special Medicare/Medicaid Programs
Medicare and Medicaid Differences Explained
Medicaid Managed Care
Medicaid Claim
Completing the CMS-1500 Form Using Medicaid Guidelines
Resubmission of Medicaid Claims
Reciprocity
Medicaid and Third Party Liability
Common Medicaid Billing Errors
Medicaid Remittance Advice
Special Billing Notes
Time Limit for Filing Medicaid Claims
Copayments
Accepting Assignment
Services Requiring Prior Approval
Preauthorization
Retention, Storage, and Disposal of Records
Fraud and Abuse in the Medicaid System
What Is Medicaid Fraud?
Patient Abuse and Neglect
Chapter 9 CONQUERING MEDICARE¿S CHALLENGES
Medicare Program
Medicare Program Structure
Enrollment
Premiums and Cost-Sharing Requirements
Medicare Part C (Medicare Advantage Plans)
Medicare Part D (Medicare Prescription Drug Benefit Plan)
Program of All-Inclusive Care for the Elderly
Medicare Combination Coverages
Medicare/Medicaid Dual Eligibility
Medicare Supplement Policies
Medicare and Managed Care
Why This Information Is Important to the Health Insurance Professional
Preparing for the Medicare Patient
Medicare¿s Lifetime Release of Information Form
Determining Medical Necessity
Local Medical Review Policies and Local Coverage Decisions
Advanced Beneficiary Notice
Health Insurance Claim Number and Identification Card
Medicare Billing
Physician Fee Schedule
Medicare Participating and Nonparticipating Providers
Determining What Fee to Charge
Completing the CMS-1500 Form for Medicare Claims
Completing a Medigap Claim
Medicare Secondary Policy
Medicare Part B Crossover Program
Medicare/Medicaid Crossover Claims
Deadline for Filing Medicare Claims
Medicare Summary Notice
Information Contained on the Medicare Summary Notice
Medicare Remittance Advice
Electronic Funds Transfer
Medicare Audits and Appeals
Audits
Appeals
Quality Review Studies
Quality Improvement Organizations
Medicare Beneficiary Protection Program
Peer Review Organizations
Physician Review of Medical Records
Healthcare Quality Improvement Program
Payment Error Prevention Program
Clinical Laboratory Improvement Amendment
Chapter 10 MILITARY CARRIERS: TRICARE AND CHAMPVA
Military Health Programs
TRICARE
Who Is Eligible for TRICARE
Who Is Not Eligible for TRICARE
What TRICARE Pays
TRICARE¿s Three Choices for Healthcare
Other Health Insurance
TRICARE Standard Supplemental Insurance
TRICARE for Life
Verifying Eligibility
TRICARE Participating Providers
TRICARE Claims Processing
TRICARE Explanation of Benefits
CHAMPVA
Eligibility
CHAMPVA Benefits
What CHAMPVA Pays
CHAMPVA-TRICARE Connection
CHAMPVA-Medicare Connection
CHAMPVA and Health Maintenance Organization Coverage
CHAMPVA Providers
CHAMPVA for Life
Filing CHAMPVA Claims
CHAMPVA Claims Filing Deadlines
Instructions for Completing TRICARE/CHAMPVA Claim Forms
Claims Filing Summary
CHAMPVA Explanation of Benefits
Claims Appeals and Reconsiderations
HIPAA and Military Insurers
Chapter 11 MISCELLANEOUS CARRIERS: WORKERS¿ COMPENSATION AND
DISABILITY INSURANCE
Workers¿ Compensation
History
Federal Legislation and Workers¿ Compensation
Eligibility
Workers¿ Compensation Claims Process
Special Billing Notes
HIPAA and Workers¿ Compensation
Workers¿ Compensation Fraud
Private and Employer-Sponsored Disability Income Insurance
Defining Disability
Disability Claims Process
Federal Disability Programs
Americans with Disabilities Act
Social Security Disability Insurance
Supplemental Security Income
State Disability Programs
Centers for Disease Control and Prevention Disability and Health Team
Ticket to Work Program
Filing Supplemental Security Income/Social Security Disability Insurance Disability
Claims
UNIT 3 CRACKING THE CODES
Chapter 12 DIAGNOSTIC CODING
History and Development of Diagnostic Coding
ICD-9-CM Manual
Volume 2, The Alphabetic List (Index)
Three Sections of Volume 2
Process of Classifying Diseases
Volume 1, The Tabular List
Supplementary Sections of Volume 1
Locating a Code in the Tabular List (Volume 1)
Conventions Used in ICD-9-CM
Type Faces
Instructional Notes
Essential Steps to Diagnostic Coding
Special Coding Situations
Coding Signs and Symptoms
Etiology and Manifestation Coding
Symptoms, Signs, and Ill-Defined Conditions
Combination Codes
Coding Neoplasms
Coding Hypertension
HIPAA and Coding
Code Sets Adopted as HIPAA Standards
HCPCS Level 3 Codes
ICD-10
Three Volumes of ICD-10
ICD-10-PCS
Implementation of ICD-10
Chapter 13 PROCEDURAL, EVALUATION AND MANAGEMENT AND HCPCS
CODING
Overview of Current Procedural Terminology Coding
Purpose of CPT
Development of CPT
Three Levels of Procedural Coding
CPT Manual Format
Introduction and Main Sections
Category III Codes
Appendices A through L
CPT Index
Symbols Used in CPT
Modifiers
Unlisted Procedure or Service
Special Reports
Format of CPT
Importance of the Semicolon
Section, Subsection, Subheading, and Category
Cross-Referencing with See
Basic Steps of CPT Coding
Evaluation and Management (E & M) Coding
Vocabulary Used in E & M Coding
Documentation Requirements
Three Factors to Consider
Key Components
Contributing Factors
Prolonged Services
Subheadings of the Main E & M Section
Outpatient or Other Outpatient Services
Hospital Observation Status
Hospital Inpatient Services
Consultations
Emergency Department Services
Critical Care Services
Neonatal Intensive Care Services
Additional Categories of the E & M Section
E & M Modifiers
Importance of Documentation
E & M Documentation Guidelines: 1995 versus 1997
Deciding Which Guidelines to Use
Overview of the HCPCS Coding System
HCPCS Level II Format
Modifiers
HIPAA and HCPCS Coding
Elimination of Unapproved Local Codes and Modifiers
What Is a Crosswalk?
Current Procedural Terminology, Fifth Edition (CPT-5)
UNIT 4 THE CLAIMS PROCESS
Chapter 14 THE PATIENT
Patient Expectations
Professional Office Setting
Relevant Paperwork and Questions
Honoring Appointment Times
Patient Load
Getting Comfortable with the Healthcare Provider
Privacy and Confidentiality
Financial Issues
Future Trends
Aging Population
The Internet as a Healthcare Tool
Patients as Consumers
HIPAA Requirements
Authorization to Release Information
HIPAA and Covered Entities
HIPAA Requirements for Covered Entities
Patient¿s Right of Access and Correction
Accessing Information through Patient Authorization
Accessing Information through De-Identification
Billing Policies and Practices
Assignment of Benefits
Keeping Patients Informed
Accounting Methods
Billing and Collection
Billing Cycle
Arranging Credit or Payment Plans
Problem Patients
Laws Affecting Credit and Collection
Truth in Lending Act
Fair Credit Billing Act
Equal Credit Opportunity Act
Fair Credit Reporting Act
Fair Debt Collection Practices Act
Collection Methods
Collection by Telephone
Collection by Letter
Billing Services
Collection Agencies
Small Claims Litigation
Who Can Use Small Claims
How the Small Claims Process Works
Chapter 15 THE CLAIM
General Guidelines for Completing the CMS-1500 Form
Keys to Successful Claims
First Key: Collect and Verify Patient Information
Second Key: Obtain the Necessary Preauthorization and Precertification
Third Key: Documentation
Fourth Key: Follow Payer Guidelines
Fifth Key: Proofread Claim to Avoid Errors
Sixth Key: Submit a Clean Claim
HIPAA and the National Standard Employer Identifier Number
Claim Process
Step One: The Claim Is Received
Step Two: Claims Adjudication
Step Three: Tracking Claims
Step Four: Receiving Payment
Step Five: Interpreting Explanation of Benefits
Step Six: Posting Payments
Time Limits
Processing Secondary Claims
Appeals
Incorrect Payments
Denied Claims
Appealing a Medicare Claim
UNIT 5 ADVANCED APPLICATION
Chapter 16 THE ROLE OF COMPUTERS IN HEALTH INSURANCE
Impact of Computers on Health Insurance
HIPAA¿s Role in Electronic Transmissions
Electronic Data Interchange Electronic Data Exchange
History of Electronic Data Exchange
Benefits of Electronic Data Exchange
Electronic Claims Process
Enrollment
Electronic Claims Clearinghouse
Direct Data Entry Claims
Clearinghouse versus Direct
Other Methods Available for Filing Claims Electronically
Advantages of Filing Claims Electronically
Getting Started
Obtaining Electronic Claim Capability
Typical Hardware and Software Requirements
Medicare and Electronic Claims Submission
Additional Electronic Services Available
Electronic Funds Transfer
Electronic Remittance Advice
Electronic Medical Record
Future of Electronic Medical Records
Privacy Concerns of Electronic Medical Records
Chapter 17 REIMBURSEMENT PROCEDURES: GETTING PAID
Understanding Reimbursement Systems
Types of Reimbursement
Medicare and Reimbursement
Systems for Determining Reimbursement
Medicare¿s Transition to Resource-Based Relative Value Scale
Other Reimbursement Systems
Significance of Reimbursement Systems to the Health Insurance Professional
Peer Review Organizations and Prospective Payment System
Understanding Computerized Patient Accounting Systems
Selecting the Right Billing System
Managing Transactions
Generating Reports
HIPAA and Practice Management Software
Chapter 18 HOSPITAL BILLING AND THE UB-04
Hospital versus Physician Office Billing and Coding
Modern Hospital and Health Systems
Emerging Issues
Common Healthcare Facilities
Acute Care Facilities
Ambulatory Surgery Centers
Other Types of Healthcare Facilities
Legal and Regulatory Environment
Accreditation
Professional Standards
Governance
Confidentiality and Privacy
Fair Treatment of Patients
Common Hospital Payers and Their Claims Guidelines
Medicare
Medicaid
TRICARE
CHAMPVA
Blue Cross and Blue Shield
Private Insurers
The National Uniform Billing Committee and the UB-04
Data Specifications
Structure and Content of the Hospital Health Record
Standards in Hospital Electronic Medical Records
Standard Codes and Terminology
Billing Process
Informed Consent
Hospital Charges
Hospital Coding
Manuals Used for Coding Hospital Claims
New HIPAA Edit¿ICD-9 Procedure Codes
National Correct Coding Initiative
ICD-9-CM Procedure Codes and Medicare
Outpatient Hospital Coding
Hospital Billing and the UB-04: Understanding the Basics
Standard Data Elements
UB-04 Claim Form Completion Guidelines
Common Hospital Billing Errors
Electronic Claims Submission
HIPAA/Hospital Connection
The ANSI 835 Electronic Remittance Notices
Understanding the Full Circle Process: Guide to Medical Compliance
Career Opportunities in Hospital Billing
Training, Other Qualifications, and Advancement
Job Outlook
APPENDICES
Appendix A Sample Blank CMS-1500 Form (08/05)
Appendix B Sample Completed Claim Forms
Appendix C TANF Programs
Library of Congress Subject Headings for this publication:
Health insurance claims -- United States.
Insurance, Health -- United States.