简介
Summary:
Publisher Summary 1
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.
目录
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
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
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