Insurance Handbook for the Medical Office (7 PAP/CDR)

Insurance Handbook for the Medical Office (7 PAP/CDR)

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  • 製本 Paperback:紙装版/ペーパーバック版/ページ数 663 p.
  • 言語 ENG,ENG
  • 商品コード 9780721695181
  • DDC分類 368.38002461

Table of Contents

Unit 1 Career Role and Responsibilities
Role of an Insurance Billing Specialist 2 (18)
Role of the Insurance Billing Specialist 4 (6)
Job Responsibilities 4 (1)
Educational and Training Requirements 4 (1)
Career Advantages 5 (4)
Qualifications 9 (1)
Medical Etiquette 10 (1)
Medical Ethics 11 (1)
Confidential Communication 12 (2)
Privileged Information 12 (1)
Nonprivileged Information 13 (1)
Professional Liability 14 (4)
Employer Liability 14 (1)
Employee Liability 15 (2)
Embezzlement 17 (1)
Future Challenges 18 (2)
Unit 2 The Claims Process
Basics of Health Insurance 20 (30)
History 22 (1)
Insurance in the United States 22 (1)
Legal Principles of Insurance 23 (1)
Insurance Contracts 23 (1)
Physician/Patient Contracts and Financial 23 (1)
Obligation
Implied or Expressed Contracts 23 (1)
The Insurance Policy 24 (4)
Policy Application 25 (1)
Policy Renewal Provisions 25 (1)
Policy Terms 25 (1)
Coordination of Benefits 26 (1)
General Policy Limitations 26 (2)
Choice of Health Insurance 28 (2)
Group Contract 29 (1)
Individual Contract 30 (1)
Prepaid Health Plan 30 (1)
Types of Health Insurance Coverage 30 (2)
CHAMPVA 30 (1)
Competitive Medical Plan 31 (1)
Disability Income Insurance 31 (1)
Exclusive Provider Organization 31 (1)
Foundation for Medical Care 31 (1)
Health Maintenance Organization 31 (1)
Independent or Individual Practice 31 (1)
Association
Maternal and Child Health Program 31 (1)
Medicaid 31 (1)
Medicare 31 (1)
Medicare/Medicaid 31 (1)
Point-of-Service Plan 31 (1)
Preferred Provider Organization 32 (1)
TRICARE 32 (1)
Unemployment Compensation Disability 32 (1)
Veterans Affairs Outpatient Clinic 32 (1)
Workers' Compensation Insurance 32 (1)
Examples of Insurance Billing 32 (1)
Procedure: Handling and Processing 33 (14)
Insurance Claims
Preregistration---Patient Registration 33 (1)
Form
Insurance Identification Card 34 (2)
Patient's Signature Requirements 36 (4)
Encounter Form 40 (1)
Physician's Signature 41 (1)
Determine Fees 42 (1)
Bookeeping---Ledger Card 42 (1)
Insurance Form 42 (2)
Provider's Handwritten Signature 44 (1)
Office Pending File and Insurance Claims 45 (1)
Register
Mailing the Claim Form 46 (1)
Insurance Payments 46 (1)
Monthly Statement 47 (1)
Procedure: Posting to a Patient's Ledger 47 (2)
Keeping Up to Date 49 (1)
Medical Documentation 50 (42)
The Documentation Process 52 (1)
Medical Record 52 (1)
Documenters 52 (1)
Reasons for Documentation 53 (1)
General Principles of Medical Record 53 (1)
Documentation
Medical Necessity 53 (1)
External Audit Point System 53 (1)
Enforcement of Medical Record Keeping 54 (1)
Documentation Guidelines for Evaluation and 54 (2)
Management Services
Contents of a Medical Report 56 (8)
Documentation of History 56 (4)
Documentation of Examination 60 (2)
Documentation of Medical Decision-Making 62 (2)
Complexity
Documentation Terminology 64 (9)
Terminology for Evaluation and Management 64 (2)
Services
Diagnostic Terminology and Abbreviations 66 (5)
Directional Terms 71 (1)
Surgical Terminology 71 (2)
Review and Audit of Medical Records 73 (5)
Internal Reviews 73 (3)
External Audit 76 (2)
Legalities of Medical Records 78 (14)
Patient Confidentiality 78 (2)
Principles for Release of Information 80 (5)
Retention of Records 85 (5)
Termination of a Case 90 (1)
Prevention of Legal Problems 91 (1)
Diagnostic Coding 92 (22)
The Diagnostic Coding System 94 (1)
Types of Diagnostic Codes 94 (1)
Reasons for the Development and Use of 94 (1)
Diagnostic Codes
Physician's Fee Profile 94 (1)
History of Coding Diseases 95 (1)
International Classification of Diseases 95 (1)
How to Use the Diagnostic Code Books 96 (2)
Properly
Coding Instructions 96 (2)
Procedure: Basic Steps in Coding 98 (6)
Rules for Coding 104(8)
Signs, Symptoms, and III-Defined 104(1)
Conditions
Sterilization 105(1)
Neoplasms 105(2)
Circulatory System Conditions 107(1)
Diabetes Mellitus 108(1)
Pregnancy, Delivery, or Abortion 108(1)
Admitting Diagnoses 109(1)
Burns 110(1)
Injuries and Late Effects 110(2)
ICD-10-CM Diagnosis and Procedure Codes 112(2)
Procedural Coding 114(40)
Understanding the Importance of Procedural 116(1)
Coding Skills
Current Procedural Terminology (CPT) 116(1)
Methods of Payment 117(2)
Fee Schedule 117(1)
Usual, Customary, and Reasonable (UCR) 117(1)
Relative Value Studies (RVS) 118(1)
Procedure: Determining Conversion Factors 119(1)
How to Use the CPT Code Book 120(12)
Code Book Symbols 120(2)
Evaluation and Management Section 122(2)
Surgery Section 124(8)
Procedure: How to Code Effectively 132(7)
Unlisted Procedures 134(130)
Coding Guidelines for Code Edits 134(4)
Code Monitoring 138(1)
Helpful Hints in Coding 139(1)
Office Visits 139(1)
Drugs and Injections 139(1)
Adjunct Codes 139(1)
Basic Life and/or Disability Evaluation 139(1)
Services
Code Modifiers 139(15)
Correct Use of Common CPT Modifiers 140(13)
Comprehensive List of Modifier Codes 153(1)
The Health Insurance Claim Form 154(82)
History 156(1)
Types of Claims 156(1)
Abstracting from Medical Records 157(4)
Cover Letter Accompanying Insurance Claims 157(1)
Life of Health Insurance Applications 157(4)
Health Insurance Claim Form (HCFA-1500) 161(4)
Basic Guidelines for Submitting a Claim 161(1)
Completion of Insurance Claim Forms 162(3)
Common Reasons Why Claim Forms Are Delayed 165(2)
or Rejected
Additional Reasons Why Claim Forms Are 167(1)
Delayed
Optical Scanning Format Guidelines 167(3)
Optical Character Recognition 167(1)
Do's and Dont's for Optical Character 167(3)
Recognition
Instructions for the Health Insurance Claim 170(66)
Form (HCFA-1500)
Insurance Program Templates 224(12)
Electronic Data Interchange 236(22)
History of an Electronic Claim 238(1)
Advantages of Electronic Claim Submission 238(1)
Computer Components 239(2)
Hardware 239(1)
Software 240(1)
Memory 240(1)
Networks 241(1)
Local Area Network 241(1)
Wide Area Network 241(1)
Internet/World Wide Web 241(1)
Computer Confidentiality 242(2)
Confidentiality Statement 242(1)
Prevention Measures 242(2)
Records Management 244(1)
Data Storage 244(1)
Electronic Power Protection 244(1)
Selection of an Office Computer System 244(1)
Computer Claims Systems 244(1)
Carrier-Direct 245(1)
Clearinghouse 245(1)
Electronic Claims Processor 245(1)
Electronic Data Interchange 246(7)
Carrier Agreements 246(1)
Signature Requirements 246(1)
Multipurpose Billing Forms 247(1)
Keying Insurance Data for Claim 247(1)
Transmission
Electronically Completing the Claim 248(3)
Electronic Processing Problems 251(1)
Facsimile Communication Transmission 251(2)
Electronic Inquiry or Claims Status Review 253(1)
Eligibility Verification 253(1)
Remittance Advice Statements 254(4)
Receiving Payments and Insurance Problem 258(28)
Solving
Follow-Up After Claim Submission 260(1)
Claim Policy Provisions 260(1)
Insured 260(1)
Payment Time Limits 260(1)
Explanation of Benefits 260(1)
Components of an EOB 261(1)
Interpretation of an EOB 261(1)
Posting an EOB 261(1)
State Insurance Commissioner 261(3)
Commission Objectives 261(2)
Types of Problems 263(1)
Commission Inquiries 263(1)
Claim Management Techniques 264(1)
Insurance Claims Register 264(1)
Tickler File 265(1)
Insurance Company Payment History 265(1)
Claim Inquiries 265(2)
Problem Claims 267(7)
Types of Problems 267(7)
Rebilling 274(1)
Review and Appeal Process 274(1)
Procedure: Filing an Official Appeal 274(12)
Medicare Review and Appeal Process 275(8)
TRICARE Review and Appeal Process 283(3)
Office and Insurance Collection Strategies 286(44)
Linda L. French
Cash Flow Cycle 288(2)
Accounts Receivable 288(1)
Patient Education 289(1)
Patient Registration Form 289(1)
Fees 290(12)
Fee Schedule 290(1)
Fee Adjustments 291(2)
Communicating Fees 293(1)
Collecting Fees 294(8)
Procedure: Seven-Step Billing and 302(1)
Collection Guideline
Credit Arrangements 302(3)
Payment Options 302(3)
Credit and Collection Laws 305(3)
Statute of Limitations 306(1)
Equal Credit Opportunity Act 306(2)
Fair Credit Reporting Act 308
Fair Credit Billing Act 306(1)
Truth in Lending Act 306(2)
Truth in Lending Consumer Credit Cost 308(1)
Disclosure
Fair Debt Collection Practices Act 308(1)
The Collection Process 308(2)
Office Collection Techniques 308(2)
Procedure: Telephone Collection Plan 310(10)
Insurance Collection 313(5)
Collection Agencies 318(2)
Credit Bureaus 320(1)
Credit Counseling 320(1)
Small Claims Court 320(1)
Procedure: Filling a Claim 320(5)
Tracing a Skip 322(2)
Special Collection Issues 324(1)
Procedure: Filing an Estate Claim 325(5)
Unit 3 Health Care Payers
Managed Care Systems 330(20)
History 332(3)
Prepaid Group Practice Health Plans 332(2)
Health Care Reform 334(1)
Managed Care Systems 335(2)
Health Maintenance Organizations 335(1)
Exclusive Provider Organizations 335(1)
Foundations for Medical Care 335(1)
Independent Practice Association 336(1)
Preferred Provider Organizations 336(1)
Physician Provider Groups 336(1)
Point of Service Plans 337(1)
Triple Option Health Plan 337(1)
Medical Review 337(1)
Professional Review Organizations 337(1)
Utilization Review or Management 337(1)
Management of Plans 338(6)
Contracts 338(1)
Preauthorization or Prior Approval 338(2)
Diagnostic Tests 340(1)
Managed Care Guide 340(1)
Plan Administration 341(3)
Financial Management 344(6)
Payment 344(1)
Statement of Remittance 345(1)
Accounting 345(1)
Fee for Service 345(1)
Year-End Evaluation 346(2)
Bankruptcy 348(2)
Medicare 350(36)
Chartrand's Medicare Laws 352(1)
Policies and Regulations 352(7)
Eligibility Requirements 352(1)
Health Insurance Card 353(1)
Enrollment Status 354(1)
Benefits and Nonbenefits 354(5)
Additional Insurance Programs 359(1)
Medicare/Medicaid 359(1)
Medicare/Medigap 359(1)
Medicare Supplemental Insurance 359(1)
Medicare Secondary Payer 359(1)
Procedure: Determining If Medicare Is 360(2)
Primary or Secondary/Determining Additional
Benefits
Automobile or Liability Insurance Coverage 361(1)
Medicare Managed Care Plans 362(3)
Health Maintenance Organizations 362(3)
Carrier Dealing Prepayment Organization 365(1)
Utilization and Quality Control 365(2)
Peer Review Organization 365(1)
Federal False Claims Amendment Act 365(1)
Health Insurance Portability and 366(1)
Accountability Act
Civil Monetary Penalties Law 366(1)
Stark I and II Regulations---Physician 366(1)
Self-Referrals
Clinical Laboratory Improvement Amendment 367(1)
Payment Fundamentals 367(5)
Provider 367(1)
Prior Authorization 368(2)
Waiver of Liability Provision 370(1)
Elective Surgery Estimate 371(1)
Prepayment Screens 371(1)
Medicare Reimbursement 372(2)
Chronology of Payment 372(1)
Reasonable Fee 373(1)
Resource-Based Relative Value Scale 373(1)
Medicare Fee Schedule 374(1)
Health Care Financing Administration 374(1)
Common Procedure Coding System (HCPCS)
Claim Submission 374(3)
Fiscal Intermediaries and Fiscal Agents 374(1)
Provider Identification Numbers 374(1)
Patient's Signature Authorization 375(1)
Time Limit 375(1)
Manual Claims 376(1)
Electronic Claims 376(1)
Medicare/Medicaid Claims 376(1)
Medicare/Medigap Claims 376(1)
Medicare/Supplemental and MSP Claims 377(1)
Deceased Patients Claims 377(1)
Physician Substitute Coverage 377(1)
After Claim Submission 377(9)
Remittance Advice 377(2)
Medicare Summary Notice 379(4)
Beneficiary Representative/Representative 383(1)
Payee
Posting Payments 383(1)
Review and Appeal Process 384(2)
Medicaid and Other State Programs 386(12)
History 388(1)
Medicaid Programs 388(1)
Maternal and Child Health Program 388(1)
Low-Income Medicare Recipients 389(1)
Medicaid Eligibility 389(3)
Categorically Needy 390(1)
Medically Needy 390(1)
Maternal and Child Health Program 390(1)
Eligibility
Accepting Medicaid Patients 391(1)
Identification Card 391(1)
Retroactive Eligibility 392(1)
Medicaid Benefits 392(1)
Covered Services 392(1)
Disallowed Services 392(1)
Medicaid Managed Care 392(1)
Claim Procedure 393(3)
Copayment 393(1)
Prior Approval 393(2)
Time Limit 395(1)
Reciprocity 395(1)
Claim Form 395(1)
After Claim Submission 396(1)
Remittance Advice 396(1)
Appeals 396(1)
Medicaid Fraud Control 396(2)
TRICARE and CHAMPVA 398(28)
History of TRICARE 400(1)
TRICARE Programs 400(1)
Eligibility 400(1)
Nonavailability Statement 401(1)
TRICARE Standard 401(8)
Enrollment 401(1)
Identification Card 401(1)
Benefits 401(2)
Fiscal Year 403(1)
Authorized Providers of Health Care 403(4)
Preauthorization 407(1)
Payment 408(1)
TRICARE Extra 409(1)
Enrollment 409(1)
Identification Card 409(1)
Benefits 409(1)
Network Provider 409(1)
Preauthorization 409(1)
Payments 409(1)
TRICARE Prime 409(2)
Enrollment 410(1)
Identification Card 410(1)
Benefits 410(1)
Primary Care Manager 410(1)
Preauthorization 411(1)
Payments 411(1)
TRICARE Prime Remote Program 411(1)
Enrollment 411(1)
Identification Card 411(1)
Benefits 411(1)
Payments 412(1)
Supplemental Health Care Program 412(1)
Enrollment 412(1)
Identification Card 413(1)
Benefits 413(1)
Payments 413(1)
TRICARE Hospice Program 413(1)
TRICARE and HMO Coverage 413(1)
CHAMPVA Program 413(3)
Eligibility 414(1)
Enrollment 414(1)
Identification Card 414(1)
Benefits 415(1)
Provider 415(1)
Preauthorization 416(1)
Medical Records Access 416(1)
Privacy Act of 1974 416(1)
Computer Matching and Privacy Protection 416(1)
Act of 1988
Claims Procedure 416(3)
Fiscal Intermediary 416(1)
TRICARE Standard and CHAMPVA 416(1)
TRICARE Extra and TRICARE Prime 417(1)
TRICARE Prime Remote and Supplemental 417(1)
Health Care Program
TRICARE/CHAMPVA and Other Insurance 417(1)
Medicare and TRICARE-CHAMPVA 418(1)
Medicare and TRICARE 418(1)
Medicare and CHAMPVA 418(1)
Third Party Liability 418(1)
Workers' Compensation 418(1)
Procedure: Completing a CHAMPVA Claim Form 419(3)
After Claim Submission 422(4)
TRICARE Summary Payment Voucher 422(1)
CHAMPVA Explanation of Benefits Document 422(1)
Quality Assurance 422(3)
Claims Inquiries and Appeals 425(1)
Workers' Compensation 426(40)
History 428(1)
Workers' Compensation Statutes 428(1)
Workers' Compensation Reform 428(1)
Workers' Compensation Laws and Insurance 429(1)
Purposes of Workers' Compensation Laws 429(1)
Self-Insurance 429(1)
Managed Care 429(1)
Eligibility 430(1)
Industrial Accident 430(1)
Occupational Illness 430(1)
Coverage 430(5)
Federal Laws 430(1)
State Laws 430(4)
State Disability and Workers' Compensation 434(1)
Benefits 435(1)
Types of State Claims 436(2)
Nondisability Claim 436(1)
Temporary Disability Claim 436(1)
Permanent Disability Claim 437(1)
Fraud and Abuse 438(1)
Occupational Safety and Health 438(3)
Administration (OSHA) Act of 1970
Background 438(1)
Coverage 438(1)
Regulations 438(2)
Filing a Complaint 440(1)
Inspection 441(1)
Record Keeping and Reporting 441(1)
Legal Situations 441(3)
Medical Evaluator 441(1)
Depositions 441(1)
Medical Testimony 442(1)
Liens 442(1)
Third Party Subrogation 443(1)
Medical Reports 444(2)
Confidentiality 444(1)
Documentation 444(1)
Medical Record Keeping 444(1)
Terminology 444(2)
Reporting Requirements 446(4)
Employer's Report 446(1)
Medical Service Order 446(4)
Physician's First Report 450(1)
Procedure: Completing the Doctor's First 450(10)
Report of Occupational Injury or Illness
Progress or Supplemental Report 458(2)
Final Report 460(1)
Claim Submission 460(4)
Financial Responsibility 460(1)
Fee Schedules 460(2)
Helpful Billing Tips 462(1)
Billing Claims 462(2)
Out-of-State Claims 464(1)
Delinquent Claims 464(2)
Disability Income Insurance and Disability 466(22)
Benefits Programs
Disability Claims 468(1)
History 469(1)
Disability Income Insurance 469(1)
Individual 469(1)
Group 470(1)
Federal Disability Programs 470(4)
Workers' Compensation 470(1)
Disability Benefit Programs 471(3)
State Disability Insurance 474(4)
Background 474(2)
State Programs 476(1)
Funding 476(1)
Eligibility 476(1)
Benefits 476(1)
Time Limits 477(1)
Medical Examinations 477(1)
Restrictions 477(1)
Voluntary Disability Insurance 478(1)
Procedure: Claims Submission 478(10)
Disability Income Claims 478(1)
Federal Disability Claims 479(1)
Veterans Affairs Disability Outpatient 479(1)
Clinic Claims
State Disability Claims 479(3)
Conclusion 482(6)
Unit 4 Inpatient and Outpatient Billing
Hospital Billing 488(40)
Patient Service Representative 490(2)
Qualifications 490(1)
Primary Functions and Competencies 490(1)
Principal Responsibilities 490(2)
Medicolegal Confidentiality Issues 492(2)
Documents 492(1)
Verbal Communication 493(1)
Computer Security 494(1)
Admission Procedures 494(3)
Appropriateness Evaluation Protocols 494(1)
Admitting Procedures for Major Insurance 494(2)
Programs
Preadmission Testing 496(1)
Utilization Review 497(1)
Peer Review Organization 497(1)
Coding Hospital Procedures 497(1)
Outpatient-Reason for Visit 497(1)
Inpatient-Principal Diagnosis 498(1)
Coding Inpatient Procedures 498(1)
ICD-9-CM Volume 3 Procedures 498(1)
Procedure: Coding from Volume 3 499(1)
Coding Outpatient Procedures 500(1)
Current Procedural Terminology 500(1)
Health Care Finance Administration Common 500(1)
Procedure Coding System
Modifiers 500(1)
Inpatient Billing Process 500(3)
Admitting Clerk 500(1)
Insurance Verifier 501(1)
Attending Physician and Nursing Staff 501(1)
Discharge Analyst 502(1)
Charge Description Master 502(1)
Code Specialist 503(1)
Insurance Billing Editor 503(1)
Procedure: Editing a Uniform Bill (UB-92) 503(1)
Claim Form
Nurse Auditor 504(1)
Reimbursement Process 504(3)
Reimbursement Methods 504(2)
Electronic Data Interchange 506(1)
Hard Copy Billing 506(1)
Receiving Payment 506(1)
Outpatient Insurance Claims 507(1)
Hospital Professional Services 507(1)
Billing Problems 507(1)
Duplicate Statements 508(1)
Double Billing 508(1)
Phantom Charges 508(1)
Hospital Billing Claim Form 508(12)
Uniform Bill Inpatient and Outpatient 508(1)
Claim Form
Instructions for Completing the UB-92 508(12)
Claim Form
Diagnosis-Related Groups 520(2)
History 520(1)
The Diagnosis-Related Groups System 520(2)
Diagnosis-Related Groups and the Medical 522(1)
Assistant/Insurance Billing Specialist
Outpatient Classification 522(6)
Ambulatory Payment Classification System 522(6)
Unit 5 Employment
Seeking a Job and Attaining Professional 528(31)
Advancement
Employment Opportunities 530(9)
Insurance Billing Specialist 530(9)
Claims Assistance Professional 539(1)
Job Search 539(7)
On-line Job Search 540(1)
Job Fairs 541(1)
Application 541(1)
Letter of Introduction 541(3)
Resume 544(2)
Procedure: Creating an Electronic Resume 546(1)
Procedure: Preparing a Resume in ASCII 547(3)
Interview 547(3)
Follow-Up Letter 550(1)
Self-Employment 550(4)
Setting up an Office 550(1)
Finances 551(2)
Equipment 553(1)
Insurance 553(1)
Marketing, Advertising, Promotion, and 553(1)
Public Relations
Contracts or Agreements 553(1)
Documentation 553(1)
Statements and Pricing 553(1)
Professional Associations: Certification 554(3)
and Registration
American Association of Medical Assistants 554(1)
American Medical Technologists 555(1)
National Electronic Biller's Alliance 555(1)
Nationally Certified Insurance Coding 555(1)
Specialist
American Association of Medical Billers 555(1)
International Billing Association 555(1)
American Academy of Professional Coders 556(1)
American Health Information Management 556(1)
Association
Medical Management Institute 556(1)
Alliance of Claims Assistance 556(1)
Professionals
American Guild of Patient Account 556(1)
Management
Professional Association of Health Care 557(1)
Office Managers
Medical Group Management Association 557(1)
Keeping Current 557(2)
Mentor 557(1)
Networking 557(2)
Appendix A Addresses for Submitting Claims or 559(34)
Contacting State Insurance Commissioners and
State Board of Medical Examiners
Appendix B Reference List of Audiotapes, Books, 593(12)
Newsletters, Periodicals, Software, and
Videotapes
Appendix C Medi-Cal 605(22)
Appendix D How to Use the Student Software 627(6)
Challenge: Installation and Operating
Instructions
Glossary 633(17)
Index 650