...Week 2 Checkpoint Different standards of medical records documentation have different compliance plans that correspond to them. Staff members must follow all billing rules and medical facilities have to be certain that this is taking place. When filing medical records they have to be accurate: they have to contain the patient’s conditions and diagnoses, and they must trace the patient’s course of care, also they have to have the patient medical history, including family history. Medical records of patients are legal documents; physicians may use them in their defense if they are accused of improperly treating patients. Doctors have to provide documentation for the reasoning behind treatment decisions as a means of protection from lawsuits. This has to be done because it helps prevents lawsuits for malpractice. When the medical facility has rules and compliance plan in place, they have showed that they are committed to finding and preparing any types of weak spots in their management. Some of the areas that are helped when compliance plans are place are: making sure your employees are educated and trained for their position, by doing this is helps prevent future problems in the work place and avoid any type of legal action that can be taking against them. Not just the coding and billing are covered in the compliance plans; every area of government regulation of medical practices is coved as well. The medical billing process has ten different steps that re connected to...
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...Running head: Evaluating Compliance Strategies Assignment: Evaluating Compliance Strategies Name Axia College of University of Phoenix HCR 220 Date “Guidelines established by the healthcare staff and laws established by HIPAA are what make up the compliance process. These laws and guidelines were established to protect the patients, physicians, and staff members” (U.S. Dept. of Health and Human Services, n.d.). Errors in the office can be avoided by having a compliance process in effect. Using updated billing and coding software will help reduce errors made in the billing process. I agree with having a guide consisting of codes to aid in the billing process. I do regard this as cheating rather, to be used as a guide. Many offices currently have sheets that are located on the front of the patients’ file with the diagnosis and the code next to the diagnosis which the physician fills out. This eliminates an unnecessary step in the billing process and is a quicker, easier, and more accurate way to avoid errors. “In order to avoid rejection of the claim, it is important that the diagnoses and procedures are correctly linked” (AAFP, 1999). This also ensures that the claim is paid for the correct procedure performed by the physician. If an incorrect procedure was billed this could result in a loss of money by the physician for the type of procedure that was performed. The claim will have to be adjusted and resubmitted...
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...CheckPoint: Errors and Compliance in Coding HCR 220 CheckPoint: Errors and Compliance in Coding Double billing, typos, and incorrect dates are among the most common causes of billing and coding errors that can happen. Double billing is when you have a procedure done by your provider and they try to charge you for two procedures. It could also be something as simple as a hospital billing you for taking two pills when you were only given one. Typo’s is another common billing and coding error, and can be found in the patients name or address. The last is incorrect dates entered into the file. It could be that you stayed in the hospital for four days but the hospital has you listed as staying for seven days and they end up charging you for those seven days. Solutions for the coding and billing errors are to make sure you double check you statements when they come in to make all the information are correct. If a mistake is found then you need to write a detail letter and send it to the facility or to a patient representative to make sure the error is corrected. The Medicare National Correct Coding Initiative (CCI) controls improper coding that would lead to inappropriate payment for Medicare claims. CCI has coding policies in place that are based on the coding conventions in CPT, Medicare’s national and local coverage and payment policies, National medical societies’ coding guidelines, and Medicare’s analysis of standard medical and surgical practice. CCI has thousands...
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...Features of Heath Plans Sharain A. Houser HCR 220 April 30, 2014 Instructor, Felecia Pettit-Wallace These major types of health plans have a great deal of differences as well as similarities. The similarities of most of these plans are that they have low co pays and exceedingly close insurance coverage. The Health Maintenance Organization and Point-of-Service plans consume lower co pays than most of the other plans and these plans address the full cost of preventative care. Most of the plans accord you to extend out of the network and other plans bequeath not to compensate or address unless it is within the network. The deviations are that the plans address dissimilar portions and most plans do within network coverage as well as out of the network coverage. The price can be a braggart (big) deviation with the plans. The price of deductibles and treatments are dissimilar likewise. The portion of coverage is dissimilar within each plan. There are some plans that do not demand for you to have a referral, merely there are plans that do demand referrals. I think that for each one plan something is proposed for each consumer and provider. There are dissimilar plans to assist individuals that have dissimilar drutherses. Because you are the consumer, you necessitate the plan that is better for you and your funds. Because you are the provider, the plans attain money for the insurance on dissimilar dismantles, there is money being attained on each plan through the consumer...
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...There are many different types of health plans in this world. One of them is called an Indemnity plan. The plan covers medically necessary medical costs, the insurer will also pay a premium and a deductible. After the premium and the deductible is paid then the patient will pay a coinsurance which is usually a 80-20 percent ratio. The insurance will pay 80% then the rest will need to be cover by the patient. The next plan is called a managed care it uses a method called fee-for-service it has a lower deductibles and premiums, but has a smaller provider network. What happens is the patient will see the provider pay for the services rendered then the provider files a claim with the third party (insurance company) then the insurance will reimburse the the provider and patient, while the patient is paying a premium to the third party to cover their costs. There are several different plans that are offered and use the managed care philosophy. The health maintenance organization (HMO) an HMO offers the capitation to the providers which is a fixed prepaid payment agreement between both provider and third party that is based upon how many patients with the provider. This system works by the patient receiving services from the provider and the patient paying the third party a set premium, while the third party insurance pays the capitation fee to the provider. Point-of-service plans are called an open HMO because it allows more providers in their network but with additional fee's...
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...CheckPoint: Features of Health Plans When looking at the similarities and differences of these plans, it was hard to determine which plan was best. For me, I like the idea of having an Indemnity Plan, This allows me to have any provider I want, Have little to no cost, even though I might need pre-authorization for some procedures that fine, I understand that it comes with higher costs but they have deductibles, coinsurance that can help with the high cost, and I can understand that preventive care isn’t covered but that is where an HMO(coinsurance) can help. They cover preventive care and have low copayments. They are all the same in that they are all likely to have pre-authorization for some procedures for the insurance company to pay. Most are low to no cost to the patients. Also they mostly all have little to no co-payments. They differ In that some require that you must pay until the deductible is met, this can become costly for those on a budge. People with a PPO or a Customer-driven Plan are like the others in that they have a high deductible and others are low to no deductible like the Indemnity plan and the HMO. Some require you to have a specific providers in your area, like POS and if you do its costly. Whereas, Indemnity Plan you can have any provider you want. This to me is best, because it is nice having a doctor you’re comfortable with. POS allows you to have both in and out of network providers but out of area costs more than those who are in the indemnity...
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...HCR 220 Week 5 Assignment Assigning Evaluation and Management (E M) Codes To Buy This material Click below link http://www.uoptutors.com/HCR-220/HCR-220-Week-5-Assignment-Assigning-Evaluation-and-Management-(EM)-Codes Assignment: Assigning Evaluation and Management (E/M) Codes Resources:Figure 5.3 on p. 161, and Table 5.4 on p. 165 of Medical Insurance Assign appropriate E/M codes for the following five cases: Initial consultation performed for a 43-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed. A 32-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. An examination reveals bronchitis and sinus infection. The patient is prescribed a 7-day course of Zithromax. Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function. A nurse reviews the results and advises the patient that tests are normal, and no change in dosage is indicated. A 78-year-old diabetic female presents for check-up and dressing change of wound on left foot. An examination reveals the wound is healing. The nurse applied new dressing and patient will return for a check-up in one week. A mother brings in her 4 ½ month-old baby for a routine wellness check. An examination reveals the child to be in good health and making adequate progress. Provide the rationale you used to assign a particular...
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...HCR 220 Week 9 Final Project How HIPAA Violations Affect the Medical Billing Process To Buy This material Click below link http://www.uoptutors.com/HCR-220/HCR-220-Week-9-Final-Project-How-HIPAA-Violations-Affect-the-Medical-Billing-Process Part One: Resources:Appendix A, Appendix C, and Table 8.3 on pp. 258–259 of Medical Insurance Refer toTable 8.3 on pp. 258–259 of your text to complete the CMS-1500 form, located in Appendix C, according to the following case study: A 67-year-old Medicare patient presents to the office, exhibiting symptoms of HIV infection. After detailed examination, symptoms are determined to be advanced AIDS with manifestation of Kaposi’s sarcoma and other opportunistic infections. Name: James Brown Account Number: 080811 Insurer: Medicare Policy Number: 1098765 ID number: 12345678910 DOB: 02/01/1940 Gender: Male Insured: James Brown Address: 1600 Pennsylvania Ave. Wash. D.C. 60000 Marital Status: Widowed Patient’s Employer: Retired Nature of Condition: HIV, AIDS, Kaposi’s sarcoma Date of Illness: 06/01/2007 Referring Physician: Thomas Glassman, M.D. Physician ID: 1080808080 Federal Tax ID: 5551116679 Dates of Service: 06/01/2007, 06/15/2007, 07/07/2007, 08/01/2007 Procedure: Detailed examination, screening blood panel, pathology services Patient Signature Include ICD (categories only), CPT, HCPCS, and insurance information. If you believe there is insufficient information provided to fill a required field with data...
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...Steps in the Medical Billing Process Stacy Dickson HCR/220 March 20, 2011 Alexander Mejia Steps in the Medical Billing Process The medical billing process is one that requires attention to detail to ensure that all the proper paperwork is completed properly and accurately. This process will begin form the time the patient enters to register for their appointment until after they have finished their appointment. This paper will provide the step by step process. Visit Step 1 Preregister Patients As part of the medical billing process, preregistering patients is required. This could be scheduling a patient for an appointment or it could be to update a patients appointments. This also allows insurance information to be updated in the patient’s files and to retrieve any demographic information. The medical scheduler will also inquire for the reason of the visit so that the appropriate amount of time is allotted for the visit. Step 2 Evaluate Financial Responsibility Evaluating the financial responsibility of the visit is extremely important, to ensure that the patients insurance covers and what the patients is responsible for. It is also establish if any prior authorizations are required before services are performed. Step 3 Check In Patients When a patient new patient arrives it is necessary to take a copy of their insurance card, drivers’ license, and have them complete a new patient form with their medical history, home address...
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...Working with CPT Modifiers Traci Cruz December 15, 2011 HCR 220- Luci Shipley Bilateral procedure code -50 Bilateral services are procedures that are performed on both sides of the human body during an operative session or on the same day. The modifier 50 would not be applicable for procedures that are bilateral by definition or their descriptions that include the terminology as “bilateral” or “unilateral”. Multiple procedures code -51 When multiple procedures, other than E/M service are performed at the same time by the same provider, the primary procedures or services are reported as listed. Any additional procedures or services may be identified by an appending modifier of 51 to any additional procedure or service codes. Prolonged evaluation and management code -21 When a face-to-face or floor unit services are provided and is prolonged or otherwise greater than and is usually required for the highest level of evaluation. Unusual anesthesia code -23 This would indicate that the anesthesia was unusual, and rather using anesthesia during a particular procedure was unusual. This means that occasionally a procedure which is unusually would requires no anesthesia or local anesthesia, because of the unusual circumstances that are being performed under general anesthesia. Under this circumstance this may be reported by adding the modifier 23 to the procedure code of any basic service. Mandated services code -32 This code is used in healthcare to describe diseases, injuries...
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...Eligibility, Payment, and Billing Procedures Janessa Ashford HCR/220 There are a few factors that determine a patient’s benefits eligibility. Some of these include: whether coverage may end on the last day of the month in which the employee’s active full-time service ends. The employee may no longer qualify as a member of the group. For instance if a part time employee does not get benefits at that job, the employee may lose benefits when they lose hours. An eligible dependent’s coverage may end on the last day of the month in which the dependent status also ends, or reaching the age limit stated in the policy. When you work for a company full time and receive benefits, if you drop down to part time, you may lose those benefits. Most places do this. If someone is not eligible for the benefits trying to be used, the patient will then be responsible for the total themselves. Most offices require a signature stating that if your insurance does not cover the procedure or visit, the patient is then responsible for all charges. The place of business must let the patient know, first, that their insurance denied a claim and that they now have a balance due. If someone with full-time benefits has preventative care with no co-pay, then drops down to part-time and less benefits, their policy could change and they could no longer have preventative services covered...
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...Features of Health Plans Donna Kimble HCR/220 October 16th, 2013 Harry Holt A health plan is an organization that provides and pays for medical care. Either to an individual or group. There are different kinds of health plans, major which are the more known plans. Some examples would be HIP Ins. Group, Cigna health group, and Aetna group. Next would be state plans, such as Medicaid or child health plus. With state health insurance an individual and family are covered either according to what they make annually or if they have no income at all. Concerning major health plans, most of the time people pay monthly and have full coverage. People also can be covered by their employer, which can have full or limited coverage. Health plans can be very tricky and everyone should know the policy, and services covered for their health plan. Without full knowledge of your health plan you could result in having to pay a large amount of money for medical care you assumed was covered. Providers and consumers are both covered by these plans. Both financial and benefits but I believe that a providers coverage is a little more in depth than a consumers. A consumer will be covered for routine exams, if they fall, etc. under their plan. Sometimes certain things are not covered by a consumers plan, such as mammograms, and pap smears. Which are only covered every nine-twelve months. With a provider coverage is more detailed, for instance a doctor will have coverage in case of accidental...
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...Features of Health Plans HCR/220 12/14/14 When looking for different health care plans that’s offered there are five different kinds. Everyone just have to search and find what healthcare plan is right for them. Indemnity, Managed Care, Point of Service, HMO, and PPO are all five health care plan. Indemnity healthcare plan. Indemnity the patient choses the healthcare provider they wishes to see, with no limit. There is a deductible that a patient must pay before the insurance starts to pay. Managed care doesn’t have an open policy where you can see whatever health care provider you want. Managed care offers lower deductible to patients. Health maintenance organization also known as HMO have a network of providers. The people who enroll in HMO only use the providers within the HMO network. Point of service plans is part of the, it gives patient an option to choose a provider outside the HMO network. When patient do this they have to pay a fee to see other providers. Preferred provider organization also known as PPO is one of the popular insurance plans. PPO offers a discounted price to its patients from the providers, when the patient have an office visit they will have to pay a co-payment of $20 and PPO will pay the remainder balance. I don’t think that any one plan is great, I think that all of the plans are great. When you do the research on them they are great for the person who can afford them or for the person that it’s right for. But if having to choose one I think...
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...Corrie Crittle HCR/220 Medical Building Process Documentation at the Front Desk: The patient hand over an insurance card, this case the patient has Humana. On the care the office manager needs to verify if a referral or pre-authorization needs to be obtained and then contact the respective Primary care physician and get his documentation. Insurance verification data and a copy of the insurance card is sent to the billing office. The billing office scans the information and saves the documents. The Scanning department retrieve the information and it sent to the appropriate departments. Pre-coders then enter the key-in codes for insurance companies, doctors and modifiers. Pre-coders also add insurance companies, referring doctors, modifiers, diagnosis codes and procedure codes. The coding team assigns the Numerical codes for current procedural terminology and the diagnosis code based on the description given by the provider. The charge team has competent individuals who would first enter the patient personal information form the information given. Also they check for the relationship of the diagnosis code and the current procedural terminology. They create a charge, according to the billing rules pertaining to the specific carriers and locations. All charges are accomplished within an agreed turnaround time, about 24 hours. The daily charge entry then needs to be audited to double check the accuracy. Claims are filed and information sent to the transmission...
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...Checkpoint 1 Checkpoint Eligibility, Payment, and Billing Procedures Patricia Walker HCR 220 / Claims Preparation 1: Clean Bills of Health Axia College of University of Phoenix Professor Natalie Cooper June 9, 2011 Checkpoint 2 In patient benefits eligibility there is a number of factors that could determine whether a patient is eligible for certain benefits , such as checking to see if a premium is required , if so then the patient has to pay them on time. Although eligibility for Medicaid is able to change on a monthly basics. Another is if a person has an employer – sponsored health plan, the person’s status of employment becomes a deciding factor as well as the providers’ status as an in network or out –of- network provider as being listed on the plan master list of providers. The appropriate steps that would need to be taken if the patient insurance does not cover the plan and procedure to be done, then the healthcare provider need to inform the patient of the situation about their insurance eligibility of coverage. Therefore Ms. Smith should become aware that her delivery and prenatal care is not covered threw her insurance. So that way she could settle the financial account at that time. The two examples that I provided below relates to the eligibility factor of Ms. Sandra Smith charges with corresponding billing transactions...
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