Fordney's Medical Insurance

15th Edition - January 18, 2019
Editor: Linda M. Smith
Language: English
eBook ISBN:
9 7 8 - 0 - 3 2 3 - 5 9 4 2 9 - 5

Get a solid foundation in insurance billing and coding! Trusted for more than 30 years, Fordney’s Medical Insurance equips you with the medical insurance skills you need to succee… Read more

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Get a solid foundation in insurance billing and coding! Trusted for more than 30 years, Fordney’s Medical Insurance equips you with the medical insurance skills you need to succeed in any of today’s outpatient settings. The 15th edition has been expanded to include inpatient insurance and billing and ambulatory surgical center billing. Updated coverage emphasizes the role of the medical insurance specialist in areas such as diagnostic coding, procedural coding, Medicare, HIPAA, and bill collection strategies. As with previous editions, all the plans that are most commonly encountered in clinics and physicians’ offices are incorporated into the text, as well as icons for different types of payers, lists of key abbreviations, and numerous practice exercises that accurately guide you through the process of filling out claim forms. In addition, SimChart® for the Medical Office (SCMO) activities on the companion Evolve website give you the opportunity to practice using electronic medical records.

Cover image
Title page
Table of Contents
Copyright
About the Author
Acknowledgments
Contributors and Reviewers
Welcome to the Fifteenth Edition
Unit 1. Career Role and Responsibilities
1. Role of an Insurance Billing Specialist
Key Abbreviations
Background of Insurance Claims, Coding, and Billing
Role of the Insurance Billing Specialist
Medical Etiquette
Professional Ethics
Scope of Practice and Liability
Future Challenges
Key Points
Student Assignment
2. Privacy, Security, and HIPAA
Key Abbreviations
Health Insurance Portability and Accountability
Transaction and Code Set Regulations
National Identifiers
The Privacy Rule: Confidentiality and Protected Health Information
The Security Rule: Administrative, Technical, and Physical Safeguards
Health Information Technology for Economic and Clinical Health Act
Application to the Health Care Setting
Best Practices to Avoid Common Hipaa Violations
Key Points
Student Assignments
3. Compliance, Fraud, and Abuse
Key Abbreviations
Compliance Defined
Fraud and Abuse Laws
Compliance Programs
OIG Compliance Program Guidelines
Compliance as a Career
What to Expect from the Health Care Organization
Key Points
Student Assignment
Unit 2. Introduction to Health Insurance
4. Basics of Health Insurance
Key Abbreviations
History of Health Insurance in the United States
Health Care Reform
Legal Principles of Insurance
Health Care Organization–Patient Contracts and Financial Obligation
The Insurance Policy
Choice of Health Insurance
Types of Health Insurance Coverage
Exception
Handling and Processing Insurance Claims
Life Cycle of an Insurance Claim
Keeping up to Date
Key Points
Student Assignment
5. The Blue Plans, Private Insurance, and Managed Care Plans
Key Abbreviations
Private Health Insurance
Managed Care
Managed Care Systems
Medical Review
Management of Plans
Plan Administration
Financial Management
Key Points
Student Assignment
6. Medicare
Key Abbreviations
Background
Policies and Regulations
Additional Insurance Programs
Utilization and Quality Control
Program Fundamentals
Medicare Reimbursement
Claim Submission
After Claim Submission
Key Points
Student Assignment
7. Medicaid and Other State Programs
Key Abbreviations
Medicaid
Medicaid Programs
Medicaid Eligibility
Medicaid Benefits
Medicaid Managed Care
Claim Procedures
After Claim Submission
Key Points
Student Assignment
8. TRICARE and Veterans’ Health Care
Key Abbreviations
TRICARE
History of Tricare
Health Plans
Veterans Health Administration Program
Claims Procedure
After Claim Submission
Key Points
Student Assignment
9. Workers’ Compensation
Key Abbreviations
History
Workers’ Compensation Laws and Insurance
Eligibility
Coverage
Types of State Compensation Benefits
Types of State Workers’ Compensation Claims
Fraud and Abuse
Legal Situations
Medical Reports
Reporting Requirements
Claim Submission
Key Points
Student Assignment
10. Disability Income Insurance and Disability Benefit Programs
Key Abbreviations
Disability Claims
History
Disability Income Insurance
Federal Disability Programs
State Disability Insurance
Voluntary Disability Insurance
Claims Submission Guidelines
Conclusion
Key Points
Student Assignments
Unit 3. Documentation and Coding for Professional Services
11. Medical Documentation and the Electronic Health Record
Key Abbreviations
The Documentation Process
Incentive Programs for Adoption of Electronic Health Records
General Principles of Health Record Documentation
Legible Documentation
Documentation Terminology
Abstracting from Health Records
Review and Audit of Health Records
Release and Retention of Health Records
Documentation Guidelines for Evaluation and Management Services
Key Points
Student Assignment
12. Diagnostic Coding
Key Abbreviations
Diagnosis Coding Overview
International Classification of Diseases
Official Guidelines for ICD-10-CM
The Future of Diagnosis Coding
Key Points
Student Assignments
13. Procedural Coding
Key Abbreviations
Understanding the Importance of Procedural Coding Skills
A Coding Specialist’s Tools
Healthcare Common Procedure Coding System
Current Procedural Terminology Content and Format
Code Modifiers
Correct Coding Edits and Practices
Methods of Payment
Key Points
Student Assignment
Unit 4. Claims Submission in the Medical office
14. The Paper Claim CMS-1500
Key Abbreviations
The Paper Claim CMS-1500
Types of Submitted Claims
Abstracting from Medical Records
Health Insurance Claim Form (CMS-1500)
Common Reasons Why Claim Forms are Delayed or Rejected
Additional Claim Submission Errors
Claim Completion Guidelines
Instructions for Completing the Health Insurance Claim Form (CMS-1500)
Key Points
Student Assignment
15. The Electronic Claim
Key Abbreviations
Electronic Data Interchange
Electronic Claims
Advantages of Electronic Claim Submission
Clearinghouses
Transaction and Code Sets Regulations: Streamlining Electronic Data Interchange
Electronic Standard HIPAA 837P
Claim Attachments Standards
Standard Unique Identifiers
Practice Management System
Building the Claim
Putting Hipaa Standard Transactions to Work
Methods of Sending Claims
Computer Claims Systems
Transmission Reports
Key Points
Student Assignment
Unit 5. The Claim Follow-Up and Payment Process
16. Receiving Payments and Insurance Problem Solving
Key Abbreviations
Revenue Cycle Management
Response from a Submitted Claim
Claim Policy Guidelines
Explanation of Benefits
Claim Management Techniques
Claim Inquiries
Problem Claims
Rebilling
Review and Appeal Process
Filing an Appeal
State Insurance Commissioner
Claim Denial Management
Key Points
Student Assignment
17. Collection Strategies
Key Abbreviations
Collection Strategies
Accounts Receivable
Patient Education
Fees
Credit and Collection Laws
The Collection Process
Key Points
Student Assignment
Unit 6. Healthcare Facility Billing
18. Ambulatory Surgery Center
Key Abbreviations
History of Ambulatory Surgery Centers
Types of Ambulatory Surgery Centers
Ambulatory Surgery Center Payment System
Payment for Ambulatory Surgery Center Services
Payment Rates
Medicare Setting Component Within Base Rate
Separately Payable Services
Hospital Outpatient Prospective Payment
Differences Between ASC and Hospital Outpatient Department Reimbursement Models
Revenue Cycle Management
Reimbursement Process
Other Types of Reimbursement
Medicaid Overview
Medical Records for Reimbursement
Medical Coding and Billing Guidance
Claims Management and Health Care Claim Submission
Modifiers
Status (Payment) Indicators
National Correct Coding Initiative Edits
Other Payers
Local Coverage Determinations and National Coverage Determinations
Ambulatory Surgery Center Quality Reporting (ASCQR)
Consumer Assessment of Health Care Providers and Systems Outpatient and Ambulatory Surgery Survey
Student Assignment
19. Hospital Outpatient and Inpatient Billing
Key Abbreviations
Revenue Cycle
Types of Reimbursement Methodologies
Medicare
Key Points
Student Assignment
Unit 7. Employment
20. Seeking a Job and Attaining Professional Advancement
Key Abbreviations
Employment Opportunities
Professional Organizations
Job Search
Self-Employment
Attaining Professional Advancement
Key Points
Student Assignment
Key Abbreviations
Glossary
Index

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Fordney's Medical Insurance

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Linda M. Smith