Health Insurance Today

7th Edition - September 10, 2020
Authors: Janet I. Beik, Julie Pepper
Language: English
Paperback ISBN:
9 7 8 - 0 - 3 2 3 - 6 5 5 5 3 - 8
eBook ISBN:
9 7 8 - 0 - 3 2 3 - 6 5 5 5 4 - 5

Master the complexities of health insurance with this easy-to-understand guide! Health Insurance Today: A Practical Approach, 7th Edition provides a solid foundation in basics su… Read more

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Master the complexities of health insurance with this easy-to-understand guide! Health Insurance Today: A Practical Approach, 7th Edition provides a solid foundation in basics such as the types and sources of health insurance, the submission of claims, and the ethical and legal issues surrounding insurance. It follows the claims process from billing and coding to reimbursement procedures, with realistic practice on the Evolve website. This edition adds coverage of the latest advances and issues in health insurance, including EHRs, Medicare, and other types of carriers. Written by Medical Assisting educators Janet Beik and Julie Pepper, this resource prepares you for a successful career as a health insurance professional.

Cover image
Title page
Table of Contents
Copyright
Reviewers
Preface
A word about HIPAA
About the authors
Acknowledgments
List of Tables
List of Illustrations
UNIT I. Building a Foundation
1. The origins of health insurance
What Is Insurance?
History
Metamorphosis of Health Insurance
Key Health Insurance Issues
Basic Health Insurance Plans
Summary Checkpoints
Chapter Review Questions
Websites to Explore
2. Tools of the trade: A career as a health insurance professional
Your Future as a Health Insurance Professional
Job Duties and Responsibilities
Career Prospects
Is a Career in Healthcare Right for You?
Certification Possibilities
Career Focus for the Health Insurance Professional
Summary Checkpoints
Chapter Review Questions
Websites to Explore
3. The legal and ethical side of health insurance
Medical Law and Liability
Insurance and Contract Law
Medical Law and Ethics Applicable to Health Insurance
Important Legislation Affecting Health Insurance
Medical Ethics and Medical Etiquette
Medical Health Record
Documentation and Maintenance of Patient Medical Health Records
Health Insurance Portability and Accountability Act and Compliance
Confidentiality and Privacy
Healthcare Fraud and Abuse
Summary Checkpoints
Chapter Review Questions
Websites to Explore
4. Healthcare reform: Coverage types and sources
The Changing Face of Health Insurance
The Health Insurance Marketplace
Major Healthcare Payers
Miscellaneous Healthcare Coverage Options
CMS-1500 Claim Form
Consolidated Omnibus Budget Reconciliation Act
Health Insurance “Watchdogs”
Other Terms Common to Third-Party Carriers
Summary Checkpoints
Chapter Review Questions
Websites to Explore
5. The patient and the billing process
Patient Expectations
Future Trends
HIPAA Requirements
Billing Policies and Practices
Billing and Collection
Laws Affecting Credit and Collection
Collection Methods
Billing Services
Collection Agencies
Small Claims Litigation
Summary Checkpoints
Chapter Review Questions
Websites to Explore
UNIT II. Health Insurance Basics
6. Claim submission methods
Overview of the Health Insurance Claims Submission Process
Electronic Claims
Health Insurance Portability and Accountability Act
HIPAA Version 5010 Transactions and Code Standards
The Electronic Insurance Claims Process
Advantages of Electronic Claims
Two Ways to Submit Electronic Claims
The Universal Claim Form (CMS-1500)
Summary Checkpoints
Chapter Review
Websites to Explore
7. Claims management
Overview of the Claims Management Process
Keys to Successful Claims
HIPAA and National Standard Employer Identification Number
Claims Process
Processing Secondary Claims
Optimizing the Billing and Claims Process
Appeals
Summary Checkpoints
Chapter Review Questions
Websites to Explore
8. Reimbursement models
Fee-for-Service/Indemnity Insurance
Managed Care Insurance
Minimum Essential Coverage and the Marketplace
Standard Costs Associated With Insurance Plans
How Medical Fees Are Determined
The Changing Structure of Healthcare in the United States
Healthcare Reform and Preexisting Conditions
HIPAA and Healthcare Reform
Commercial or Private Health Insurance
Largest Commercial Insurance Companies
Coverage When Traveling Abroad
Participating Versus Nonparticipating Providers
Submitting Commercial Claims
Commercial Claims Involving Secondary Coverage
Summary Checkpoints
Chapter Review
Websites to Explore
9. The changing face of managed care
What Is Managed Care?
Origins of Managed Care
Goals of Managed Care
The Changing Face of Managed Care
Managed Care’s Challenges
Types of Managed Care Organizations
Managed Care and Government-Sponsored Health Plans
Managed Care and the Affordable Care Act
Managed Care Accreditation and Regulation
Claims Management
HIPAA and Managed Care
Impact of Managed Care
Future of Managed Care
Summary Checkpoints
Chapter Review Questions
Websites to Explore
10. Understanding medicaid
What Is Medicaid?
Medicaid and Healthcare Reform
Medicaid Benefits
Dual Eligible Beneficiaries
Other Medicaid Programs
Medicaid Premiums and Cost-Sharing
Prescription Drugs
Emergency Medical Treatment and Labor Act
Accepting Medicaid Patients
Medicare/Medicaid Relationship
Processing Medicaid Claims
Medicaid and Third-Party Liability
Medicaid Remittance Advice
Special Billing Notes
Fraud and Abuse in the Medicaid System
Medicaid Quality Practices
The Health Insurance Professional’s Role
Summary Checkpoints
Chapter Review Questions
Websites to Explore
11. Conquering Medicare’s challenges
The Medicare Program
The Effects of the ACA on Medicare Coverage
Medicare Combination Coverages
Medicare and Managed Care
Preparing for the Medicare Patient
Medicare Billing
Filing Medicare Claims
Using the CMS-1500 Form for Medicare Claims
Medicare Summary Notice and Remittance Advice
Medicare Audits and Appeals
Quality Review Studies
Medicare Billing Fraud
Clinical Laboratory Improvement Amendments Program
Summary Checkpoints
Chapter Review Questions
Websites to Explore
12. Military carriers
Military Health Programs
TRICARE
TRICARE’s Additional Coverage Options
Verifying TRICARE Eligibility
TRICARE Provider Types
TRICARE Beneficiary Cost-Sharing
TRICARE Claims Processing
CHAMPVA
CHAMPVA Program Options and Benefits
Filing CHAMPVA Claims
Military Carriers and HIPAA
Summary Checkpoints
Chapter Review Questions
Websites to Explore
13. Miscellaneous carriers
Workers’ Compensation
Private and Employer-Sponsored Disability Income Insurance
Federal Disability Programs
Summary Checkpoints
Chapter Review Question
Websites to Explore
UNIT III. Cracking The Codes
14. Diagnostic coding
Introduction to the International Classification of Diseases Coding System
History and Development of the International Classification of Diseases Coding System
Process of Classifying Diseases
Overview of the ICD-10 Coding System
Coding Steps for the Alphabetic Index
Tabular List
ICD-10-CM Official Guidelines for Coding and Reporting
Other Coding Features of the ICD-10-CM
Coding Steps for the Tabular List
HIPAA and Coding
General Equivalence Mappings
Looking Ahead to ICD-11
Summary Checkpoints
Chapter Review Questions
Websites to Explore
15. Procedural, evaluation and management, and HCPCS coding
Overview of Current Procedural Terminology Coding
Two Levels of Procedural Coding
Current Procedural Terminology Manual Format
Conventions and Punctuation Used in Current Procedural Terminology
Basic Steps of Current Procedural Terminology Coding
Evaluation and Management Coding
Subheadings of Main Evaluation and Management Section
Evaluation and Management Modifiers
Importance of Documentation
Overview of HCPCS
National Correct Coding Initiative
HIPAA and HCPCS Coding
Summary Checkpoints
Chapter Review Questions
Websites to Explore
UNIT IV. Advanced Application
16. The role of computers in health insurance
Introduction
Impact of Computers on Health Insurance
Role of HIPAA in Electronic Transmissions
Electronic Data Interchange
Electronic Claims Process
Medicare and Electronic Claims Submission
Additional Electronic Services Available
Electronic Medical Record
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
What Is Interoperability in Healthcare?
Summary Checkpoints
Chapter Review Questions
Websites to Explore
17. Reimbursement procedures: Getting paid
Understanding Reimbursement Systems
Medicare and Reimbursement
Additional Systems for Determining Reimbursement
Transition of Medicare to a Resource-Based Relative Value Scale
Significance of Reimbursement Systems to the Health Insurance Professional
Peer Review Organizations and Prospective Payment Systems
Understanding Computerized Patient Accounting Systems
HIPAA and Practice Management Software
Summary Checkpoints
Chapter Review Questions
Websites to Explore
18. Hospital billing and the UB-04
Introduction
Hospitals and Health Systems
Common Healthcare Facilities
Legal and Regulatory Environment
Common Hospital Payers and Their Claims Guidelines
National Uniform Billing Committee and the UB-04
Structure and Content of the Hospital Health Record
Inpatient Hospital/Facility Coding
Outpatient Hospital Coding
The Hospital Billing Process: Understanding the Basics
HIPAA–Hospital Connection
Billing Compliance
Career Opportunities in Hospital Billing
Summary Checkpoints
Chapter Review Questions
Websites to Explore
Appendix A: Sample blank CMS 1500 (02/12)
Appendix B: CMS 1500 claim forms and completion instructions
Appendix C: UB 04 claim forms and completion instructions
Glossary
Resources
Index

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Janet I. Beik

Julie Pepper