1. Clinical Medical Assisting
Chapter 18: Medical Insurance and Coding

2. Objectives Understand the process of procedure and diagnosis coding
Recognize common errors in completing insurance claim forms
Explain the difference between the CMS-1500 and the UB-04 forms

3. Objectives (con’t)
Describe the way computers have altered the claims process
Discuss why claims follow-up is important to the ambulatory care setting
Discuss legal and ethical issues related to coding and insurance claims processing

4. Chapter Overview
Medical care is undeniably expensive. Payment is required for hospitalizations, physician visits, diagnostic procedures, treatments, and prescription medications. Payment is received by providers through several mechanisms, including private health-insurance programs, consumer-driven health plans, and government health coverage plans. Each program requires extensive documentation and procedural and diagnostic coding to ensure adequate coverage of fees and to expedite reimbursement.

5. Reimbursement
Monetary compensation for medical care provided

6. Health Insurance
Protects people from the high costs associated with medical care

7. Affordable Care Act
The goal of the ACA is to expand coverage and improve access to health care for more Americans and make insurance companies more accountable for their coverage decisions.

8. Managed Care
A system in which an organization contracts with providers to provide comprehensive healthcare services to its subscribers or enrollees at a reduced cost

9. Network
Providers who are contracted to provide services

10. Commercial Insurance Programs
Privately owned and managed health-insurance providers

11. Annual Premium
The amount an individual pays to purchase the insurance coverage each year

12. Deductible
The amount that an individual must pay on his or her own before the insurance provider will begin paying for services

13. Co-pay
The amount that an individual must pay toward each service provided

14. Co-insurance
A percentage of the total cost that an individual must contribute toward each service

15. Health Maintenance Organizations
A commercial insurance plan that requires individuals to select a primary care provider

16. Primary Care Provider
A general practitioner, family practice physician, or internist who acts as a “gatekeeper” for all of the individual’s medical care

17. Preferred Provider Organizations
A type of commercial insurance plan that contracts with a network of providers to provide services to patients

18. Consumer-Driven Health Plans
Enables consumers to make more choices regarding how their healthcare dollars are spent

19. Health Savings Account
A savings account that can be used to pay for medical expenses

20. Flexible Spending Account
A means of paying for medical expenses

21. Government Health Plans
Federal and state government programs are available to provide medical care to patients who do not have private health-insurance coverage.

22. Medicare
A federal program that provides health insurance for individuals older than 65 years of age

23. Medicaid
A state-administered program that provides health-insurance coverage for low-income individuals, uninsured pregnant women, and individuals with disabilities

24. Children’s Health Insurance Program
Coverage for children in low-income families

25. TRICARE
Provide health-insurance coverage for active and retired military personnel and their dependents

26. CHAMPVA
The Civilian Health and Medical Program of the Veterans’ Administration provides coverage for the dependents of military personnel who have permanent service-related disabilities.

27. Uninsured Individuals
Nearly 50 million Americans do not have health-insurance coverage.

28. Secondary Insurance Coverage
Patients may have more than one insurance provider.

29. Coordination of Benefits
The method for determining which insurance carrier pays what portion of the medical-care costs

30. Diagnostic and Procedural Codes
To ensure accurate reimbursement from insurance providers, proper coding is essential.

31. Coding
The process of assigning alphanumeric designations to diagnoses, procedures, and services

32. Encounter Form
In an office setting, codes will be documented on a patient’s encounter form.

33. International Classification of Diseases
A means of classifying deaths, statistically assessing diseases, categorizing illnesses, and retrieving records

34. Diagnosis-related Group
Medicare uses DRGs to determine the amount of reimbursement provided for related procedures.

35. Healthcare Common Procedure Coding System
A set of codes that identifies healthcare procedures

36. Current Procedural Terminology
Level I codes are five-digit numeric codes. Level II codes are five-digit alphanumeric codes; the first digit is always a letter and the remaining four digits are numbers.

37. Current Procedural Terminology
The codes are divided into six sections.

38. Coding Accuracy
Accurate coding is required, not only to guarantee appropriate reimbursement but to maintain a high standard of ethical.

39. Unbundling
Reporting multiple codes when only one is appropriate

40. Upcoding
Assigning additional codes that do not match patient documentation

41. Bundling
Insurance companies only pay for certain claim codes and ignore others

42. Downcoding
Insurance companies pay for a lower level of care than what was actually provided

43. Claims Forms
Must be submitted to insurance providers for providers to receive reimbursement

44. Errors
When errors are detected on a claims form, the claim for reimbursement is rejected.

45. Tracking Claims
Ensures prompt follow-up for any issues that might delay payment

46. Skills for the Medical Assistant
Maintain accurate and complete records and submit factual claims reflecting the patient’s diagnoses, treatments, and procedures.

47. Using Medical Coding to Reflect Care Provided
You will learn how to assign a CPT code based on a patient encounter form.

48. Completing a Medical Insurance Claim Form
You may be asked to complete a medical insurance claim form.

49. Summary
Health insurance protects individuals from the high costs associated with medical care. Through private health-insurance programs, consumer-driven health plans, and government health coverage, individuals prepay for medical care so they do not have to pay the entire cost of care at the time of service.

50. Summary (con’t)
As a medical assistant, you will have the opportunity to participate in verifying medical insurance coverage for individuals and completing and submitting claims forms. Attention to detail and accuracy in completing forms will ensure that the maximum insurance benefits are received in a timely manner.