Medical Insurance

Medical Insurance

Medical insurance plays an important role in the financial well-being of every healthcare business. The regulatory environment of medical insurance is now evolving faster than ever. Changes due to healthcare reform require medical office professionals to acquire and maintain an in-depth understanding of compliance, electronic health records, medi-

cal coding, and more.

The eighth edition of Medical Insurance: A Revenue Cycle Process Approach emphasizes the revenue cycle—ten steps that clearly iden- tify all the components needed to successfully manage the medical insurance claims process. The cycle shows how administrative medical professionals “follow the money.” Medical Insurance

Medical insurance specialists must be familiar with the rules and guidelines of each health plan in order to submit proper docu- mentation. This ensures that offices receive maximum, appropriate reimbursement for services provided. Without an effective administrative staff, a medical office would have no cash flow!

The following are some of the key skills covered for you and your students in Medical Insurance, 8e:

Skills Coverage

Procedural Learning administrative duties important in medical practices as well as how to bill both payers and patients

Communication Working with physicians, patients, payers, and others using both written and oral communication

Health information management

Using practice management programs and electronic health records technology to manage both patient records and the billing/ collections process, to electronically transmit claims, and to con- duct research

Medical coding Understanding the ICD-10, CPT, and HCPCS codes and their importance to correctly report patients’ conditions on health insur- ance claims and encounter forms as well as the role medical cod- ing plays in the claims submission process Medical Insurance

HIPAA/HITECH Applying the rules of HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health act) to ensure compliance, maximum reimbursement, and the electronic exchange of health information

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x Preface

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Organization of Medical Insurance, 8e An overview of the book’s parts, including how they relate to the steps of the revenue cycle, follows:

Part Coverage

1: Working with Medical Insurance and Billing

Covers Steps 1 through 3 of the revenue cycle by introducing the major types of medical insurance, payers, and regulators, as well as the steps of the cycle. Also covers HIPAA/HITECH Privacy, Security, and Electronic Health Care Transactions/Code Sets/Breach Notification rules.

2: Claim Coding Covers Steps 4 through 6 of the revenue cycle while building skills in correct coding procedures, using coding references, and comply- ing with proper linkage guidelines.

3: Claims Covers Step 7 of the revenue cycle by discussing the general procedures for calculating reimbursement, how to bill compliantly, and preparing and transmitting claims.

4: Claim Follow-Up and Payment Processing

Covers Steps 8 through 10 of the revenue cycle by describing the major third-party private and government-sponsored payers’ proce- dures and regulations along with specific filing guidelines. Also explains how to handle payments from payers, follow up and appeal claims, and correctly bill and collect from patients. This part includes two case stud- ies chapters that provide exercises to reinforce knowledge of complet- ing primary/secondary claims, processing payments from payers, and handling patients’ accounts. The case studies in Chapter 15 can be completed using Connect for simulated exercises. The case studies in Chapter 16 can be completed using the CMS-1500 form. Medical Insurance

5: Hospital Services Provides necessary background in hospital billing, coding, and payment methods.

New to the Eighth Edition Medical Insurance is designed around the revenue cycle with each part of the book dedicated to a section of the cycle followed by case studies to apply the skills discussed in each section. The revenue cycle now follows the overall medical documentation and revenue cycle used in practice management/electronic health records environments and applications.


Medical Insurance offers several options for completing the case studies at the end of Chapters 8–12 and throughout Chapter 15:

• Paper Claim Form: If you are gaining experience by completing a paper CMS-1500 claim form, use the blank form supplied to you (from the back of Medical Insurance) and follow the instructions in the text chapter that is appropriate for the particular payer to fill in the form by hand.

• Connect Simulations: The ability to understand and to use Electronic Health Records (EHR) systems are critical job skills and competencies required for employment in a Medical Office or Hospital. In the past, teaching students the hows and whys of using an EHR has been challenging. Live software solutions require complex installation and support, and often don’t translate well into the classroom. Simulated educational solutions often fall short in giving students the realistic experience of working in real world scenarios.

McGraw-Hill Education is proud to introduce EHRclinic, the educational EHR solution that provides the best of both worlds, both the experience of working in a Medical Insurance

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live, modern EHR application, along with the convenience and reliability of simu- lated educational solutions.

EHRclinic is integrated into Connect, McGraw-Hill’s digital teaching and learning environment that saves students and instructors time while improving performance over a variety of critical outcomes.

For Medical Insurance, Connect provides simulated, auto-graded exercises in mul- tiple modes to allow the student to use EHRclinic to complete the claims. If assigned this option, students should read the User Guide at as the first step, and then follow the instructions with each chapter’s case studies. Note: some data may be prepopulated to allow students to focus on the key tasks of each exercise.

• Connect CMS-1500 Form Exercises: Another way to complete the claims exercises is by using the CMS-1500 form exercises in Connect if directed by your instructor. These exercises allow you to complete the necessary fields of the form in an auto- graded environment. Medical Insurance

Medical standards of care are state-specified performance measures for the delivery of healthcare by medical professionals. Medical malpractice can result when a provider injures or harms a patient because of failure to follow the standards.

malpractice failure to use professional skill when giving medical services that results in injury or harm

A patient’s medical record contains the results of all tests a primary care physician (PCP) ordered during a comprehensive physical examination. To follow up on a prob- lem, the PCP could refer the patient to a cardiologist, also sending the pertinent data for that doctor’s review. By studying the medical record, the specialist treating a referred patient learns the outcome of previous tests and avoids repeating them unnecessarily.

Documentation means organizing a patient’s health record in chronological order using a systematic, logical, and consistent method. A patient’s health history, examina- tions, tests, and results of treatments are all documented. Complete and comprehensive documentation is important to show that physicians have followed the medical standards of care that apply in their state. Healthcare providers are liable (that is, legally respon- sible) for providing this level of care to their patients. The term medical professional liability describes this responsibility of licensed healthcare professionals Medical Insurance

Also check: Evidence-Based Practice and the Quadruple Aim