TRICARE

.docx

School

Technical University of Mombasa *

*We aren’t endorsed by this school

Course

RESEARCH P

Subject

Health Science

Date

Nov 24, 2024

Type

docx

Pages

7

Uploaded by MateFieldWalrus14

Report
1 Compensation Student’s Name University Affiliation Course Name Instructor’s Name Assignment Due Date
2 Compensation Identify the different components of TRICARE billing and different types of benefits available to active duty members, veterans, and their family members. Over the years the military and their families have struggled to afford their medical care and this has triggered the United States Congress to develop the Civil Health and Medical Program of the Uniformed Services which is currently referred to as TRICARE (Vines, Braceland, Rollins, & Miller, 2013, p. 440). TRICARE has come to the rescue of the forces because they are offering various services to active force members and their families and it is necessary for medical billers and coders to understand the personal requirements for qualification, benefit coverage and other plan regulations for a successful and precise billing procedure. Active members of the forces are referred to as sponsors while those who are legible for TRICARE are known as beneficiaries. There are various plans that are available for different active duty members and they include, TRICARE Standard which is a free for service scheme, TRICARE Prime is the HMO plan and TRICARE Senior Prime is offered for members aged 65 years and above who qualify for Medicare. TRICARE also has another pack of plans that they offer to incorporate the active force families and give PPO solutions for issues through non- military providers. Legends who have disabilities that they suffered 100% in the line of duty do not qualify for TRICARE but instead they are served through CHAMPVA. There are some fundamental backgrounds of the system that the medical billers and coders need to understand in the delivery of their services. They first need to understand the timely filing requirements, the qualification verification process through Defense Enrollment Eligibility Reporting System.
3 They need an understanding of what services are covered under which plan and who are covered. They also need to be conversant with the procedures of filing claims for every plan that is offered by the system. Understand the history of workers’ compensation and distinguish between federal workers’ compensation and state workers’ compensation The Office of Worker’s Compensation Programs is responsible for compensating all employees working under federal agencies. Other workers are compensated based on the statutes set if their places of work and they differ from state to state (Vines, Braceland, Rollins, & Miller, 2013, p. 440). It is necessary for medical billers and coders to understand the statutes of their state so that it can enable them to code and bill with the dictated boundaries. There are two ways of filing claims, claims can be filed manual or electronically and the two procedures and the manual process demands more oversight ("Billing Workers’ Compensation | Medical Billing and Coding U," 2017). The claim filing process the progress note must be attached to a Work Status Report and deep explanation in completing the CMS-1500 form is needed to eliminate denial. Fraud is a major issue when dealing with workers’ compensation claims and that is why it is important for medical billers and coders to be informed of all the requirements and procedures involved. At the time of developing and presenting claims and backup details it is important to highlight which services were offered to make sure they are accurately matched to the billing codes. The most common medical provider fraud plans are creative coding and upcoding. Explain the importance of the Explanation of Benefits and Electronic Remittance Advice Forms.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
4 The significance of having background detail of the history of healthcare, a deep comprehension of different insurance schemes and coverage benefits linked with each scheme, the precise stages of filing claims for every scheme adds up to the review and posting of the Explanation of Benefits ‘EOBs’ also known as Electronic Remittance Advice Forms ‘EAAs’ in the digital space. An ERA is the alert from a member on the status of a claim and it is inclusive of reason codes also known as remarks from insurance carriers and they facilitate the identification of a situation connected to a given line product on an EOB or ERA (Vines, Braceland, Rollins, & Miller, 2013, p.484). In the provider’s office financial health can only be promoted if key players have the knowledge and understanding of what the insurance scheme cover gains are and being in a position to harmonize what the charges and diagnoses filed on the claim were against the ERA notice. Also having a functional medical office expert, biller and coder who have the capacity to evaluate the ERA notice or decide if an appeal is required or additional details will ease the successful processing of the claim can be important to how providers will be compensated and how the practice will fund itself. Understand the reimbursement follow-up, explain the appeals process for reimbursement, and identify refund guidelines. There is the notion in the billing space that reimbursement is all about follow up. The rule in the billing world is that for great reimbursement claims must be monitored until they are paid. In instances where denials are highlighted then evaluation of denial reason and declaration of the next stages should be addressed in time. In some scenarios all that is needed is a follow up call to the carrier while in some instances when the EOBs are reviewed and posted it may be decided that an appeal is the solution. It is important that before a decision to file an appeal, all medical
5 records are analyzed for detailed documentation and the documentation can defend the case for the CPTs and ICD10’s attached to the claim. Every payer has their defined appeal procedure that must be observed and it is significant for the medical office specialist to be concerned of the punctual filing for appeals as well as put certain payer contracts in place for easy approach in procedural appeal. Deciding if the denial is of the complete charges or if it disallowances, in this space a disallowance is a limited payment that is made in cases where the claim submissions are more than the maximum allowable compensations. Guided by the knowledge of the denial circumstances the appeal process will be treated either as a formal appeal in written form or by phone call. Reason codes on a claim that would contain a formal appeal is inclusive of a permitted number of exceeded visits, billing mistakes and duplicate processes (Vines, Braceland, Rollins, & Miller, 2013, p. 525). It is proposed that as a good customer service it is good to involve the patient ion any appeal letters being submitted. An effective way of overcoming denial is observing perseverance when assured of due payments. According to Henry Wadsworth “Perseverance is a great element of success. If you only knock long and loud enough at the gate, you are sure to wake up somebody.” (Wadsworth, n.d) The medical office specialist, biller or coder is also tasked with handling funds. There are instances when overpayments are made from insurance carriers as a result of primary and secondary insurance compensating as primary, a client paying over what their financial responsibility is at time of visit and instances when the carriers make mistakes in payment duplication. After assurance that a refund is due it is important to hold clean accounts thus the preferred way is to adjust off the client accounts as the refunds are generated. It is good to keep
6 off overpayments as frequent as possible and this is possible through consistent verification of qualification at the time of visit. Discuss the history of workers’ compensation and distinguish between federal workers’ compensation and state workers’ compensation. Workers’ compensation dates back to the late 19 th century when Otto Von Bismarck introduced the Sickness and Accident Laws. Employers’ Liability Law was enacted in 1871 and it offered partial protection to employees in identified factories, quarries and mines. In 1884 the Workers’ Accident Insurance was enacted and it developed a modern workers’ compensation system. Over the years worker’s compensation schemes have evolved and they have become a valuable part of any occupation. In the United States there is federal workers’ compensation and state workers’ compensation and they have notable differences. The main difference between the two plans is that to receive the federal compensation claim benefits from the OWCP one must be a civilian working with the US government. The injury must be experienced in the line of duty. Those who are not civilian employees of the government file for state compensation.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
7 References Billing Workers’ Compensation | Medical Billing and Coding U. (2017). Retrieved June 25, 2017, from http://www.medicalbillingandcodingu.org/billing-workers compensation/ Vines, D., Braceland, Rollins, & Miller. (2013). Student workbook, Comprehensive health insurance: Billing, coding, and reimbursement, Second edition (2nd ed.). Boston, MA: Pearson Wadsworth, H. (n.d.). Henry Wadsworth Longfellow quotes. Retrieved June 26, 2017, from http://thinkexist.com/quotation/perseverance_is_a_great_element_of_success if_you/208922.html