MOA115_Wk5_Lab_03182024
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MOA115 Medical Records and Insurance Week
5 Lab – Claims Simulation Chapter 15 Medical Billing and Reimbursement Essentials - Part 2
A. Medical Billing Process 1.
List four types of information collected when a patient calls to schedule an appointment.
a.
FULL NAME
b.
D.O.B
c.
HOME ADDRESS/ PHONE NUMBER d.
INSURANCE PLAN
2.
At the time of the appointment, what two things are copied or scanned into the computer? a.
ID/DRIVERS LICENSE
b.
INSURANCE
CARD
3.
Describe how the patient’s insurance eligibility is confirmed. YOU CAN CONTACT THE INSURANCE COMPANY BY CALLING THE NUMBER ON THE BACK OF THE CARD OR YOU CAN VERIFY ELIGIBILITY BY LOOKING THE PATIENT UP USING THE INSURANCES WEB PORTAL.
4.
Referring to the information on the ID card, answer the following questions.
MOA115 Medical Records and Insurance Week
5 Lab – Claims Simulation a.
What is the member’s name? JOHN SMITH
b.
What is the member’s ID number? ZGY123456789
c.
What is the group number? 123456
d.
Who is the member’s primary care provider (PCP)? DR. SMITH
e.
What is the effective date of the plan? 05/01/11
f.
What is the deductible for prescriptions (Rx)? $50
g.
What is the copay for primary care (PC)? $20
h.
What number should the patient call if he has a concern? 1-888-697-0683
i.
What number should you call if you need to get a preauthorization? 1-800-441-9188
MOA115 Medical Records and Insurance Week
5 Lab – Claims Simulation j.
What number should a healthcare professional working with Dr. Smith call if there is a question about the coverage? 1-800-451-0287
B. Explanation of Benefits Using the explanation to answer the following questions: 1.
For Tai Yan’s office visit, 99205, there is a difference between the Charge Amount and Covered Amount. Based on the reason code supplied what will be done with the difference? THE COVERED AMOUNT IS CREDITTED TO THE CHARGED AMOUNT
2.
How much is Tai Yan responsible for? $121.07
3.
How much will be written off for Jana Green? $104.18
4.
How much is Jana Green responsible for? $83.34
5.
What is the covered amount services provided to Pedro Gomez? $28.55
C. The Patient’s Financial Responsibility
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MOA115 Medical Records and Insurance Week
5 Lab – Claims Simulation Use the following information as you answer the following questions. Patient: Zach Green Deductible: $750 Coinsurance: 80/20 Patient out-of-pocket expense maximum: $2000 1.
During Zach’s first visit of the year, he incurred a $500 bill. Who pays this bill? ZACH
2.
During Zach’s second visit of the year, he incurred a $450 bill. Describe how much is paid
by Zach and the insurance carrier. ZACH WOULD PAY $160 AND THE INSURANCE $40
3.
Zach had surgery, which was his third claim of the year. He had a bill of $5000. Considering the prior visits, what is Zach’s portion of this bill and what is the responsibility of the insurance carrier? INSURANCE PAYS $4,000 AND ZACH PAYS $1,000
4.
How much is Zach responsible for so far this year considering his first three visits? $210
Part 3 – Submission Errors and Appeals
Directions
:
•
Using online resources research the common errors with claim submission and the appeal process. •
Research the appeal process for either your insurance carrier or an insurance carrier popular in your area. 1.
What are the most common errors when submitting claims? Entering incorrect information, ie. demographic information, provider information, cpt information
MOA115 Medical Records and Insurance Week
5 Lab – Claims Simulation 2.
How can these errors be prevented? Verifying patient eligibility, verify your own work by making sure all input information is correct
including patient info icd codes and cpt codes.
3.
What can a medical assistant do to prevent those errors? Master coding, create an efficient system, include sufficient data/documentation.
4.
Who can start the appeal process? The provider or the patient can start the appeal process.
5.
What steps are involved in the appeal process?