Chapter 1, Problem 1R

True or false: Home health care is considered an institutional service.

A patient receives a $420 medical procedure and has a 70/30 coinsurance agreement and a $100 deductible with their insurance company which they have not met. The insurance allows $300 on the procedure and the provider will write off the difference in cost. How much will the insurance be responsible for? How much will the patient responsible for?

To process claims accurately and effectively, billing professionals must understand how a clean claim is prepared and what issues can contribute to a dirty claim. When managing a team of billing professionals, it is important to understand how internal and external factors contribute to a smooth process vs. a rejection or denial. Summarize internal factors (within your organization/facility) that can positively or negatively influence the life cycle of a claim. Summarize external factors (outside of your organization/facility) that can positively or negatively influence the life cycle of a claim. From a leadership perspective, how can you ensure your team is effectively trained and confident in navigating internal and external challenges with claim processing? Please be sure to validate your opinions and ideas with citations and references in APA format.

Should the woman who gives birth to a child with fetal alcohol syndrome (FAS) be penalized in some manner? The answer to this question is a bit more complicated than a simple yes or no, however. The child will require economic and psychosocial support, possibly for the rest of his or her life, an expenditure that might cost many tens of thousands (or hundreds of thousands) of dollars over the child’s lifespan. This will be necessitated because the child’s struggles were entirely preventable, had the mother abstained from alcohol use during her pregnancy. The mother’s alcohol use behaviors during pregnancy are the sole determinant whether the infant develops FAS. Many infants who have FAS have a mild form of the disorder that might not even be recognized by a physician with great experience in working with children with FAS. Even the most severe form can be difficult to diagnose at times. The subtle forms of FAS would be exceptionally difficult to definitively diagnose, and the danger…

A patient received $800 medical procedure . The patient has an insurance plan with a 70/30 coinsurance agreement and a $200 deductible which they have not met . The insurance allows $550 on the procedure and the provider will write off the difference in cost . How much will the insurance be responsible for? How much will the patient be responsible for?