Heath care reimbursement is the study of reimbursement for services rendered to a person in which an entity other than the receiver of the service is responsible for the payment. Third-party reimbursement for the cost of a subscriber’s health care is commonly paid in full or in part by a health insurance plan, such as Blue Shield or Blue Cross, Medicare, or Medicaid. (Mosby, 2009, p. 436). The purpose of studying healthcare reimbursement is to become proficient in billing and coding so that health care providers can be paid and continue to provide quality healthcare to patients. By completing this project you will demonstrate your understanding of medical reimbursement; a skill used by medical assistants in the workplace.
Course Outcomes:
1. Define basic health insurance terms & abbreviations.
2. Analyze and discuss insurance plans.
3. Analyze the legal and ethical impact of fraud and abuse.
4. Use CPT, ICD and HCPCS coding systems to complete claim forms.
5. Evaluate the impact of reimbursement from various plans with regard to effective practice management.
6. Reflect on the impact of health care reimbursement policies to individuals and providers.

MAERB Competencies Evaluated in this Project
Third Party reimbursement VIII.C
1. Identify
a. Types of third party plans
b. Information required to file a third party claim
c. The steps for filing a third party claim
2. Outline managed care requirements for patient referral
3. Describe processes for:
a. Verification of eligibility for services
b. Precertification
c. Preauthorization
4. Define a patient-centered medical home (PCMH)
5. Differentiate between fraud and abuse
Procedural and Diagnostic Coding IX.C
1. Describe how to use the most current procedural coding system
2. Describe how to use the most current diagnostic coding classification system
3. Describe how to use the most current HCPCS coding
4. Discuss the effects of:
a. upcoding
b. downcoding
5. Define medical necessity as it applies to procedural and diagnostic coding
Case Study I
As the Medical Insurance Specialist individuals addresses all the tasks that are completed by administrative staff members during the medical billing process. You will prepare an analysis of the case study as it relates to the questions below, using knowledge gained from in-class discussions.
Scenario: A patient shows the following insurance identification card to the Medical Insurance Specialist for medical treatment for the following medical treatment: Richard Moore COPD flare: Patient has a long history of COPD requiring multiple hospitalizations. Inpatient status is required secondary to hypoxemia, for which supplemental oxygen is needed, aggressive bronchodilator therapy and the risk of rapid deterioration. In anticipation of discharge the patient will require home health services.
Notice to Members and Providers of Care
To avoid a reduction in your hospital benefits, you are responsible for obtaining
Certification for hospitalization and emergency admissions. The review is required
Regardless of the reason for hospital admission. For specified procedures, Second
Surgical Opinions may be mandatory.
For certification, call Utilization Management Services at 800-837-8808:
• At least 7 days in advance of Scheduled Surgery of Hospital Admissions.
• Within 48 hours after Emergency Admissions or on the first business day following
Weekend or holiday Emergency Admissions.
CONNECTICUT PILGRIM HEALTHPLAN C/O
Robert S. Weiss & Company
Silver Hill Business Center
500 S. Broad Street
P.O. Box 1034
Meriden, CT 06450
(800) 466-7900
THIS CARD IS FOR IDENTIFICATION ONLY AND DOES NOT ESTABLISH ELIGIBILITY FOR
COVERAGE BY CONNECTICUT HEALTH PLAN. Please refer to your insurance booklet

CONNECTICUT PILGRIM

INSURANCE INFORMATION
I.D.#: 1002.9713
Employee: RICHARD MOORE
Group #: A0000323
Eff. date: 03/01/2010
Status: Dependent Coverage? F
In-network: $25 Co-Pay
Out-of-network: $250 Ded; 80%/20%

Front Card

Directions: You will prepare an analysis of the case study as it relates to the questions below. When completing this assignment use complete sentences.
1. Identify What Type of Health Plan
o What type of third party plan is in the case above?(VIIIC1a)
o What information is required to file a claim in the case above? (VIIIC1b)
o What steps are required to file a claim in the case above? (VIIIC1c)
o Outline the required procedure for obtaining a referral. (VIIIC2)
o What steps are required to verify if the patient is eligible for services, before the patient can be admitted to the hospital? (VIIIC3a)
2. In the treatment of Outpatient and Inpatient service will Mr. Moore need a referral or preauthorization? Explain why and describe the process. (VIIIC2; VIIIC3c)
3. Prior to discharge the patient needs precertification for home health services. What is the process for obtaining precertification for these services? VIIIC3b)
4. Define a patient-centered medical home service. (VIIIC4)
5. Describe and identify the difference between fraud and abuse. Provide at least one example of each.