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This combination textbook and workbook provides a complete overview of the medical claim process from initial patient appointment through final financial transaction. Chapters discuss types of insurance payors, basic coding and billing rules. Also discussed are standard requirements for outpatient billing using the HCFA-1500 claim form. Legal aspects for each level of the medical claim cycle are also included. Throughout the book, strong emphasis is placed on the medical office employee's responsibility for successful reimbursement.
While the practice of medicine dates back to the earliest civilizations, medical insurance is a relative newcomer, only invented during the past century. Over the course of the last 35 years, laws regulating health care have become increasingly complex as both government and private medical insurance plans have tried to control rapidly growing costs.
In the medical office, clinical employees are primarily responsible for production (the process of delivering medical care, and business office employees are primarily responsible for collections (the process of collecting payment). However, both clinical employees and business office employees play a significant role in the reimbursement process.
Clinical employees are held accountable for collecting physician-supplied information for the bottom half of the medical claim form, and the physicians are held accountable for meeting clinical documentation requirements.
Business office employees are held accountable for collecting patient-supplied information for the top half of the medical claim form, and they are held accountable for filing medical claims and collecting all payments due.
Delivering medical care is expensive. The business expenses-rent, telephone, electricity, furniture, equipment, supplies, malpractice insurance, salaries, and employee benefits-are paid from the revenue (money] that is collected. A medical business cannot survive unless correct payment is collected for every service delivered.
In the average medical office today, most of the payments are collected from medical insurance companies, and just small portions of the payments are collected fromindividual patients. Collecting payment from medical insurance plans can be very time consuming, and the rules that must be followed often change every year. One tiny piece of missing information or one missed step in the documentation process can result in a payment of 30% or less of the amount rightfully earned by the physician, and occasionally the payment is zero. Therefore, it is imperative that every employee learns about medical insurance and learns to work together as a cohesive reimbursement team.
Note: Increasingly, non-physician providers, such as Physician Assistants (PA/ and Nurse Practitioners (NP), also provide medical care. Unless an exception is noted in the text, items that apply to physicians also apply to non-physician providers.