Health Insurance Claims

Long time ago, there was no need for health insurance in America, as doctors had many clients because their services were not so expensive and in some cases in rural areas, people could pay by giving other items. Doctors were not as knowledgeable as they are nowadays to care for the sick, therefore this didn't have much effect then on the patients, as they were treated for the basic illnesses.

The judiciary, executive, legislature, at both state and federal levels, are the three branches of government primarily responsible for the formulation of healthcare policies in the United States. There are other non-governmental organizations such as professional and ethics bodies that provide rules and guidelines in some health care policies.

n Baltimore, Maryland theSt. Agnes Healthcarehad False Claims Act alleging that they submitted false claims to Medicare by billing for evaluation and management services at a higher reimbursement rate than the Federal healthcare programs allowed. They agreed to pay the United States $122,928 to resolve the claims under the False Claims Act. In June 2011, St. Agnes acquired a medical practice consisting of twelve cardiologists who were formerly members of MidAtlantic Cardiovascular Associates. The twelve cardiologists became employees of St. Agnes and continued to provide services to their patients through Maryland Cardiovascular Specialists, a specialty practice affiliated with St. Agnes. Medicare permits a higher rateof reimbursement

Unaffordable health insurance/coverage is a major issue in the United States (US). There is a lot of coverage in the news media about The Affordable Care Act (ACA) that was signed into law in 2010 by President Obama to aid in assist in health insurance for all residents of United States.the US. The purpose of this paper is to address some of the questions most frequently asked; 1. What is health care reform and specifically what is the ACA? 2. What benefits does one see for nursing? 3. What are Accountable Care Organizations and can this improve access to patient care?

Certainly, UB-04 is a hospital billing claim form and it can be used for inpatient and outpatient services. Some examples of the facilities that use UB-04 are skilled nursing facility, rural health clinic. There are many characteristics on the UB -04 form that are not required by Medicare. For instance, the patient i.d, admission hour, revenue code description, assignment of benefits, external cause of injury codes. In addition, some locators on the form have conditions if insurance is Medicare. For instance, the group name is not required if Medicare is the primary insurer. The other example is the locator of principal procedure code and date is not required by Medicare for outpatient

What I have learned about CMS1500 and UB-04 is that they are both forms for medical billing purposes.

The CMS-1500 form, also recognized as the Healthcare Financing Administration, and the Professional Paper Claim Form, is used for reimbursement from several government insurance plans including Medicare, Medicaid and Tricare.

In a study entitled " Who are the Remaining Uninsured and Why Haven't They Signed Up for Coverage?" there were factors identified that attributes to higher rates of uninsured groups. The factors are as follows: the ACA's exclusion of undocumented immigrants from the coverage expansion; the lack of Medicaid expansion in 19 states; less awareness of marketplaces in some demographic groups; concerns about affordability and eligibility; difficulty selecting plans during the enrollment process, and lack of assistance in selecting

Thanks for the informative post on the underinsured problems. I agree with you in the fact that, people have a tendency to attempt to solve one issue with another, as you mentioned trying to treat insomnia by drinking alcohol. The lack of adequate health insurance coverage has noted an impact on the health of the people. People would ignore the preventive care measures and visiting the primary care physician for regular checkups as these costs high. When people have to use a major part of their income towards health care costs, people become non-compliant with their health needs. If these people have any chronic conditions, it gets difficult to manage these illnesses. These people will end up in many complications. The uncontrollable progression

Most claims today are submitted through an electronic format directly or indirectly through a “clearinghouse” where claims are grouped and sent to the payer. Two primary payment grouping algorithms are DRG’s and APCs, both are used by Medicare for hospital payment and many commercial payers. Providers and payers use claims editing software to detect possible errors in claim submission to assure maximum payment for medical services and to shorten an amount of time from claim submission to payment. CMS has developed the National Correct Coding Initiative (NCCI) to promote national correcting coding methodologies and to control improper coding leading to inappropriate payment (Cleverley 26). CMS also has designated edit checks called the outpatient code edits (OCE). The OCE uses claim-level and line item-level information in the editing process. Each category in the OCE has six dispositions which help to ensure all Fiscal Intermediary/Medicare Administrative Contractor (FI/MACs). The four claim-level is rejection, denial, return to provider, and suspension; and the two-line item-level is rejection and

The issue of healthcare coverage under the federal health reform has been politically debated by many Americans, including the current Democratic presidential candidates Hillary Clinton and Bernie Sanders. The healthcare reform enacted in 2010 under President Obama’s regime intended to support the ongoing healthcare system as a building block to enhance more access to health insurance coverage for millions of uninsured Americans; yet the government’s tireless effort to ensure all individuals are covered remains a major issue across the country.

In Tennessee alone, we are once again facing an obstacle under the umbrella of healthcare coverage. In 2017, 3 regions in the state of Tennessee will lose coverage from BlueCross BlueShield of Tennessee (BlueCross BlueShield of Tennessee, 2016). It will leave 100,000 individuals looking for coverage through other marketplace plan providers. BlueCross BlueShield of Tennessee stated that they had to pull out of Obamacare in these three regions due to profit losses over the last 3 years (BCBST, 2016). It may seem simple enough to others that these individuals just go get another plan from someone else. We must first consider affordability. Will Cigna and Humana offer plans that are similar to the BlueCross BlueShield of Tennessee plans? Will consumers have nearly the same or the same benefits as before? There are many different changes that may occur by simply changing insurance plans. The consumers may not be able to have the same providers. They may not have the same medication coverage as before. The deductible could change and make the policy invaluable to the individual based on their needs. Obtaining coverage has been an ongoing uphill battle for some. Our state and federal legislators all share different views on healthcare issues. The Healthcare Reform Act of 2010 brought

The lifecycle of physician-based claim (CMS 1500) is something that we not only need to know, but also how to do from start to finish.

In April of 2014 legislation required an electronic submission of claims. These days everything we do seems to be converting to the electronic way. They changed the CMS-1500 (the health insurance claims form) to an updated version. This meant that everyone needed to change their systems, when a new system comes out each office needs to update the policy. Although for an older generation it can be hard to see the benefits to electronics, there are many pros when it comes to electronic claims.

Currently, the issue of health insurance has been a bone of contention for the public regarding whether the United States government should provide this health plan or not. People often possess different perspectives and refer to pros and cons on both sides of the spectrum. While some believes a universal healthcare system will set a foundation for a lower quality of service, increasing governmental finance deficit, and higher taxes, others do not hold the same thought. A universal healthcare system brings enormous advantages rather than disadvantages, such as all-inclusive population coverage, convenient accessibility, low time cost, and affordable medical cost, all of which not only provide minimum insurance to the disadvantaged but also improve the efficiency of medical resources distribution.