The Administrative Life Cycle Of Health Insurance Claims

This week I began my 6-week internship at Blue Cross Blue Shield of Nebraska (BCBSNE). The first day was a common orientation for all new employees, internally denoted to as the “onboarding process” where all employees are told they matter. This full-day session communicates the core mission, vision and goals of BCBSNE, organizational structure, operating objectives, and workplace culture. BCBSNE is a not-for-profit health insurance company that is focused on collaboration to find the best solution for their customers; in other words, they are customer-focused. Since the implementation of the Affordable Care Act (ACA), many changes to the health insurance market required a change in the organizational structure and culture of BCBSNE. Through partnerships with providers, the goals of BCBSNE are to be responsive, accountable, minimize errors, and decrease costs – all components of the ACA. BCBSNE has strategically aligned their goals to those of the government-mandated goals, and implemented them at all levels of the organization, making them competitive in the health insurance market. I found this very fascinating: I was very excited after day one!

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

The process of developing of an insurance claim will be essential to the healthcare and medical business. And all starts when the patient makes a call to a healthcare provider;s office then makes an appointment. The assigned administrative staff or workers makes certain if the patient is new requesting an initial appointment or an established patient returning for more or additional services required from the provider. Now the pre-clinical interview

When working as a medical office administrator you will need to know how to complete the different procedures dealing with physician billing and reimbursement. Reimbursements involves more than what you just get paid, it’s a long and often convoluted process that start when you patients first contacts your office. In order to get the correct reimbursement it is important that you know the basics about reimbursements which includes the correct coding. The way to understand the aspects of the business is to know the basic of Medicare. Physician reimbursement is a three step process. The first step of the process would be having the appropriate coding number of the service provided by utilizing the current procedural terminology which is commonly

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

A current LCD for the regional Medicare intermediary (Michigan - Region V) is shown in the example below. This LCD is for Erythropoiesis Stimulating Agents, L25211. The LCD is active and became effective on 12/1/2007 with an date of 11/01/2013 for the 10/22/2013 revision (cms.gov, 2014b).

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

Claim submission processes are claims that are submitted online, and payments are processed electronically after a visit to the doctor office the physician send out a bill to the insurance claims processing center all information that is relevant the intake forms and the patient appointment sheet as well as the proper services documentation. Which is evaluated to see if it covers the services if the services are covered by the insurance company a payment is then submitted for the balance that is remained if not insured the person is reliable for the balance that is left over as well as the co-payment.

The Basic Health program could be structure in several ways. It could expand programs such as Medicaid and CHIP and contract with managed care plans on behalf of its Medicaid and CHIP beneficiaries outside the private insurance market. These changes would allow both programs to continue as a "separate program with a separate financing mechanism and risk pool from that of Medicaid and CHIP, but would leverage the state's existing infrastructure for information technology, contracting, rate setting, and other function" (Angeles, 2012). Alternatively, a state could expand the Medicaid managed care by increasing the number and types of service through different network of providers, other than those that serve Medicaid and CHIP beneficiaries (Angeles,

The key elements to a healthy and successful medical practice are a reliable and properly trained staff and a sound revenue cycle that produces satisfactory reimbursement. Revenue cycle management starts at the front-end with pre-registration of the patient. Complete and accurate recording of patient insurance and billing information is imperative. Insurance verification plays a major role in the assurance of reimbursement. The front desk should counsel and confirm financial responsibility with the patient during the registration process. Patient encounter is equally as important. Correct coding of patient diagnosis and procedures minimizes the likelihood of claim rejection. The next step in the revenue cycle is claim submission. The claims process begins with the provider treating the patient then sending a bill to the designated payer. Before the bill is sent, a certified coding specialist or medical billing specialist prepares and reviews the claim for any inaccuracies. There are a few ways the claim is submitted, either manually or electronically. Once the claim is submitted, follow-up with third party payers is a necessary step in the

OCE designed to processes claims for all outpatient institutional providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as hospitals that are NOT (Non-OPPS). Each OCE results in one of six different dispositions. The dispositions help to ensure that all fiscal intermediaries are following similar procedures. There are four claim-level dispositions: Rejection, Claim must be corrected and resubmitted; denial, claim cannot be resubmitted but can be appealed; return to provider, problems must be corrected and claim resubmitted; and suspension, claim requires further information before it can be processed. There are two line item–level dispositions: rejection, claim is processed but line item is rejected and can be resubmitted later; and denial, claim is processed but line item is rejected and cannot be resubmitted. (Essentials of Health Care Finance, 7th Edition. Jones & Bartlett Publishers p. 26).

California Association of Health Plans (CAHP) represents statewide trade association with 46 full-service healthcare plans, which provide coverage to millions of California residents. Most member programs are introduced through group and individual markets to Californians. CAHP are dedicated to providing accessible, high quality and affordable health plans. All health plans through Covered California are members of CAHP. Their goal is to serve their members by providing and sustaining opportunities that allow them to grow and maintain viability as organizations. An organization like Kaiser Permanente, Anthem Blue Cross, Delta Dental, Bayer Healthcare LLC and Crowell & Moring are members of CAHP.

Once again, we have a new president who is working hard to put change once again to America. Our new president Donald Trump is using executive orders to try and replace Obamacare. What are executive orders? Executive order are orders that the current president gives to the government and basically has the full force of power to make changes. Obamacare was a plan that our former president Barak Obama created to make affordable healthcare and insurance (Amadeo). The issue that Donald Trump was trying to go at was completely removing Obamacare and puting in a new plan that will be more affordable and more beneficial to people.

The A single-payer national health program (NHP) has similarity to the Affordable Healthcare Act. However, it better because is addresses some of the issues that were left out of the ACA. Like, free choice of providers and the preservation of doctor–patient relationships are threatened by our current system (Gaffney, Woolhandler, Angell, & Himmeslstein, 2016). With each enrollment cycle, patients seeking affordable premiums or changing jobs must often switch insurers and risk breaking existing relationships with providers.

The role of the Medical Insurance Specialist is very important to the financial operation of a doctor practice, hospital or other medical facility. A Medical Insurance Specialist collects all the information necessary to prepare insurance claims, enter patient demographics and insurance information, enter ICD codes and CPT billing codes, research, correct and resubmit rejected and denied claims, bill patients and answer patient questions regarding charges. The billing process is actually the process of communication between the insurance specialist, medical provider, patient and the insurance company. This is considered the billing cycle. The billing cycle could takes days to complete or it could take months.