Understanding Health Insurance: A Guide to Billing and Reimbursement 2020 15th Edition by Michelle Green

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Book Description

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Prepare for a successful career in medical billing and insurance processing or revenue management with Green’s UNDERSTANDING HEALTH INSURANCE: A GUIDE TO BILLING AND REIMBURSEMENT, 2020 Edition. This comprehensive, inviting presentation explains the latest medical code sets and coding guidelines as you learn how to complete health care claims and master revenue management concepts. This edition focuses on today s most important topics, including managed care, legal and regulatory issues, coding systems and compliance, reimbursement methods, clinical documentation improvement, coding for medical necessity, and common health insurance plans. Updates introduce new legislation that impacts health care; ICD-10-CM, CPT, and HCPCS level II coding; revenue cycle management; and individual health plans. Helpful workbook exercises provide application-based assignments and case studies as well as CMRS, CPC-P, and CPB mock exams. In addition, MindTap digital learning tools offer hands-on practice.

Complete information You should immediately decide to buy this book. But before you decide to make a purchase at a bookstore, it’s a good idea to look at the table of contents.

List of Contents

  • Table of Contents
  • Preface
  • About the Author
  • Reviewers
  • Acknowledgments
  • How to Use This Text
  • How to Use SimClaim CMS-1500 Software
  • Chapter 1: Health Insurance Specialist Career
  • Introduction
  • Health Insurance Overview
  • Health Insurance Career Opportunities
  • Education and Training
  • Job Responsibilities
  • Professionalism
  • Chapter 2: Introduction to Health Insurance
  • Introduction
  • What Is Health Insurance?
  • Health Insurance Coverage Statistics
  • Major Developments in Health Insurance
  • Health Care Documentation
  • Electronic Health Record (EHR)
  • Health Insurance Marketplace
  • Chapter 3: Managed Health Care
  • Introduction
  • History of Managed Health Care
  • Managed Care Organizations
  • Managed Care Models
  • Consumer-Directed Health Plans
  • Accreditation of Managed Care Organizations
  • Effects of Managed Care on a Physician’s Practice
  • Chapter 4: Revenue Cycle Management
  • Introduction
  • Revenue Cycle Management
  • Encounter Form
  • Chargemaster
  • Processing an Insurance Claim
  • Managing New Patients
  • Managing Established Patients
  • Managing Office Insurance Finances
  • Insurance Claim Revenue Cycle
  • Maintaining Insurance Claim Files
  • Credit and Collections
  • Chapter 5: Legal and Regulatory Issues
  • Introduction
  • Introduction to Legal and Regulatory Considerations
  • Federal Laws and Events That Affect Health Care
  • Retention of Records
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Chapter 6: ICD-10-CM Coding
  • Introduction
  • ICD-9-CM Legacy Coding System
  • Overview of ICD-10-CM and ICD-10-PCS
  • ICD-10-CM Coding Conventions
  • ICD-10-CM Index to Diseases and Injuries
  • ICD-10-CM Tabular List of Diseases and Injuries
  • Official Guidelines for Coding and Reporting
  • Chapter 7: CPT Coding
  • Introduction
  • Overview of CPT
  • CPT Sections, Subsections,Categories, and Subcategories
  • CPT Index
  • CPT Modifiers
  • Coding Procedures and Services
  • Evaluation and Management Section
  • Anesthesia Section
  • Surgery Section
  • Radiology Section
  • Pathology and Laboratory Section
  • Medicine Section
  • Chapter 8: HCPCS Level II Coding
  • Introduction
  • Overview of HCPCS
  • HCPCS Level II National Codes
  • Determining Payer Responsibility
  • Assigning HCPCS Level II Codes
  • Chapter 9: CMS Reimbursement Methodologies
  • Introduction
  • Historical Perspective of CMS Reimbursement Systems
  • CMS Payment Systems
  • Ambulance Fee Schedule
  • Ambulatory Surgical Center Payment Rates
  • Clinical Laboratory Fee Schedule
  • Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule
  • End-Stage Renal Disease (ESRD) Composite Rate Payment System
  • Federally Qualified HealthCenters Prospective Payment System (FQHC PPS)
  • Home Health Prospective Payment System
  • Hospital Inpatient Prospective Payment System
  • Hospital Outpatient Prospective Payment System
  • Inpatient Psychiatric Facility Prospective Payment System
  • Inpatient Rehabilitation Facility Prospective Payment System
  • Long-Term (Acute) Care Hospital Prospective Payment System
  • Skilled Nursing Facility Prospective Payment System
  • Medicare Physician Fee Schedule
  • Chapter 10: Coding Compliance, Clinical Documentation Improvement, and Coding for Medical Necessity
  • Introduction
  • Coding Compliance
  • Clinical Documentation Improvement
  • Coding for Medical Necessity
  • Chapter 11: CMS-1500 and UB-Claims
  • Introduction
  • General Claims Information
  • Optical Scanning Guidelines
  • Entering Patient and Policyholder Names
  • Entering Provider Names
  • Entering Mailing Addresses and Telephone Numbers
  • Recovery of Funds from Responsible Payers
  • National Provider Identifier (NPI)
  • Assignment of Benefits versus Accept Assignment
  • Reporting Diagnoses: ICD-10-CM Codes
  • Reporting Procedures and Services: HCPCS Level II and CPT Codes
  • National Standard Employer Identifier
  • Reporting the Billing Entity
  • Processing Secondary CMS-1500 Claims
  • Common Errors That Delay CMS-1500 Claims Processing
  • Final Steps in Processing CMS-1500 Claims
  • Maintaining CMS-1500 Insurance Claim Files for the Medical Practice
  • UB-04 Claim
  • Chapter 12: Commercial Insurance
  • Introduction
  • Commercial Health Insurance
  • Automobile, Disability, and Liability Insurance
  • Commercial Claims
  • Commercial Secondary Coverage
  • Commercial Group Health Plan Coverage
  • Chapter 13: BlueCross BlueShield
  • Introduction
  • History of Bluecross and Blueshield
  • Bluecross Blueshield Insurance
  • Billing Notes
  • Claims Instructions
  • Bluecross Blueshield Secondary Coverage
  • Chapter 14: Medicare
  • Introduction
  • Medicare Eligibility
  • Medicare Enrollment
  • Medicare Part A
  • Medicare Part B
  • Medicare Part C
  • Medicare Part D
  • Other Medicare Health Plans
  • Employer and Union Health Plans
  • Medigap
  • Participating Providers
  • Nonparticipating Providers
  • Mandatory Claims Submission
  • Private Contracting
  • Advance Beneficiary Notice of Noncoverage
  • Experimental and Investigational Procedures
  • Medicare as Primary Payer
  • Medicare as Secondary Payer
  • Medicare Summary Notice
  • Billing Notes
  • Claims Instructions
  • Medicare and Medigap Claims
  • Medicare-Medicaid (Medi-Medi) Crossover Claims
  • Medicare as Secondary Payer Claims
  • Roster Billing for Mass Vaccination Programs
  • Chapter 15: Medicaid
  • Introduction
  • Medicaid Eligibility
  • Medicaid-Covered Services
  • Payment for Medicaid Services
  • Billing Notes
  • Claims Instructions
  • Medicaid as Secondary Payer Claims
  • Mother/Baby Claims
  • SCHIP Claims
  • Chapter 16: TRICARE
  • Introduction
  • TRICARE Background
  • TRICARE Administration
  • TRICARE Options
  • TRICARE Special Programs
  • TRICARE Supplemental Plans
  • Billing Notes
  • Claims Instructions
  • TRICARE as Secondary Payer
  • TRICARE and Supplemental Coverage
  • Chapter 17: Workers’ Compensation
  • Introduction
  • Federal Workers’ Compensation Programs
  • State Workers’ Compensation Programs
  • Eligibility for Workers’ Compensation Coverage
  • Classification of Workers’ Compensation Cases
  • Special Handling of Workers’ Compensation Cases
  • Workers’ Compensation and Managed Care
  • First Report of Injury Form
  • Progress Reports
  • Appeals and Adjudication
  • Fraud and Abuse
  • Billing Notes
  • Claims Instructions
  • Appendix I: Forms
  • Appendix II: Dental Claims Processing
  • Appendix III: Abbreviations
  • Bibliography
  • Glossary
  • Index

Book Details

  • Publisher ‏ : ‎ Cengage Learning; 15th edition (January 2, 2020)
  • Language ‏ : ‎ English
  • Paperback ‏ : ‎ 688 pages
  • ISBN-10 ‏ : ‎ 0357378644
  • ISBN-13 ‏ : ‎ 978-0357378649
  • Item Weight ‏ : ‎ 3.45 pounds
  • Dimensions ‏ : ‎ 8.5 x 1.25 x 10.75 inches

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