cclary4
A patient calls to schedule an appointment. What minimum …
A patient calls to schedule an appointment. What minimum demographic information do you need to collect?
You work at a dermatologist’s office. The figurebelow illustrates the insurance card that a patient presents. The patient has met theirdeductible and has 20% coinsurance. The allowed amount for the service is $150. How much will the patient need to pay? Show your work.
Image transcription text
ID Blue Product ABC1234567891 Name Office Visit $0 John Smith Specialist Copay $25 GRP 14444
Emergency $100 RXBIN 89884 Plan PPO
A patient has a deductible of $500. Your UCR for a serviceis $600, but the insurancecompany allows for only $200. How much will the patient be responsible for? How much will be applied to their deductible?
A child comes into your office. Both parents have insurance coverage for the child. Mom is 45 years old and was born on January 2; Dad is 50 years old and was born on March 4. The mother works part-timeas a school nurse, while Dad’s job is full-timeas an insurance sales agent. Dad’s insurance has only 80% coverage, but Mom’s insurance will cover the service at 100%. What insurance is the child’s primary insurance?
A patient has Medicare as their primaryinsurance and Medicaidas their secondaryinsurance. Medicare pays $125 on a serviceand lists $25 as patient coinsurance. They’ve automatically forwarded the remittance to Medicaid, yet Medicaid hasn’t paid. When you inquire about Medicaid’s payment, they inform you that they allow only $100 for that service. What do you do?
Part 2
Patient Celesta Fogarty has been coming to Steinway Orthopedic Clinic for several months for the evaluation and treatment of chronic back pain radiating down the right leg. She has undergonetwo surgeries with a minimallevel of diminishing pain. She inquireswhat the criteriaare for SSDI benefits. How do you respond?
A CHAMPVA beneficiary whose husband has passed away from a service-connected disability is about to be eligiblefor Medicare. She is worried that she might not be able to afford Medicare’s cost-sharing features in the event she is hospitalized. What do you tell her?
Erica Taller, a new employee at Green Acres Health Clinic, noticed a $5 deduction on her payroll check voucher titled “WC.” When she asked the personnel manager what the deductionwas for, she was informedthat it was a share of the clinic’s workers’compensation premium. Is this a legal
employee wage deduction or fraud?
Jennifer Ellerhoff is the spouse of an E-5 ADSM stationed in Southeast Asia. She is enrolled in a family policy with TRICARE Select. On January 12, Jenniferhas a medical encounter in a civilianoutpatient clinic. The provider (a nonPAR) charged$240. This is the first medical encounterof the year for Jennifer and her two children. The TRICARE allowable charge (TMAC) for this procedure is $212. After the EOB is received, the clinic sends Jennifer a statement for $212. She calls and asks you why she has to pay this charge. How would you explain the reason why she owes this amount?
Some media reports have caused many Americans to view managed care, particularly HMOs, negatively. Obviously, not everyone has a clear picture of exactly what managed care is and how it functions. How can the general public be better informed so that managedcare and traditional healthcare can be compared equitably and without bias?
You’re newly employed as a health insurance professional with the Great Arch Medical Clinic in the state of Missouri. To maximize your on-the-job efficiency, you broughtyour health insurance professional notebook from your previousemployment in the state of California. When it comestime to complete Blue Cross and Blue Shieldforms at GreatArch, you referto the claims completion guidelines from your notebook. What problems, if any, might you experience if you follow the California claims completion guidelines?
A patient can terminate a doctor-patient (implied)contract by simply paying the fee(s) associated with the procedures and/or services renderedand not returning to the practice. However, if the healthcare provider wants to terminate this same contract, he or she must follow specific guidelines before doing so to avoid abandonment. How do medical ethics play a role in this scenario?
Sharon Lassiter has a medicalsavings account (MSA). Her coworker,Neola Carlson, has a flexiblespending account (FSA). Sharon and Neola think they have basically the same thing. Explain to them how these two methods of paying for healthcare costs are similar and how they differ.
After Darren Bossley suffered a job-related injury to his left hand and couldn’t perform his regular job, his employer assigned him to alternative duties, which consisted of completing coursework for an electrician’s apprenticeship. Bossley claimed that he was unable to complete the hours due to severe pain; however, his treating physician released him to return to work because the physician believed that Bossley was able to perform in this alternative work arrangement. Bossley was terminated from his job for failing to complete his work hours and for not reporting to work. As a result, his employer’s workers’ compensation insurer refused to pay disability benefits. Were Bossley’s workers’ compensation claims wrongly denied?
Dr. Argyle, your employer, has asked you to providean “easily understandable” explanation of the MedicarePart D “donut hole” to one of his elderly patients. How would you explain this?
Medicaid pays for only what it considers medically necessary. If a patientrequests a service/procedure that doesn’t fall under this specific definition, what are their options? How can the health insurance professional determine medical necessity, and whose responsibility is it to know what services/procedures come under this description?
Most healthcare facilities today have computerized software programs that handle patientaccounting. Therefore, studentsoften ask, “Whydo I have to understand basic accounting principles if computers can do it?” Why is it important for students to understand accounting basics?
As you prepare for a career as a health insurance professional, you should know your possiblefuture. How can you plan for a successful career in healthcare?
There’s a long history regarding the value of hospital accreditation. In your opinion, is the accreditation process important? Why or why not?
Until 2019, the ACA containedan “individual mandate,” which required everyoneto have health insurance. A person who could not obtain health insurance through an employer was required to buy it through the exchanges. Why was this requirement in place?
Part 3
Corrina Barclay had been suffering from a severe earache for several days. She made an appointment with otolaryngologist Amanda Morrison, whom she had not seen before. When Corrina arrived for her scheduled 2 pm appointment the next afternoon, Paula Troutman, the medical receptionist, checkedher in and asked for her insuranceID card. Corrina,after searching throughher purse, determined that she had left it at home. Shetold Paula that she was employed with the localcity police forceand was enrolledin the city’s group employerplan. The city’splan was through Blue Cross and Blue Shield and the ID numbers (at that time)were the same as the enrollees’ SocialSecurity numbers. Paulainformed Corrina that providing a Social Security number wasn’t adequate, that it was the policy of the practice not to see new patients unless they could show proof of insurance, and that the doctor could not see her until she produced her insurance ID card. Corrina left without receiving treatment and went to the emergency room. Blue Cross and Blue Shield subsequently refused to pay the ER fees, stating that Corrina’s medical problem wasn’t a bona fide emergency. Was Paula ethically right in refusing to allow Corrina to see Dr. Morrison for treatment? How would you have handled this situation? Can you explain why Corrina could be treated in the ER without proof of insurance and not in a physician’s office?
You’re training a new assistantat the Mid-Prairie Health Clinic.He asks you to furtherexplain the rationaleof the CLIA program and what servicesit provides. Answer his question.
Doris Westerly, a patient new to Medicare, is referred to your office and states, “The girl at the front desk said I would have to pay today’s charges, but that I shouldn’t pay just yet. I’m very confused. Now that I’m on Medicare,I thought they would pay for my healthcare. She said I have to pay for my medical bills until I reach a certain limit. What is this limit and how do I meet it?” Answer her question.
Medicaid fraud is a problemand a considerable waste of taxpayer dollars.The Affordable Care Act of 2010 requiredstates and US territories to establish Medicaid Recovery Audit Contractor (RAC) programs. Medicaid RACs have the responsibility of identifying and recovering misspent Medicaid funds. Identify and discuss ways that you, as a health insurance professional, can learn more about and help combat Medicaid fraud.
Elaine Arlington calls the medical clinic where you’re employed, asking to schedule an appointment for her 15-month-old son, Noah. When you inquire about insurance, Ms. Arlington explains that, even though she is employed part-time, she doesn’t make enough money to be able to afford even the cheapest plans on the exchange. She further explainsthat she isn’t eligible for Medicaid becauseshe earns too much at her job. She also tells you that Noah has multiple health problems. Identify and discuss what options are open to Elaine for obtaining healthcare coverage for Noah.
Gloria McGraw, a patient at Broadmoor Medical Clinic, underwent an arthroscopic surgical procedure of her right knee. Dr. Jones’s fee for this procedure was $1400; however, the claim paymentfrom her insurance carrier was reducedto $1100 becauseof UCR provisions. Ms. McGraw doesn’t understand why this occurred and asks you to explain. What do you tell her?
Although most medicalpractices now submitclaims electronically, it’s important for health insurance professionals to know how to complete paper claims and understand what goes in each block, why that information is necessary, and where the information comes from. Why is this important?
Dorothy Stamper was looking for a qualified ophthalmologist to perform cataract surgery. A friend suggested Dr. Evan Voss; he had performed her eye surgerythe previous year,and she had been very happy with the resultsof the surgery and aftercare. Dorothy decided to have Dr. Voss remove the cataract from her left eye, and she was so satisfied with Dr. Voss’s expertise that she decided to have the right eye operated on the following month. The outcomes of the second surgery did not result in immediate success, and Dorothy had to undergo another procedure several weeks later to correct a minor problem. As a result, Dorothy vowed she would never recommend Dr. Voss to anyone. Can you explain why Dorothy wasn’t satisfied?
Pertaining to insurance claims, why is accurate and thorough documentation in a patient’s health record so important?
Patient Delores Andrewstells you that she will soon be turning 65 and will be eligiblefor Medicare. She asks you whether Medigapis the same as Medicare Part C. How would you answer her question?
