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Chapter 14 Health Insurance and Processing Claims 271
$250.00, the provider will need to adjust the difference of $175.00. If the physician elects not to accept the
assignment of benets, the payment will go directly to
the patient and the full charge can be collected.
C
O
G
Denied claims can lead to lengthy delays in payment to the
physician. Here are the most frequent reasons for denial
of a claim and actions you should take to address them:
r
r
r
r
r
viders to accept assignment of benets. Here’s what
you’ll need to do:
r
r
r
for the difference between the physician’s usual charge
and the health plan’s allowable charge. The patient is
responsible for payment of this amount.
HANDLING DENIED
CLAIMS
The patient cannot be identied as a covered person.
Conrm that the coverage information on le is correct,
including the health plan’s name, policy or group number, and the patient’s Social Security number.
Coding is not appropriate for the services provided.
Review provided services and recode as necessary.
The patient is no longer covered by the plan. Bill the
patient for the charges. The patient may produce evidence of new coverage. Verify coverage prior to every
visit.
The data are incomplete. Complete the required data
and resubmit the claim.
The services are not covered by the plan. Bill the patient
for the services unless there’s a basis for an appeal.
Always verify benets prior to the patient’s visit.
Most managed care plans require participating pro-
Obtain the patient’s electronic signature assigning
insurance benets to the ofce.
If you are unable to obtain an electronic signature, have
the patient sign a hard copy and scan it into their record.
Finally, enter signature on le on the patient’s signature line when you le the claim.
Balance billing is the practice of billing the patient
Explanation of Benets
When a claims administrator settles a claim, it sends
an explanation of benets (EOB) to both the patient
and the provider. The EOB tells about the payment (if
any) the plan made. It also includes information about
deductible amounts and coinsurance as they apply to
the claim. The EOB may include information for several
claims for several patients the plan has processed during
a stated period. You may be responsible for checking
the EOB to make sure all payments are for the correct
procedures and amounts. These payments are credited
to the patients’ accounts and any deductibles and coinsurance billed to the patient.
Figure 14-4 shows an explanation of benets listing
the insurance allowable, amount applied to the deductible, and the coinsurance or copayment amounts.
Worker’s Compensation Claims
In every state, a workers’ compensation program covers
employees. This program is operated by the state or by
a TPA, the state hires to run the plan. The plan’s benets
cover medical expenses resulting from work-related illnesses or injuries.
If you bill the patient’s health plan for services related
to a work-related condition, the plan will return your
claim with instructions to le it with the workers’ compensation claims administrator.
When your ofce treats patients for injuries, always
inquire if the injury is work related. Also, be aware that
some illnesses can be work related too. It’s important
to know this before services are provided so you can
account and le for the charges correctly. In Worker’s
Compensation claims, it is important to submit the First
Report of Injury within 48 hours of the patient’s visit.
Delay in ling of this claim and paperwork will delay
the patient’s benets and could affect his care.
Medicare Claims
Whether or not your ofce participates in the Medicare
program, you must le all Medicare claims. Physicians who
participate in the Medicare program are required to accept
assignment of benets. Most physicians are participating
providers (PAR providers) with Medicare. A PAR provider
must agree to Medicare’s fee schedule. They submit the bill
to Medicare and get payment in return. The payment will
be for 80% of the Medicare-approved amount for the service. The remaining 20% is patient coinsurance.
PAR providers can bill a Medicare patient for the
coinsurance and any deductible amount. PAR providers are not allowed to do balance billing. This makes
PAR providers much like members of a PPO. They must
accept the insurer’s approved fee as payment in full.
Physicians who aren’t PAR providers also must le
the patient’s claim. Medicare will send the payment to
the patient instead of the provider. This means non-PAR
providers must collect both Medicare’s share and the
coinsurance from the patient. However, non-PAR providers are permitted to balance bill patients for charges
that exceed what Medicare allows.
Some non-PAR providers ask patients to make part
or full payment at the time of the service. This can be
a nancial hardship for the patient, especially until
Medicare reimburses the patient.
Crossover Claims
Medicare patients whose nancial hardship is great may
be excused from paying the 20% coinsurance. In some
272 Section III Administrative Medical Assistant Skills
Explanation of Benefits
Employee Name: Joe Doe
SSN: 555-55-5555
Group No. 55555
Patient Name: Joe Doe
Date of
Service
23 456
6-15-2009 57 87.00 82.00
Payable to:
Comment Code:
57 - The amount charged exceeds Usual and Customary
Comment
Code
Dr. Jones
Address
1
Amount of
Charge
Amount
Allowed At
8
Total
Less Deductible
Amount Paid
Date of Service: 6-15-2016
Provider: Dr. Jones
Provider TIN: 35-5555555
9
10
Amount
Paid
80% 65.60
65.60
25.00
40.60
7
Reading the EOB (Explanation of Benefits)
After the claim has been processed, an EOB will be issued. Although
each payer has his or her own EOB format, this sample EOB
illustrates the key points included in an EOB. The terms used may
differ, and the formats differ widely.
1
The top section typically includes the name of the employee
and the Social Security number (SSN) or other identifying
number, as well as the name of the patient, the group number,
the date of service and provider name, and employer identification number (EIN) (Federal identification number assigned to
the physician).
The date of service is included and is shown as the date the ser-
2
vice is actually rendered, not the date that was posted or billed.
The Comment Code is a tool used on many EOBs to indicate
3
a coded comment that is on the bottom as exceeding "Usual and
Customary." In this situation, the claim will be processed on the
Usual and Customary amount. The difference between the amount
charged ($87.00) and the amount allowed ($82.00) is $5.00.
Unless the physician is contractually bound by an agreement with
a managed care plan that forbids the practice of balance billing,
that difference of $5.00 may be billed to the patient.
4
Amount of Charge shows the amount that the physician's
office billed for the service.
5
Amount Allowed shows the amount of charge upon which the
claim processing will be based (in this example, it is the
amount of Usual and Customary).
6
This indicates the percentage of co-insurance payable by
the plan.
7
Amount Paid shows the amount payable by the plan after
co-insurance has been applied, but is not necessarily the
amount that is actually paid (see #10).
8
The Total shows the total submitted and payable after the
claim has been processed.
9
After all processing on the claim has been completed, any
deductible is applied. In this example, Joe still had $25.00 to
be applied to his annual deductible. Therefore, $25.00 is
deducted from the amount paid and the actual reimb
to the physician is $40.60. The amount applied to the
deductible should be billed to the patient.
10
The amount actually reimbursed.
Figure 14-4 Explanation of benets. (Reprinted from Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
cases, such patients also may be eligible for Medicaid.
This is referred to as a crossover claim because the
unpaid amount of the Medicare claim crosses over automatically to Medicaid.
When both Medicare and Medicaid cover a patient,
Medicare is billed rst. Medicare is always primary and
Medicaid is secondary. Always ask Medicare patients if
they have any other coverage. Many who are not eligible
for Medicaid may have Medigap insurance.
ursement
Chapter 14 Health Insurance and Processing Claims 273
Procedure 14-1 Obtaining Preauthorization for Services
Purpose: To obtain approval prior to certain services
to insure the procedure is covered by the patient’s
insurance.
Equipment: Computer with access to the patient’s EHR,
telephone or secure Internet, CPT for procedure to be
performed, date of service, location of service, physician’s name, and tax identication number.
1. Locate the appropriate phone number or Web
site to begin the preauthorization request. Call or
access the Web site.
2. Provide complete details of the procedure or service to be performed including date, time, physician
Externship
Demonstrate your strong work ethic and quality
skills every day while at extern to insure a great reference or possibly even a position. Oftentimes, cell
phones become a distraction and block the ability to
focus. Keep your cell phone on silent or off and stored
information, CPT code with detailed information
about the procedure, and information regarding
past treatments the patient has received.
3. After providing all necessary information, either by
phone or computer, wait for the approval authorization or denial. If denied, obtain information
regarding the appeals process.
4. If approved, notify the patient proceed with the
procedure or service. If declined, notify patient and
cancel the procedure or service. Inform the physician to see if he/she wants to move forward with
an appeal.
out of sight. This will protect you from the urge to
send that one quick text or e-mail. Your focus should
be 100% dedicated to your patients and work. Only
check your cell phone during your lunch break or
after work hours.
Chapter Recap
● Medicare Part A benets cover hospitalization and
are provided at no charge to those who qualify for
coverage.
● Scan insurance cards, front and back, into the patient
record.
● Worker’s Compensation claims require that the First
Report of Injury be submitted within 48 hours of the
initial visit.
● Payments from health plans provide the majority of
most ofces’ income.
Online Resources for Students
Resources for students available on thepoint.
lww.com include the following:
● Audio Glossary
● Animations
● Competency Evaluation Forms
● Types of health plans include group, individual, and
government-sponsored plans.
● Many physicians have contracts with managed care
plans such as HMOs and PPOs.
● Each plan and type of plan has certain requirements
about eligibility for payment of services.
● Your primary duty in ling claims is to do so in a
timely and correct manner that will ensure maximum
reimbursement for the ofce.
● Harris CareTracker Case Studies
● Interactive Games & Activities
● Certication Preparation Question Bank
● Videos
274 Section III Administrative Medical Assistant Skills
Exercises and Activities
Certication Preparation Questions
1. An insurance plan with lower monthly premiums
due to high deductible is:
a. HMO.
b. PPO.
c. HDHP.
d. HPHD.
e. EPO.
2. The insurance plan that covers retired individuals
aged 65 or older:
a. Medicare
b. Medigap
c. Medicaid
d. TRICARE
e. CHAMPVA
3. A health care assistance program funded by both
federal and state governments:
a. Medicare
b. Medigap
c. Medicaid
d. TRICARE
e. CHAMPVA
4. The percentage owed by the patient after the
insurance has paid:
a. copayment.
b. coinsurance.
c. deductible.
d. third-party payer.
e. third-party administrator.
5. Sue Smith has two insurances, one through her
employer and one through her husband. Sue’s
insurance company processed and paid their
potion of the bill. Which of the following clauses
would come into play when collecting from her
husband’s insurance?
a. Birthday rule
b. Coordination of benets
c. Third-party administrator
d. Assignments of benets
e. Crossover claim
6. If a patient is covered by Medicare and Medicaid,
which of the following would describe how the
claim is transferred from one insurance to the
other?
a. Balance billing
b. Coordination of benets
c. Crossover claim
d. Assignment of benets
e. Third-party payments
7. When a child is insured by both parents, which of
the following is used to determine which insurance
is billed as primary?
a. Crossover claim
b. Coordination of benets
c. Birthday rule
d. Balance billing
e. Assignment of benets
8. Prior to a patient having expense testing or an
MRI, you must rst acquire:
a. precertication.
b. utilization review.
c. utilization management.
d. assignment of benets.
e. coordination of benets.
9. When electronically submitting claims instead of
sending each claim separately to their insurance
provider, which of the following can be used?
a. Utilization management
b. Participating provider
c. Clearinghouse
d. Third-party administrator
e. Gatekeeper
10. The physician who coordinates care for patients
with an HMO is referred to as:
a. participating provider.
b. nonparticipating provider.
c. third-party payer.
d. gatekeeper.
e. dependent.
Chapter 14 Health Insurance and Processing Claims 275
P
S
Y
CareTracker Connection
Generating, Filing, and Managing
Insurance Claims
CareTracker Activities Related to
This Chapter
Case Study 14: Submitting an Electronic Claim
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Case Study 15: Generate and Print Paper Claims
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NOTE: Case Studies 14 and 15 have prerequisite cases
(in addition to Cases 1–13), which must be completed
rst. See Case Studies 14 and 15 on thePoint for the list
of prerequisites.
Health care services can be extraordinarily expensive. Because of this, most people in the United States
rely on health insurance—whether public or private—
to cover their health care expenses. With the passage
of the Patient Protection and Affordable Care Act in
2010, Americans are required to have health insurance
of some type. Therefore, properly generating, submitting, and following up on insurance claims are critical
skills for the medical assistant to possess. Practice management and electronic health record systems, such as
CareTracker, simplify this process by integrating health
insurance plan parameters and data into the nancial
system of the practice and allowing automatic electronic
claim submission and payment.
Tasks discussed in this chapter that can be performed
in CareTracker include the following:
Generating electronic and paper claims
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Filing claims with Medicare, Medicaid, workers’
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compensation, and private insurance
Handling denied claims
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Performing balance billing and collection procedures
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Entering payments from third-party payers
r
Many of these tasks are discussed in CareTracker
Connection features in other chapters. A task we’ll consider here is making payments on open items.
Once a patient’s ofce visit is completed and has been
captured in the system, charges related to the visit have
been entered (as discussed in the CareTracker Connection
feature in Managing Medical Ofce Finances), claims to
the patient’s insurance company have been submitted,
and payments from the insurance company have been
received, then the medical assistant may enter these payments into CareTracker. Payments may be entered in the
Charge application of the Transactions module when a
patient is in context.
Clicking on the Pmt Open Item tab in this application will cause a list of procedures and their associated
charges for the patient in context to display. Note that
the charges are divided between private pay (what the
patient is required to pay out of pocket) and the patient’s
insurance company or companies.
276 Section III Administrative Medical Assistant Skills
To enter a payment by an insurance company, you
simply click on the Payment link next to insurance
company’s name (such as “Blue Shield of National
In this case, the insurance company has found that
only $215 of the total $230 charged for this procedure
is allowable. Thus, there will be a $15 adjustment on
this account.
You would enter “215” in the Allow eld and
“15” in the Deduct\Copay eld, as this is the patient’s
Capital Area” above) and the associated charge (such as
“$215.00” above), and a new window will appear.
copayment. Once entered, “200.00” appears in the
Payment eld and “15.00” appears in the Adjustment
eld. The adjustment amount will later have to be billed
to the patient or assumed as a loss by the practice.
You would then click on Save, and the payment
would be made.
You’ll get a chance to practice this task in Case Studies
14 (Submitting an Electronic Claim) and 15 (Generate
and Print Paper Claims).
To access Case Studies 14 and 15, go to http://thepoint.
lww.com, log in using your username and password,
search for The Complete Medical Assistant, click on
“Student Resources,” nd the Harris CareTracker materials, and click on “Case Study 14” or “Case Study 15.”
Section IV
Clinical Medical
Assistant Skills
Medical Asepsis and
15
Infection Control
Chapter Objectives
● Describe the conditions that help microorganisms
live and grow.
● Explain the chain of infection process.
● List different ways that microorganisms are
transmitted.
● Describe how the immune system works to ght
infection by microorganisms.
● Compare the three levels of infection control and
their effectiveness.
● Explain the concept of medical asepsis.
● Perform hand washing.
● Demonstrate knowledge of OSHA guidelines for
risk management in the medical ofce.
● List the components of an exposure control plan.
● Practice standard precautions.
● Identify situations when personal protective
equipment should be worn.
● Demonstrate how to use and remove personal
protective equipment.
● Prepare and maintain examination and treatment
areas.
● Dispose of biohazardous materials.
● Explain the facts about the transmission and
prevention of HBV and HIV in the medical ofce.
● Describe how to avoid becoming infected with HBV
and HIV.
CAAHEP & ABHES Competencies
CAAHEP
● Participate in training on standard precautions.
● Practice standard precautions.
● Select appropriate barrier/personal protective
equipment (PPE) for potentially infectious
situations.
● Perform hand washing.
● Describe the infection cycle, including the infectious
agent, reservoir, susceptible host, means of
transmission, portals of entry, and portals of exit.
● Dene asepsis.
● Identify personal safety precautions as established
by OSHA.
● List major types of infectious agents.
● Compare different methods of controlling the
growth of microorganisms.
● Match types and uses of personal protective
equipment (PPE).
● Discuss the application of standard precautions with
regard to all body uids, secretions, and excretions,
blood, nonintact skin, and mucous membranes.
ABHES
● Infection control
● Biohazards
Chapter Terms
Chapter 15 Medical Asepsis and Infection Control 279
Aerobe
Anaerobe
Antibody
Asepsis
Bacteria
Contagious
Contaminated
Disinfection
Fungi
Immunity
Microorganisms
Normal ora
Abbreviations
CDC
EPA
HBV
Case Study
Lucille Hawkins, an elderly patient, arrives at your
clinic with her hand wrapped in a large handkerchief.
As Judy Simmons, the medical assistant, escorts her
to an exam room, she removes the bandage from her
hand to reveal that she has an open wound on the
HIV
OPIM
OSHA
Pathogen
Protozoa
Resident ora
Resistance
Sanitization
Sterilization
PPE
SDS
palm of her hand. When the medical assistant questions her about the wound, the patient states that
her cat scratched her over 2 weeks ago. She added
that she has been taking care of it at home but it
doesn’t seem to be getting better.
Vector
Viable
Virus
TB
Patients have different reasons for visiting a medical
ofce. You are probably familiar with many of them.
Some patients need physical examinations for their jobs.
Others require follow-up care after surgery or care for
an ongoing condition. Many patients visit the medical
ofce because they have an illness.
When patients are ill, they can carry disease.
Contagious diseases are those that can spread easily
from one person to another. The words contagious,
communicable, and infectious are all used to refer to
diseases that can be transmitted from one person to
another. As a medical assistant, part of your job will be
to prevent the spread of disease. You need to protect
patients as well as yourself from contracting contagious
diseases.
C
O
G
Many diseases spread through microorganisms—tiny
living things that are too small to see without a microscope. Some people call them microbes. Many microbes
are a normal part of the environment, but others can
cause disease.
DISEASE AND THE BODY
Stop Disease from Spreading
Medical assistants help prevent disease from spreading
in two ways:
Practice medical asepsis. Asepsis is a condition in
r
which there are no living pathogens, a state of sterility. Medical asepsis is a set of procedures for preventing the spread of disease. As a medical assistant,
you’ll use specic procedures to control the spread of
disease in the medical ofce. Proper hand washing is
one example of a medical aseptic procedure.
Teach others. Medical assistants show patients and
r
their families how to prevent the spread of disease
at home. Reminding a patient to cover his nose and
mouth when coughing and sneezing is just one example of a teaching point.
Case Questions
A
F
F
cal assistant discard the bandage that Lucille had
on her hand?
What should Judy, the medical assistant,
do to avoid contact with the wound on
Lucille’s hand? Where should the medi-
280 Section IV Clinical Medical Assistant Skills
Bugs and Germs
You may have heard people say, “I’ve caught a u bug” or
“Sneezing spreads germs.” When people say these things,
they are really talking about microbes that cause disease. In
health care, such microbes are called
of causing disease. Most pathogens belong to one of four
main groups—bacteria, viruses, fungi, or protozoa.
pathogens— capable
Bacteria
Bacteria are tiny one-celled creatures found in soil or
water or on other organisms. Thousands of different
types of bacteria exist on earth. Many are harmless, and
some are even helpful to humans. But some bacteria
cause disease. For example, strep throat is caused by a
type of bacteria called streptococcus group A.
Bacteria are capable of forming spores. Spores are
protective protein capsules that some bacteria form
around them. It is like they form a coat of armor around
them. The bacteria rest in this state until the conditions
are right for growing.
Viruses
Viruses are tiny bits of protein-coated nucleic acid
that invade and take over cells in other living organisms. They need living cells to reproduce. Most viruses
cause disease. Inuenza, commonly known as “the u,”
is caused by a virus. So is the common cold.
Fungi
Fungi are a type of plant. They may be familiar to you
as mushrooms or mold. Fungi live in the air, in the soil,
on plants, and in water. Some tiny fungi also live in the
human body. Only some of these fungi cause disease. An
example of a disease caused by a fungus is ringworm, a
disease of the skin.
Protozoa
Protozoa are tiny parasites—animals that live in or on
another organism. They prefer to live in moist environments. In humans, protozoa often cause disease. One
disease caused by protozoa is malaria, a disease with
symptoms of high fever and chills.
Good Bugs Gone Bad
Most microbes are not pathogens. In fact, some microbes
are necessary to stay healthy. These include some kinds
of bacteria, fungi, and protozoa. They are referred to as
normal ora or resident ora because they normally live
in your body. Here are some places where normal ora
are normally found:
On your skin
r
In your respiratory system
r
In your gastrointestinal system
r
In your genitourinary system
r
Normal ora is usually not disease causing. But
they can sometimes become pathogens. This may
happen if:
They multiply until there are too many
r
They move to a part of the body where they are not
r
normally found
When microbes begin living in a part of the body
where they usually are not found, they are called transient ora. A key factor that affects whether transient
ora will become pathogenic is the body’s level of resistance.
Resistance refers to how well the human body
ghts disease. If a person’s resistance is low, transient
ora may become pathogens.
Body Protection
The human body has several ways to protect itself from
disease. Natural defenses help to keep pathogens out of
body organs.
Skin. Clean, unbroken skin acts as a barrier. It stops
r
pathogens from getting into the body.
Eyes. Eyelashes trap many microbes before they reach
r
the eye. Some are destroyed by tears. Tears contain
lysozyme, a substance found in the body that kills
some kinds of bacteria.
Mouth. More kinds of microbes are found in the
r
mouth than anywhere else in the body. Luckily, saliva
is slightly bactericidal. This means that it can destroy
bacteria. Good oral hygiene can stop the growth of
many pathogens in the mouth.
Gastrointestinal (GI) tract. The stomach stops many
r
microbes that enter the GI tract. Hydrochloric acid,
an acid usually found in the stomach, destroys many
pathogens.
Respiratory tract. Hairs and cilia (ne hair-like struc-
r
tures) on membranes inside the nostrils stop microbes
in the air from entering the nose. If these structures
are unable to keep pathogens out, there’s a second
line of defense. Mucus membranes in the respiratory tract trap microorganisms. They help remove
them from the body through sneezing, swallowing,
or coughing.
Genitourinary tract. Most microbes don’t last long in
r
the reproductive or the urinary systems because the
environment is slightly acidic.
These protective systems often prevent pathogens
from taking over in the human body. But the systems
sometimes fail when they must deal with a virulent
organism. A virulent organism is one that can overpower the body’s defenses.