Health-care claims are a critical part of the reimbursement process. Accurate claims sent to payers mean that physicians receive the maximum appropriate payment for the services they provide. Patients are also concerned with their health-care plans, asking "How much will my insurance pay?" "How much will I owe?" "Why are this doctor's fees different from my previous doctor's fees?"

You will handle questions such as these every day. Not only must you correctly prepare health-care claims, but you will also review patients' insurance coverage, explain the physician's fees, estimate what charges payers will cover, and prepare claims for patients. This chapter prepares you for these tasks by explaining the types of health-care insurance patients have, how payers set the charges they pay for providers' services, and how to transmit complete and accurate claims. This chapter also gives you the information you need about patients' financial responsibilities for services so that you can figure out how much patients should pay and how much will be billed to their health-care plans.

Outline

• Basic Insurance Terminology
• Types of Health Plans
• The Claims Process: An Overview
• Fee Schedules and Charges
• Preparing and Transmitting Health-Care Claims

Learning Outcomes

After completing Chapter 15, you will be able to:

 15.1 Define Medicare and Medicaid.
 15.2 Discuss TRICARE and CHAMPVA health-care benefits programs.
 15.3 Distinguish between HMOs and PPOs.
 15.4 Explain how to manage a workers' compensation case.
 15.5 List the basic steps of the health insurance claim process.
 15.6 Describe your role in insurance claims processing.
 15.7 Apply rules related to the coordination of benefits.
 15.8 Describe the health-care claim preparation process.
 15.9 Explain how payers set fees.
 15.10 Complete a Centers for Medicare and Medicaid Service (CMS-1500) claim form.
 15.11 Identify three ways to transmit electronic claims.

Summary

Part of your responsibilities as a medical assistant will be to make sure that health-care claims are processed accurately. When accurate claims are sent to payers, physicians receive the maximum appropriate payment for the ser-vices they provide.

As a medical assistant, you will handle patients' questions about their health-care plans and claims. You will re-view patients' insurance coverage, explain the physician's fees, estimate what charges payers will cover, estimate how much patients should pay, and prepare complete and accurate health-care claims for patients.