Week 1 Discussion

Introduction:

Billing for a procedure may be a complex process. It is important to have a clear picture of the flow of tasks that make up the completed process of billing and the resources needed for the work to be completed.

Tasks:

· List the steps involved in billing a commercial insurer for a broken finger treated in an urgent care clinic.

· Describe any regulatory issues encountered in billing for this case.

· Identify the procedure code and the diagnosis code for this treatment.

· Identify the resources needed to fill out the claim form.

Week 2 Discussion

Introduction:

The 1986 Health Care Quality Improvement Act established a database that is intended to improve the quality of healthcare in this country. Two other databases have merged with it and now offer many potential advantages.

Tasks:

· Describe the National Practitioner Data Bank (NPDB).

· Identify the uses of the NPDB.

· Analyze any limitations of the NPDB.

· Describe how NPDB relates to billing for services.

Week 3 Discussion

Introduction:

The Prospective Payment System of CMS consists of thirteen schedules that allow the calculation of payment for a patient encounter. The DRG or price-based system covers inpatient charges from one of these schedules.

Tasks:

· Describe the schedules of CMS.

· Provide an example of a charge for each schedule.

· Describe the case mix concept that alters payment rates.

· Describe the diagnosis related group payment system.

Week 4 Discussion

Introduction:

Commercial insurance ranges from individual health coverage to automobile liability coverage. All commercial policies have similarities and differences, and there are critical areas to address in billing for each type.

Tasks:

· Describe at least three commercial insurance programs.

· Provide the major features of each program.

· Discuss how these programs differ from each other.

· Briefly describe how to bill for each program.

Week 5 Discussion

Introduction:

TRICARE is the healthcare provider for active or retired military personnel. It also covers the family of these persons. There are a variety of plans and qualifications that go along with this coverage. In order to understand TRICARE, it is important to understand the benefits available and to whom they are available.

Tasks:

· Summarize the benefits of TRICARE for an active military person.

· What if the active military person has family?

· Describe the benefits if the active military person is overseas.

· What if the active military person overseas brings family?