Medicaid and Medicare Billing
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Explain the components of physician medical billing?
Medical billing involves following up on claims with the particular medical cover organization for payments regarding services rendered by a health care service provider. The process is carried out by a medical biller and involves eight particular steps (White et al., 2020). The first step involves patient registration, whereby a patient will make calls to set up an appointment with the health provider hence register before the visit. Secondly, confirmation of financial responsibility is confirmed by determining whether the service is covered. Thirdly, the biller determines the patients’ check-in and out. The fourth task is to ensure that the claim meets compliance standards for coding and format. The fifth step involves sending claims electronically to the health insurance company. Monitor adjudication is the sixth step that states the company’s number of times will make payments to the caregiver to verify the bill’s acceptance or rejection. The seventh step is generating a patients’ statement if the bill was accepted. Lastly, the biller will confirm that the bills are paid accordingly and included in the patients’ information.
Identify the differences between inpatient and outpatient hospital billing and describe the UB-04 hospital claim form
Whereas an inpatient person is a patient that has been admitted on a physician’s order and remains an inpatient to the day before discharge, an outpatient seeks medical consultations and may undergo tests on physicians’ orders. The inpatient billing is based on the Inpatient Prospective Payment System based on the patient’s diagnosis and treatments during the admission period (Kondamuri et al., 2021). On the other hand, outpatients are billed according to the Outpatient Prospective Payment System, which guides reimbursement for hospital outpatient services. UB 04 claim form is a standard claim form that healthcare service providers can use to bill medical and mental health claims. It is also a convectional form utilized by healthcare medical carriers developed for Medicare and Medicaid centers.
Discuss Medicare fee schedules, provider reimbursement, Fraud, and abuse
Fee schedules are a convectional listing of healthcare facilities’ charges to generate payments for doctors and suppliers. Provider reimbursement is how the health care service provider is compensated based on the customer’s services. The insurance cover is responsible for making payments based on the bills presented by the caregivers. Medical Fraud occurs whenever a medical practitioner submits false claims or intentionally inaccurate data seeking illegal payments; medicare abuse, on the other hand, involves providing substandard services to patients either intentionally or unintentionally. Fraud and abuse are both punishable by law as criminal or civil liability
Explain Medicaid eligibility and benefits and the process of submitting Medicaid claims
A for a family of four, the income requirement for Medicaid insurance for a child is $25,750 annually. For the adults, the poverty level is set to the monthly income of $1,800 to $4,580 during pregnancy (Hudson and Moriya, 2017). The parents with monthly income margins of $289 to $741 are eligible to apply for Medicaid. The elderly and disabled population with a monthly income of less than $1,145 are also eligible for the Medicaid program. However, the rates might vary according to state. The Medicaid programs are beneficial to low-income families, the elderly, and the disabled. It enhances equity in accessing quality medical care for all regardless of financial differences. Generally, every state has defined its procedure to claim Medicaid. While most states use equal billing as insurance companies, others use private health insurance companies to manage the Medicaid program. Other states may also choose to work directly with the service provider. The submission of the claim by the service provider is therefore stat-based.
References
Hudson, J. L., & Moriya, A. S. (2017). Medicaid expansion for adults had measurable ‘Welcome mat’ effects on their children. Health Affairs, 36(9), 1643-1651. doi:10.1377/hlthaff.2017.0347
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0347
Kondamuri, N. S., Gadkaree, S. K., & Rathi, V. K. (2021). Medicare reform of hospital payment for inpatient facial plastic procedures. Facial Plastic Surgery & Aesthetic Medicine, 23(1), 2-4. doi:10.1089/fpsam.2020.0392 https://www.liebertpub.com/doi/abs/10.1089/fpsam.2020.0392?journalCode=fpsam
White, A. A., Lee, T., Garrison, M. M., & Payne, T. H. (2020). A randomized trial of voice-generated inpatient progress notes: Effects on professional fee billing. Applied Clinical Informatics, 11(03), 427-432. doi:10.1055/s-0040-1713134
https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0040-1713134
Question
Directions: Be sure to make an electronic copy of your answer before submitting it to Ashworth College for grading. Unless otherwise stated, answer in complete sentences, and be sure to use correct English spelling and grammar. Sources must be cited in APA format. Your response should be four (4) pages in length; refer to the “Assignment Format” page for specific format requirements.
For this writing assignment, please explain why the following course objectives are important for medical billers and coder to understand:
1. Explain the components of physician medical billing
2. Identify the differences between inpatient and outpatient hospital billing and describe the UB-04 hospital claim form
3. Discuss Medicare fee schedules, provider reimbursement, fraud, and abuse
4. Explain Medicaid eligibility and benefits and the process of submitting Medicaid claims
Please include at least three scholarly articles within your response. Overall response will be formatted according to APA style and the total assignment should be between 3–4 pages, not including title page and reference page.