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Reimbursement and Coverage Worksheet
HCR/202 v6
Reimbursement and Coverage Worksheet
HCR/202 v6
Page 2 of 2
Reimbursement and Coverage Worksheet
Resources: Ch. 8 and 12 of Medical Insurance: A Revenue Cycle Process Approach (7th ed.)
Imagine you are a billing supervisor at a local health facility. You have been asked to determine the expected reimbursement and coverage determination on the following claims:
1. You reviewed the claim 1500 form for patient Kevin Luke. You realize it is a new calendar year and he had not met his deductible. You had an authorization on file for treatment. Total billed charge amount is $1,100.00. His benefits are as follows:
Calculate the expected reimbursement from insurance and what the patient will owe.
2. You review the claim form for Lisa Smith for treatment of hyperglycemia. You discover she received treatment from a non-network provider. She has met her annual deductible. Total charges for the date of service are $170. The plan pays at usual and customary, which is exactly what was billed. Her benefits are as follows:
Calculate the expected reimbursement from insurance and her coinsurance.
3. You are reviewing a claim for Maria Johnson, a 45-year-old who received a well check and flu shot from her in network provider. Her benefits are as follows:
Mrs. Johnson called the office because she thought she had overpaid during her visit. What was Mrs. Johnsons copay the date of the visit?
4. You are reviewing the vision exam benefits for Zach Bergman. He presented for an eye exam stating he needed new glasses. He had an examination 13 months prior and notes he can have an exam every year. His benefits are as follows:
What is Mr. Bergmans benefit?
5. Lisa Smith called your office noting she had to be transported to the hospital by ambulance while on vacation for food poisoning. She was concerned about what she will need to pay out-of-pocket. She was not admitted. Her benefits for emergency treatment are as follows:
What should Lisa Smith expect to pay out-of-pocket?
Part B: Insurance Process Discussion
Choose one of the above cases and imagine the following scenario:
1. You received a call from the patient concerning their bill, and they would like to discuss it with you. You were asked a series of questions concerning insurance processes and medical reimbursement by the patient. As the billing expert you have a conversation addressing the patients billing questions and explaining the insurance process and steps you take. In 175 to 350 words, create a conversational dialog with the patient explaining the insurance process and why their claim was paid the way it was paid. Your conversation should include:
· Explain how and why the patients insurance is verified.
· Explain how to interpret the patients benefits for reimbursement using details from your selected case.
· Explain possible pending insurance or patient actions relevant to your selected case.
· Apply a professional and customer-oriented introduction and closure to the dialog.
RUBRIC |
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Excellent Quality 95-100%
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Introduction
45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Literature Support 91-84 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met. |
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Average Score 50-85% |
40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided. |
83-76 points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration. |
52-49 points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met. |
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Poor Quality 0-45% |
37-1 points The background and/or significance are missing. No search history information is provided. |
75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration. |
48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met |
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Reimbursement and Coverage Worksheet