Sunday, 17 December 2017

Covered Service

Health benefits which are allowed per a contract with a health insurance company or a health benefit allowed by Medicare, Medicaid, Tricare or Workers Compensation.

CPT – Current Procedural Terminology: 
CPT is a list of procedure codes owned, copyrighted and developed by the American Medical Association. A procedure is something that the doctor does to a patient during a visit. For example, if you cut your finger and the doctor repairs the cut, there is a procedure code to put on the claim form. The code is recognized by coders, and insurance company claims software. Let’s look at the cut on the  finger. To convert the repair to a CPT code, you need to know the length of the wound, in centimeters so you can select the correct CPT code. For the purpose of this example. You have a 1cm simple cut on your index finger. The repair of this cut would be 12001. Every procedure performed MUST be supported by a correct diagnosis code or ICD-9 code. The diagnosis or ICD-9 code for an unspecified wound of the finger would be 883.0. Now, if you saw ICD-9 code 042 used with CPT code 12001, you would be confused. That would be like saying the doctor sutured the patient’s finger cut because the patient had AIDS. Therefore it doesn’t make sense to suture a wound if there is no open wound diagnosis.

A deductible is a contractual amount that the patient is required to pay as an out of pocket expense before the insurance company pays any claim sent to them. The amount of deductible varies per patient and per insurance policy. Commercial insurance and Medicare deductibles start in January of each year. Tricare deductibles start in October each year. A patient may have a $1,000 deductible. The patient is seen by the doctor on January 5th. The claim is for $250.00. The insurance company allows $100 for the benefit or covered service. The patient hasn’t met their deducible yet. The $100 is applied to the deductible. Now the patient has a $900 deductible to meet before the claim is paid by the insurance company. The patient comes in each month for the next 9 months. The claim is sent in September. The $100 is applied to the remaining deductible. If the patient comes in the next month (October), the deducible has been satisfied, so now a check will be sent by the insurance company. Whether the patient actually pays the deductible is between the provider and patient. The insurance company doesn’t care if the patient doesn’t actually pay the deductible. All this means is that with a $1,000 deductible, with $100 allowed for the visit it will take 10 visits before the insurance company will release any money to pay the patient’s claim. Medicare does care if the provider collects the deductible from the patient.

A Spouse and/or an unmarried child (whether natural, adopted or step) of an insured person. When looking at the insurance card (other than Medicare) you may see the policy number and at the end, you may see 01, 02, 03, 04 or another 2 digit number. These numbers have meaning, but could vary per insurance company.

00: Insured or member (Some insurance companies may have 01 as the insured)

Monday, 11 December 2017


Co-payment or co-pay is a predetermined (flat) fee, based on a contract between an employer or patient and an insurance company A co-payment that a patient pays for health care services is in addition as an out of pocket expense to what the insurance company covers for the service provided. A co-pay is separate from a deductible and co-insurance. For example, a patient may have coverage through Blue Cross and Blue Shield. The policy may require the patient to pay a $10 copayment for each office visit, regardless of the type or level of services provided during the visit. A patient coming in for daily blod pressure checks could be required to pay the co-pay for each BP check visit. Co-payments are not usually specified by percentages. Co-pays are usually paid at the time of service. Some providers will bill the patient for the co-pays. A huge question that is always asked is, “Can we write off the co-pay owed by the patient. This question has NO easy answer. Again, the co-pay is a contractual amount that the patient is required to pay. Writing off co-pays on a routine basis could be determined by a Government Inspector as an incentive to have the paient make referrals to the provider. The insurance company could take the position that writing off a co-pay is a contract violation. The key word with doing a write off is routine. Each write off should be on a case by case basis. The patient may be financially unable to pay the co-pay. If, so then it would be permissible to write off the co-pays. There are at least three (3) acceptable means of writing off what a patient may owe. (1) The provider has made every effort to make collection on what is owed and this includes a debt collection agency. (2) if it would cost more to collect than what is owed. For example, the patient owes $1.95. It costs $10 in administrative expenses to bill a patient. Therefore the cost to collect is more than what is owed. The $1,85 could ne adjusted off as a small balance adjustment, and (3) The patient is financially unable to pay. The patient must prove they are financially unable to pay. This can be in the form of wage statements, bank statement, tax statement and lists of monthly bills such as electricity, food, and other bills.

COBRA Consolidated Omnibus Budget Reconciliation Act.  
This is a Federal Law that allows a worker to continue to purchase employer paid health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For example, your employer provides you with health insurance through United Healthcare as a benefit of employment. The employer is going out of business or you leave for another job. Under COBRA, you can continue to keep your United Healthcare coverage when you leave your employer. 

The catch to this is that YOU must continue to pay the premiums that your employer paid. Some people decline this because they cant afford the premiums. If the patient kept the COBRA coverage make sure you verify that the coverage is still in effect at the time of service. The patient may present the United healthcare insurance card but you find out that the patient did not pay the premiums, so the coverage was terminated. 

Tuesday, 5 December 2017

CMS – Centers for Medicare and Medicaid Services

CMS is a Federal Agency responsible for overseeing and regulating Medicare and Medicaid. CMS come under the jurisdiction of the Department of Health and Human Services. CMS is also the agency responsible for monitoring an approving the code sets (CPT and ICD-9) under HIPAA. Medicare HMOs come under the jurisdiction of the area CMS offices. Medicaid HMOs come under the jurisdiction of a State Medicaid agency. CMS used to be called HCFA, the Health Care Financing Administration.

CMS 1500: 

The CMS 1500 is the current HIPAA approved standard paper claim form submitted to insurance companies to have the outpatient health benefit or the contracted provider visit paid. The CMS 1500 form is designed by the National Uniform Claim Commission. Most insurance companies desire to have the CMS 1500 form sent to them in an electronic format. The fields or blocks on the form are the same regardless if on paper or done electronically. The CMS 1500 claim form instructions can be found here: 


The process of converting a medical procedure, a surgical procedure, a hospital inpatient stay or a doctor visit to a CPT code. The medical diagnosis is converted to an ICD-9 code. Some supplies are converted to HCPCS Codes. The purpose of coding is to document the reason for the visit or service and what was done during that visit so that the insurance company’s computers can quickly recognize the coded numbers and process the claim for payment.

Thursday, 30 November 2017


This term can have many meanings. Capitation represents a set dollar limit that is paid to a provider by an insurance company for treating their members. This set dollar limit can be based on a monthly dollar amount, a per patient dollar amount or a per claim dollar amount. The insurance company can say that they will pay the provider $3,000 per month. This can equate to $10 per day. If the provider treats 10 patients per day, the provider makes $1.00 per patient per visit. The provider may be required to submit a claim but there won’t be any additional payment on the claim. The payment per claim could be $90 per claim. This means you send a claim and each claim should be paid $90 regardless of how many codes are submitted. With a per claim payment, the biller must keep a close eye on the claim payments, this is because some insurance companies will pay the claim less than the amount agreed upon in the contract. This will require you to appeal the incorrect payment and continue until it is paid correctly. Before agreeing to a capitated amount, the provider should make sure the capitated amount is fair and reasonable. This is something that will be discussed more in another document on Insurance Contracts.


This is nothing more than a shorter name for an insurance company. For example. First Coast is the local carrier for Medicare Part B for Florida and Georgia. Anoher example would be, $75 is the usual and customary reimbursement amount for the carriers in our geographical area. In simplistic terms, all the insurance companies in our area pay $75 for a claim.

Friday, 24 November 2017

Active/inactive employee

The benefits of a plan which covers a person as an employee who is neither laid off nor retired (or as that employee’s dependent) are determined before those of a plan which covers that person as a laid off or retired employee (or as that employee's dependent). If the other plan does not have this rule and if, as a result, the plans do not agree on the order of benefits, this rule is ignored

Some health insurance plans describe Coordination of Benefits in the Benefit Manual or Summary Plan Description (SPD). For example, the following is from an employer SPD: Coordination of Benefits (COB) applies when an individual has health care coverage through more than one group program. The purpose of COB is to insure that the individual receives all of the coverage for which the individual is entitled, but no more than the actual cost for the care received. In other words, total payments from all of the insurance coverage combined cannot be more than the total charges incurred.

As you can see, COB can be very complicated. Lets look at the following examples:

EXAMPLE: SFC Stewart Lee is former military with veterans benefits. He resides in Orlando, Florida. His place of veterans treatment is the VA hospital located in Tampa, Florida. SFC Lee also has Medicare Part B as coverage. SFC Lee was seen at the Our Lady of The Blessed Acne hospital in Orlando. He asks that the claim be sent to Medicare Part B. Medicare know SFC Lee has coverage through the Veterans Administration. In this case, either Medicare or the VA is primary. Medicare doesn’t pay for what the VA doesn’t pay and the VA doesn’t pay for what Medicare doesn’t pay. Once Medicare makes its payment, SFC Lee can be responsible to the provider for any co-insurances and deductibles. Under normal circumstances with commercial health insurance, you might send the Medicare EOB to the commercial insurance company. Two things could happen. The insurance company could pay the coinsurance and/or deductible or they could deny payment by stating they don’t pay anything more than what the primary insurance company paid. This may be a clause in the patient’s health insurance contract. However, KNOW YOUR STATE COB LAW. With Medicare and the VA, SFC Lee cannot ask that the Veterans Administration be billed to pay what he owes. If SFC Lee asks that the VA be billed first, any payment that is made by the VA is considered as payment in full. I once had a SFC Lee case. He said WE made a mistake in billing Medicare. However, we followed his telephonic instructions. We refilled the claim to the VA, they paid what they would normally pay and we refunded Medicare the payment they made. From that point on, it became office compliance policy that under NO circumstance was a patient claim with Medicare and VA to be sent to Medicare without written instructions from the patient.

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