Reimbursement and Coverage Worksheet
References: Ch. 8 and 12 of Medical Insurance: An Integrated Claims Process Approach (6th 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:
PPO-Medical Care for diagnostic testing In-network benefit preauthorization required. Pays at 100% after deductible is met. Must meet deductible. Annual family deductible is $500.
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:
PPO-Medical care office visits In-network benefit-Office visit copayment: $10.00 Out-of-network deductible and coinsurance of 20%.
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:
PPO-Medical Care office visits In-network benefit- copayment: Office visit $10.00 and Injections $25.00 Out-of-network Deductible and Coinsurance of 20%.
Mrs. Johnson called the office because she thought she had overpaid during her visit. What was Mrs. Johnson’s 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:
PPO-Medical care office visits In-network benefit-One vision exam every 2 calendar years. Out-of-network Deductible and Coinsurance of 20%. Covered every 2 calendar years.
What is Mr. Bergman’s 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:
PPO-Emergency treatment In-network benefit-Copay $100. Waived if admitted. Ambulance services no charge. Out-of-network Copay $100. Waived if admitted. Ambulance services no charge.
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 patient’s 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 patient’s insurance is verified. • Explain how to interpret the patient’s 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.