Medical Insurance: An Integrated Claims Process Approach

Medical Insurance: An Integrated Claims Process Approach

6th Edition

By Joanne Valerius and Nenna Bayes and Cynthia Newby and Amy Blochowiak

  • Copyright: 2014

  • Publication Date: Jan 11 2013

  • ISBN 10: 0073513717

  • ISBN 13: 9780073513713



The sixth edition of Medical Insurance: An Integrated Claims Process Approach emphasizes the medical billing cycle—ten steps that clearly identify all the components needed to successfully mana

The sixth edition of Medical Insurance: An Integrated Claims Process Approach emphasizes the medical billing cycle—ten steps that clearly identify all the components needed to successfully manage the medical insurance claims process. The cycle shows how administrative medical professionals “follow the money.” Medical insurance specialists must be familiar with the rules and guidelines of each health plan in order to submit proper documentation, which then ensures that offices receive maximum, appropriate reimbursement for services provided. Each part of the book is dedicated to a section of the cycle followed by case studies to apply the skills discussed in each section. These case studies can be completed with the electronic CMS-1500 at or using simulated Medisoft exercises in Connect Plus, McGraw-Hill's homework and assessment platform.

  • Language: English

  • Imprint: WCB/McGraw-Hill

  • Dimension: 8.4 x 10.8

  • Page Count: 656

New Features

  • Meets Instructor/Student Goals: The text is closely matched with the typical curriculum and goals of both instructors and students. It is tightly focused on important concepts and skills, omitting extraneous material. The coverage of procedural knowledge, communications skills, and health information management skills prepares students to successfully perform the duties of medical insurance specialists.
  • Expanded introduction to ICD-10-CM, with an optional chapter covering ICD-9-CM and ICD-10-CM available through McGraw-Hill's Create. Adoption of Medical Insurance 6e allows for 29 days free access to CodeItRight Online, an experience with an Internet-based code assignment service.
  • 2013 ICD-10-CM and CPT/HCPCS codes are included. The new Notice of Privacy Practices (NPP) that addresses disclosures in compliance with HITECH is illustrated.
  • McGraw-Hill's Connect includes all End-of-Section and End-of-Chapter questions, as well as simple interactives for each chapter.
  • Case studies can be completed with one of three methods: 1. paper CMS-1500 form; 2. electronic CMS-1500 form at; or 3. simulated Medisoft Version 17 exercises in McGraw-Hill's Connect. You can find out more about these options in the book appendices.
  • The text-specific workbook provides both review and applications learned in the textbook. The workbook is learning outcomes-based. In addition to claim completion case studies, applications include math and communication skill development.
  • Extensive instructor resources are available at, including the Instructor's Manual, Electronic Testbank, PowerPoint Slides with Teaching Notes, Sample Syllabi, Competency Correlations and an asset map.












Chapter 1

Introduction to the Medical Billing Cycle


Table of Contents





Chapter 1

Introduction to the Medical Billing Cycle

1.1 Working in the Medical Insurance Field

1.2 Medical Insurance Basics

1.3 Health Care Plans

1.4 Health Maintenance Organizations

1.5 Preferred Provider Organizations

1.6 Consumer-Drive Health Plans

1.7 Medical Insurance Payers

1.8 The Medical Billing Cycle

1.9 Achieving Success

1.10 Moving Ahead

Chapter Review

Chapter 2

Electronic Health Records, HIPAA, and HITECH: Sharing and Protecting Patients' Health Information

2.1 Medical Record Documentation: Electronic Health Records

2.2 Health Care Regulation: HIPAA and HITECH

2.3 Covered Entities and Business Associates

2.4 HIPAA Privacy Rule

2.5 HIPAA Security Rule

2.6 HITECH Breach Notification Rule

2.7 HIPAA Electronic Health Care Transactions and Code Sets

2.8 Fraud and Abuse Regulations

2.9 Enforcement and Penalties

2.10 Compliance Plans

Chapter Review

Chapter 3

Patient Encounters and Billing Information

3.1 New Versus Established Patients

3.2 Information for New Patients

3.3 Information for Established Patients

3.4 Verifying Patient Eligibility for Insurance Benefits

3.5 Determining Preauthorization and Referral Requirements

3.6 Determining the Primary Insurance

3.7 Working with Encounter Forms

3.8 Understanding Time-of-Service (TOS) Payments

3.9 Calculating TOS Payments

Chapter Review


Chapter 4

Diagnostic Coding: Introduction to ICD-10-CM

4.1 ICD-10-CM

4.2 Organization of ICD-10-CM

4.3 The Alphabetic Index

4.4 The Tabular List

4.5 ICD-10-CM Official Guidelines for Coding and Reporting

4.6 Overview of ICD-10-CM Chapters

4.7 Coding Steps

4.8 ICD-10-CM and ICD-9-CM

Chapter Review

Chapter 5

Procedural Coding: CPT and HCPCS

5.1 Current Procedural Terminology, Fourth Edition (CPT)

5.2 Organization

5.3 Format and Symbols

5.4 CPT Modifiers

5.5 Coding Steps

5.6 Evaluation and Management Codes

5.7 Anesthesia Codes

5.8 Surgery Codes

5.9 Radiology Codes

5.10 Pathology and Laboratory Codes

5.11 Medicine Codes

5.12 Category II and III Codes

5.13 HCPCS

Chapter Review

Chapter 6

Visit Charges and Compliant Billing

6.1 Compliant Billing

6.2 Knowledge of Billing Rules

6.3 Compliance Errors

6.4 Strategies for Compliance

6.5 Audits

6.6 Physician Fees

6.7 Payer Fee Schedules

6.8 Calculating RBRVS Payments

6.9 Fee-Based Payment Methods

6.10 Capitation

Chapter Review


Chapter 7

Health Care Claim Preparation and Transmission

7.1 Introduction to Health Care Claims

7.2 Completing the CMS-1500 Claim: Patient Information Section

7.3 Types of Providers

7.4 Completing the CMS-1500 Claim: Physician/Supplier Section

7.5 The HIPAA 837P Claim

7.6 Completing the HIPAA 837P Claim

7.7 Checking Claims Before Transmission

7.8 Clearinghouses and Claim Transmission

Chapter Review

Chapter 8

Private Payers/BlueCross BlueShield

8.1 Private Insurance

8.2 Features of Group Health Plans

8.3 Types of Private Payers

8.4 Consumer-Driven Health Plans

8.5 Major Private Payers and the BlueCross BlueShield Association

8.6 Participation Contracts

8.7 Interpreting Compensation and Billing Guidelines

8.8 Private Payer Billing Management: Plan Summary Grids

8.9 Preparing Correct Claims

8.10 Capitation Management

Chapter Review

Chapter 9


9.1 Eligibility for Medicare

9.2 The Medicare Program

9.3 Medicare Coverage and Benefits

9.4 Medicare Participating Providers

9.5 Nonparticipating Providers

9.6 Original Medicare Plan

9.7 Medicare Advantage Plans

9.8 Additional Coverage Options

9.9 Medicare Billing and Compliance

9.10 Preparing Primary Medicare Claims

Chapter Review

Chapter 10


10.1 The Medicaid Program

10.2 Eligibility

10.3 State Programs

10.4 Medicaid Enrollment Verification

10.5 Covered and Excluded Services

10.6 Plans and Payments

10.7 Third-Party Liability

10.8 Claim Filing and Completion Guidelines

Chapter Review

Chapter 11


11.1 The TRICARE Program

11.2 Provider Participation and Nonparticipation

11.3 TRICARE Plans

11.4 TRICARE and Other Insurance Plans


11.6 Filing Claims

Chapter Review

Chapter 12

Workers' Compensation and Disability/Automotive Insurance

12.1 Federal Workers' Compensation Plans

12.2 State Workers' Compensation Plans

12.3 Workers' Compensation Terminology

12.4 Claim Process

12.5 Disability Compensation and Automotive Insurance Programs

Chapter Review


Chapter 13

Payments (RAs), Appeals, and Secondary Claims

13.1 Claim Adjudication

13.2 Monitoring Claim Status

13.3 The Remittance Advice (RA)

13.4 Reviewing RAs

13.5 Procedures for Posting

13.6 Appeals

13.7 Postpayment Audits, Refunds, and Grievances

13.8 Billing Secondary Payers

13.9 The Medicare Secondary Payer (MSP) Program, Claims, and Payments

Chapter Review

Chapter 14

Patient Billing and Collections

14.1 Patient Financial Responsibility

14.2 Working with Patients' Statements

14.3 The Billing Cycle

14.4 Organizing for Effective Collections

14.5 Collection Regulations and Procedures

14.6 Credit Arrangements and Payment Plans

14.7 Collection Agencies and Credit Reporting

14.8 Writing Off Uncollectible Accounts

14.9 Record Retention

Chapter Review

Chapter 15

Primary Case Studies

15.1 Method of Claim Completion

15.2 About the Practice

15.3 Claim Case Studies

Chapter Review

Chapter 16

RA/Secondary Case Studies

16.1 Method of Claim Completion of Secondary Claims

16.2 Handling Denied Claims

16.3 Processing Medicare RAs and Preparing Secondary Claims

16.4 Processing Commercial Payer RAs and Preparing Secondary Claims

16.5 Calculating Patients' Balances Chapter Review


Chapter 17

Hospital Billing and Reimbursement

17.1 Health Care Facilities: Inpatient Versus Outpatient

17.2 Hospital Billing Cycle

17.3 Hospital Diagnosis Coding

17.4 Hospital Procedure Coding

17.5 Payer and Payment Methods

17.6 Claims and Follow-up

Chapter Review

Chapter 18

Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM AVAILABLE AT WWW.MCGRAWHILLCREATE.COM

18.1 ICD-9-CM

18.2 Organization of ICD-9-CM

18.3 The Alphabetic Index

18.4 The Tabular List

18.5 Tabular List of Chapters

18.6 V Codes and E Codes

18.7 Coding Steps

18.8 Official Coding Guidelines

18.9 Introducing ICD-10-CM

Chapter Review

Appendix A Guide to Medisoft

Part 1: Getting Started with Medisoft

Part 2: Overview and Practice

Appendix B Guide to the Interactive Simulated CMS-1500 Form

Appendix C Place of Service Codes

Appendix D Professional Websites

Appendix E Forms






About the Authors

Joanne Valerius

Nenna Bayes

Cynthia Newby

Amy Blochowiak