Medical Billing and Coding Lesson 1: Reimbursement, HIPAA, and Compliance Already Passed

Medical Billing and Coding Lesson 1: Reimbursement, HIPAA, and Compliance Already Passed The Medical Coder's Responsibility Each coding system plays a critical role in reimbursement. The role of the medical coder is to optimize payment while adhering to coding guidelines. The coder must accurately code the services, procedures, and diagnosis rendered so that the office is properly reimbursed. Coders may encounter ethical issues about upcoding a procedure or changing a diagnosis to obtain better payment. Upcoding or changing a diagnosis to increase payment without physician agreement is fraud. Managed Care Organizations (MCO) An MCO is an organization that combines the functions of health insurance, delivery of care, and administration. Exclusive Provider Organizatin (EPO) A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan's network (except in an emergency). Health Maintenance Organizations (HMO) A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. Point of Service Plans (POS) A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. POS plans require you to get a referral from your primary care doctor in order to see a specialist. Preferred Provider Organizations (PPOs) A type of health plan where you pay less if you use providers in the plan's network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost. Department of Health and Human Services (DHHS) The officiating government office for Medicare. The DHHS has delegated responsibility for the operations of Medicare to the Centers for Medicare and Medicaid Services (CMS). CMS was formerly the Health Care Financing Administration (HCFA). The Centers for Medicare and Medicaid Services (CMS) CMS operates Medicare, using Medicare Administrative Contractors (MACs) or Fiscal Intermediaries (FIs), which are private insurance companies that handle Medicare in specific areas. CMS delegates daily operation to Medicare Administrative Contractors (MACs), which are usually insurance companies. CMS delegates daily operation to Medicare Administrative Contractors (MACs), which are usually insurance companies. Medicare Administrative Contractors (MACs) or Fiscal Intermediaries (FIs) Private insurance companies that handle Medicare in specific areas. How is Medicare Funded Medicare is funded by Social Security taxes, which come from payroll taxes paid by employers and employees. The government provides an equal match to these funds. The Social Security Administration collects and handles the funds, which flow through CMS to the MACs or FIs. The MACs handle paperwork and pay claims. Medicare Administrative Contractors (MACs) A private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including: Process Medicare FFS claims Make and account for Medicare FFS payments Enroll providers in the Medicare FFS program Handle provider reimbursement services and audit institutional provider cost reports Handle redetermination requests (1st stage appeals process) Respond to provider inquiries Educate providers about Medicare