Insurance Claim Calculations

Assignment: Students will complete the following scenario as an essay (Insurance Claims and Appeals Management Essay-Sample). As you are completing your audits you observe Mary Johnson’s chart and notice the following: Mary Johnson saw Dr. Nichols today for a well-woman exam. Total charges are $185.00. Mary has two insurance companies: Primary Insurance Secondary Insurance BCBS Cigna Health Care Copay: $25.00 Deductible: $200.00 (already met) 100% benefit after copay 80% benefit after deductible Allowed amount: $150.00 Allowed amount: $125.00 Both claims were submitted at the same time in error. Money collected from the patient: $0.00 Complete the following questions providing rationales for your responses: How much money did Dr. Nichols receive? How much should BCBS have paid? How much should Cigna have paid? How much is this claim overpaid? Who overpaid on this claim? What would be your next steps? Address how this situation might be avoided in the future: be specific and provide steps. The well-woman exam showed this patient due to family history of cancer would benefit from BRCA genetic testing and both insurance companies denied this claim. Format a letter of appeal or BRCA testing. This assignment is completed as an APA style paper, and should be at least 2-3 pages in length. Demonstrate your business knowledge and professional ethics in your response. Assignment Expectations: Length: answers must thoroughly address each question in a clear, concise manner; complete answers will likely take 2-3 pages Structure: Title and reference page required address each question in a numbered list References: References required to be cited if used(Insurance Claims and Appeals Management Essay-Sample)

Insurance Claims and Appeals Management Essay-Sample

Managing Insurance Claims and Appeals

This paper examines a case involving Mary Johnson’s well-woman exam, insurance coverage, and subsequent claims processing. It investigates the significance of legitimate cases, the board, exact charging, and adherence to insurance policies in keeping up with the monetary security of clinical practices. It likewise directs drafting a letter of interest for BRCA genetic testing and examines ways to deal with forestall comparative circumstances later. Through this contextual analysis, we gain experience in the meaning of viable cases on the board and the moral contemplations supporting patients’ medical service needs.(Insurance Claims and Appeals Management Essay-Sample)

How much money did Dr Nichols receive?

In the given situation, it is expressed that Dr Nichols got no cash from Mary Johnson for the well-lady test. Thus, it infers that Mary made no installment towards the complete charges of $185.00 at the hour of the visit. The shortfall of an installment exchange proposes that Dr Nichols got no money-related pay from Mary Johnson for the administrations delivered during the test.

How much should BCBS have paid?

The total charges for the well-woman exam were $185.00, and the allowed sum for BCBS is $150.00. BCBS requires a copy of $25.00 and has a deductible of $200.00, which has proactively been met. Since the deductible has been met, BCBS should pay 100 per cent of the leftover equilibrium after the copay. In this manner, BCBS should have paid $150.00 – $25.00 (copay) = $125.00 for Mary Johnson’s well-lady test.(Insurance Claims and Appeals Management Essay-Sample)

How much should Cigna have paid?

Given the data given in the scenario, Cigna Medical Services is the secondary insurance for Mary Johnson. The allowed sum for Cigna is $125.00, which implies that this is the most extreme sum that Cigna will repay for the delivered administrations. Nonetheless, Cigna’s advantages are organized as follows:

Copay: $25.00

Deductible: already met

80% benefit after deductible

Since the deductible has proactively been met, Cigna should have paid 80% of the remaining balance after the copay. In this way, Cigna ought to have paid 80% of $125.00 – $25.00 (copay) = $80.00 for Mary Johnson’s well-woman exam.(Insurance Claims and Appeals Management Essay-Sample)

How much is this claim overpaid?

In determining the amount by which the case is overpaid, it is important to analyze the actual reimbursement got from the insurance agency with the complete charges for the well-woman exam. The total charges for the well-lady test are $185.00. How about we compute the complete repayment got from both insurance agencies:

BCBS repayment: $125.00

Cigna repayment: $80.00

Complete repayment: $125.00 + $80.00 = $205.00

The complete repayment is deducted from the total charges to find the overpaid sum:

Overpaid sum = Complete charges – Absolute repayment

Overpaid sum = $185.00 – $205.00

Overpaid sum = – $20.00

Based on the computations, the case is overpaid by $20.00. Thus, it implies that the complete repayment received from both insurance agencies surpasses the total charges for the well-woman exam.

Who overpaid on this claim?

In this case, the excessive charge happened concerning the insurance agency. Both BCBS and Cigna overpaid in this case. The all-out repayment from both insurance agencies surpassed the all-out charges for the well-woman exam, bringing about an excessive charge of $20.00. Thus, it features the significance of precise case handling and guaranteeing those repayments align with the allowed amount and policy guidelines.(Insurance Claims and Appeals Management Essay-Sample)

What would be your next steps?

Considering the excessive charge in this case, the subsequent stages include redressing what is happening and guaranteeing appropriate repayment. The initial step is distinguishing the particular sums overpaid by every insurance agency (BCBS and Cigna) and accommodating the records. Speaking with both insurance agencies to address the excessive charge and solicitation repayment change would be fundamental. Also, internal reviews and surveys of case cycles can be directed to distinguish any expected mistakes or issues to keep comparable circumstances from happening from now on.(Insurance Claims and Appeals Management Essay-Sample)

Avoiding Insurance Billing Errors

To avoid insurance billing errors in the future, healthcare facilities and providers can take the following steps:

Accurate Verification of Insurance Information

1. During patient enrollment, gather all vital protection subtleties, including essential and optional protection data, copay sum, and deductibles (Cooper et al., 2020).(Insurance Claims and Appeals Management Essay-Sample)
2. Conduct a hearty protection confirmation process, including electronic qualification checks, to guarantee precise inclusion subtleties (Jackson, 2020).

Effective Claims Submission

1. Train staff on appropriate case accommodation techniques, accurately underlining the significance of distinguishing essential and optional guarantors (Cooper et al., 2020).
2. Execute a twofold to examine the framework to survey claims for blunders or exclusions before accommodation (Jackson, 2020).(Insurance Claims and Appeals Management Essay-Sample)
3. Use electronic case accommodation at whatever point conceivable to diminish human mistakes (Cooper et al., 2020).

Clear Communication with Patients

1. Instruct patients about their protection inclusion, including copays, deductibles, and advantages (Jackson, 2020).
2. Give patient’s nitty gritty clarifications of advantages (EOBs) to assist them with understanding the protection (Jackson, 2020).

Regular Staff Training and Education Regular Staff Training and Education

1. Direct normal instructional meetings for staff individuals on protection charging and coding rules (Cooper et al., 2020).
2. Remain refreshed on changes in insurance contracts and guidelines to guarantee consistency (Jackson, 2020).

Implementation of Auditing Procedures

1. Lead standard reviews of protection professes to recognize any possible blunders or disparities (Jackson, 2020).
2. Survey claims documentation and installments to distinguish designs and develop future charging rehearses (Cooper et al., 2020).(Insurance Claims and Appeals Management Essay-Sample)

Conclusion

To avoid protection charging mistakes from here on out, medical care suppliers ought to zero in on exact protection checks, viable case accommodation, clear correspondence with patients, customary staff preparation, and the execution of evaluating techniques. Moreover, pushing for patients’ medical service needs, like BRCA genetic testing, requires creating a very organized bid letter that features the administration’s clinical need and significance. By following these means and exhibiting proficient morals, medical services offices can further develop their charging processes and guarantee ideal patient consideration.(Insurance Claims and Appeals Management Essay-Sample)

Appeal for BRCA Genetic Testing (Letter)

(Your Name)

(Your Address)

(City, State, ZIP)

(Email Address)

(Telephone Number)

(Date)

(Insurance Agency Name)

(Address)

(City, State, ZIP)

Subject: Appeal for BRCA Genetic Testing

Dear (Insurance Organization Name),

I am writing to pursue the refusal of the case for BRCA genetic testing on behalf of my patient, Mary Johnson, who, as of late, went through a well-woman exam. This testing is of imperative significance because of Mary’s family background of malignant growth, and it is critical for her continuous well-being and prosperity.(Insurance Claims and Appeals Management Essay-Sample)

The well-woman exam, directed by Dr Nichols, featured Mary’s expanded gamble of fostering specific kinds of disease. BRCA genetic testing is perceived as an important demonstrative instrument to evaluate genetic gamble factors and guide customized medical care choices. It considers early recognition, counteraction, and custom-made treatment designs that influence patient results and personal satisfaction.(Insurance Claims and Appeals Management Essay-Sample)

The refusal of this guarantee is discouraging, as it straightforwardly sabotages Mary’s admittance to fitting medical services and preventive measures. Considering her as an increased risk, BRCA genetic testing should be covered by protection as a therapeutically essential technique. I demand a reevaluation of the refusal and urge you to survey this case’s current realities and benefits.(Insurance Claims and Appeals Management Essay-Sample)

Encased with this letter, you will track down all applicable clinical documentation, including the well-lady test report, family clinical history, and supporting writing accentuating the meaning of BRCA testing in high-risk people. After surveying this data, you will perceive the clinical need to endorse the case.

I comprehend that insurance agencies have severe approaches and rules; nonetheless, focusing on persistent consideration and backing proof based rehearses is pivotal. By covering the BRCA genetic testing for Mary Johnson, you won’t just upgrade her well-being results yet additionally exhibit a promise of customized, preventive medical care.(Insurance Claims and Appeals Management Essay-Sample)

I am much obliged to you for your regard for this. I anticipate a brief and positive reaction that will guarantee Mary’s admittance to the vital BRCA hereditary testing. Kindly contact me if you require any additional data or, on the other hand, if I can aid you with a method for speeding up this cycle.(Insurance Claims and Appeals Management Essay-Sample)

Sincerely,

(Your Name)

(Professional Title)

(Clinical Office/Association Name)

References

Cooper, Z., Nguyen, H., Shekita, N., & Morton, F. S. (2020). Out-Of-Network Billing and Negotiated Payments For Hospital-Based Physicians. Health Affairs, 39(1), 24–32. https://doi.org/10.1377/hlthaff.2019.00507(Insurance Claims and Appeals Management Essay-Sample)

Jackson, M. (2020). Good Financial Practice and Clinical Research Coordinator Responsibilities. Seminars in Oncology Nursing, 36(2), 150999. https://doi.org/10.1016/j.soncn.2020.150999(Insurance Claims and Appeals Management Essay-Sample)

https://www.ncbi.nlm.nih.gov/