Case Study : Lesson 9 Exercise 1

IgG – funtions in neutralizing, opsonation, compliment activation, antibody dependent cell-mediated cytocity, neonatal immunity, and feedback inhibition of B-cells and found in the blood.

“Mayo Clinic has established arrangements with several different types of health care insurers” (n.d., Mayo Clinic). It is important to review information and resources relevant to your health care coverage prior to setting up your appointment. Mayo clinic also has resources available to assist patients with the insurance process including pre-authorizations and pre-certifications from their insurance company. Mayo clinic accepts coverage from several contracted insurance plans. Mayo clinic may not offer the highest benefit level or participate in every product offering from the every health plan listed; benefit coverage is determined solely by the insurance provider. A few of health care providers contracted with Mayo Clinic

To start the physician insurance claim cycle, the offices staff need to have the first encounter with the new patient. In this first encounter the office staff collect general patient information to ensure the new patient eligibility and benefits status. The Information that collect is full name, date of birth, address, insurance policy and reason of the visit. The second step the office start will verify the full benefits of the patient before the first doctor visit to make sure the patient eligibility and to stablish the patient responsibility at the time of the office visit. The day of the visit the patient complete the new patients forms and the office staff ask and make photo copy the patient insurances card and id card for purpose of

Insurance Eligibility- After determining a patient in fact has insurance coverage and the coverage is accepted by the provider, medical staff members must verify the patients covered benefits. Considering there is many different insurance companies and policies, a process should be followed to determine if the patient owes co-payments, deductibles, premiums, and services rendered that are not considered a covered entity. Medical staff should explain a patients’ rights, responsibilities, and expected charges. In some cases insurance carriers will require a referral or pre-authorization before they will agree to pay for services provided. These documents must be attained before a patient is seen by the

CMS has differential payment for inpatient and observation status patient services (Engoren. et., 2016). Observation status is covered under Medicare Part B, which is an optional coverage for beneficiaries and they are usually responsible for the co-payments, which is 20 percent of the Medicare payment for out payment services for such items as labs, x-rays and any medications they usually take at home. The beneficiary will also have to pay their yearly deductible for their Part B. The patient will receive a bill for non-covered services, including any required co-pay or deductibles. While patients are in observation, they could be charged co-payments for individual services they receive. Patients who do not have part B Medicare may incur

She beliefs that external factors – her boyfriend was under pressure for a while because he was laid off – were also responsible for her his boyfriend’s actions. She may blame these external circumstances for leading to her abuse.

Patient demographics (full name, date of birth, emergency contact information, next of kin, employer information etc...)

This will include any questions or concerns you have about your health, a detailed list of medications you are currently taking and your family's health history. Take your notes with your to your appointment so you are prepared to answer any questions that are asked.

Offices should have a well written payment/collection policy to prevent confusion in the office. All patients should never be confused about if and how much they need to pay. There are a variety of policy rules that can be overwhelming. Copayments can be tricky because sometimes you must pay them right away and sometimes they are billed to you later. If a patient does owe a payment and is not sure what for; the staff should be familiar with the policies to help explain the payment if needed.

Patients are responsible for paying a co-payment when visiting a doctor. After the patient is seen, the provider submits claim forms to the insurer for the services rendered. Once the claims are processed the insurer will reimburse the provider (Austin & Wetle, 2012). If a patient goes out-of-network, they are required to pay the provider in full. Afterwards the patient can submit a claim for reimbursement.

There are currently have two main insurance options available for consumers, Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). Both health insurance plans are great, but we will be focusing on the plan with lower costs in general which is Health Maintenance Insurance, or HMO. HMO is an organized system of health care that offers medical services to its members on a prepaid foundation. It combines health insurance and delivery functions in an effort to keep low costs and maximize the quality care provided. There are several types of HMOs that are available: staff model, group model, network model and individual practice association, or IPA. For the staff model, physicians are salaried and have offices in HMO

Criminal Justice professionals have certain responsibilities and duties in order to fulfill the needs of

The administrative life cycle of a physician-based claim has several important steps that need to be followed accordingly. The first step in the life cycle starts with Patient Scheduling and Registration. The second step is Insurance Verification. Insurance verification is a very important step because when the patient comes in for his/her visit they will need to know and be prepared to either pay something or not. The third step, once the patient comes in for their visit, is Patient Co-Pay Collection. Next is Patient Exam-Documentation. Then, Order Management. After the patient visit, the next step is Coding and Charge Entry. The rest of the steps are as follows in order: Claim Checking and Error Resolution, Claim Submission, Payment Processing

-4/SD = -4/2.7 = -1.48 ≈ -1.5 SD (negative means towards the right therefore there would be an increase)

Our office will submit claims for insurance carriers with which we accept. We are devoted to offer quality and in many cases beyond the basic therapeutic care to our patients. In the end, it is your responsibility to know your particular coverage benefits. Comprehensive physicals, inoculations, certain laboratory tests, procedures, and prescribed medications including nourishment and herbal supplements may not be covered. Prior authorizations might be finished at the consideration of our doctors. Therefore, we can not ensure that all services and treatments we give or suggest are covered by your insurance. In additional, we can not simply change codes with a specific end goal to adjust insurance coverage as it is fraudulent and prohibited.