Reading

Valerius−Bayes−Newby−Seggern: Medical Insurance: An Integrated Claims Process Approach, Third Edition

IV. Payers

Introduction

© The McGraw−Hill Companies, 2008

Chapter 9

Private Payers/Blue Cross and Blue Shield

Chapter 10

Medicare

Chapter 11

Medicaid

Chapter 12

TRICARE and CHAMPVA

Chapter 13

Workers’ Compensation and Disability

CHAPTER 9 Private Payers/Blue Cross and Blue Shield

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Valerius−Bayes−Newby−Seggern: Medical Insurance: An Integrated Claims Process Approach, Third Edition

IV. Payers

9. Private Payers/Blue Cross and Blue Shield

© The McGraw−Hill Companies, 2008

Private Payers/Blue Cross and Blue Shield

Learning Outcomes

After studying this chapter, you should be able to: 1. Compare employer-sponsored and self-funded health plans. 2. Describe the major features of group health plans regarding eligibility, portability, and required coverage. 3. Discuss provider payment under preferred provider organizations, health maintenance organizations, point-of-service plans, and indemnity plans. 4. Describe the two components of consumer-driven health plans and their effect on cash flow. 5. Compare and contrast health reimbursement accounts, health savings accounts, and flexible spending accounts. 6. List the five main parts of participation contracts and describe their purpose. 7. Describe the information needed to collect copayments and bill for surgical procedures under contracted plans. 8. Discuss the use of plan summary grids. 9. Describe the steps in the medical billing process that ensure correct preparation of private payer claims. 10. Discuss the key points in managing billing for capitated services.

CHAPTER OUTLINE

Private Insurance Features of Group Health Plans Types of Private Payer Plans Consumer-Driven Health Plans Major Private Payers and the Blue Cross and Blue Shield Association Participation Contracts Interpreting Compensation and Billing Guidelines Private Payer Billing Management and Claim...