Insurance in the Medical Office: From Patient to Payment 13 9780073374598
Insurance in the Medical Office: From Patient to Payment

Insurance in the Medical Office: From Patient to Payment

Grade Levels: 13
By Cynthia Newby and Nikita Carr
Copyright: 2014
Publication Date: January 9, 2013
MHID: 0073374598
ISBN 13: 9780073374598

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New Features

The book is tailored to the specific needs of medical assistants as they handle office administration tasks. Content and coverage have been updated and refocused to provide a practical, targeted overview of medical insurance and billing.

Expanded introduction to ICD-10-CM, with an optional chapter covering ICD-9-CM and ICD-10-CM available through McGraw-Hill's Create.

Starting in Chapter 3, in-chapter Exercises give students the opportunity to get hands-on experience with key Practice Management Program tasks through simulations of real software. Completing on-the-job tasks relating to PMPs is an important aspect of a medical assistant’s work. Insurance in the Medical Office offers options for completing these tasks: Connect Plus for simulated Medisoft exercises, as well as paper claim forms and the electronic CMS-1500 form for claims exercises.

Pedagogy Updates: Learning Outcomes are restated using the revised version of Bloom’s Taxonomy to teach and assess critical thinking about medical insurance and coding concepts. Major chapter heads are now structured to reflect the numbered Learning Outcomes. Key terms are now defined in the margins for easy reference, and are listed in the Glossary. Billing Tips and Compliance Guidelines highlight key concepts or provide additional tips to help students navigate through the material. “Thinking It Through” questions have been added at the end of each section to assess each Learning Outcome. New Chapter Summaries have been created in a tabular, step-by-step format with page references to help with review of the material. End-of-chapter elements are now tagged with Learning Outcomes. The Chapter Review section includes: Using Terminology—matching questions; Checking Your Understanding—multiple choice and short answer questions; and Applying Your Knowledge—cases.

McGraw-Hill's Connect Plus includes all End-of-Section and End-of-Chapter questions, as well as simple interactives for each chapter.

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.

Insurance in the Medical Office: From Patient to Payment




From Patient to Payment: Understanding Medical Insurance

1.1 Working with Medical Insurance

1.2 Paying for Medical Services

1.3 The Medical Billing Cycle

1.4 Using PM/EHRs: The Integrated Medical Documentation and Billing Cycle

1.5 Set for Success

Chapter Review


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

2.1 Medical Records and the Need for Accurate Documentation

2.2 Health Care Regulations

2.3 HIPAA Privacy Rule

2.4 HIPAA Security Rule and HITECH Breach Notification Rule

2.5 HIPAA Electronic Health Care Transactions and Code Sets

2.6 Avoiding Fraud and Abuse

2.7 Compliance Plans

Chapter Review


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 Communications Are Key

Chapter Review


Diagnostic Coding

4.1 ICD-10-CM

4.2 The Alphabetic Index

4.3 The Tabular List

4.4 Using External Cause Codes and Z Codes

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

4.6 Assigning Diagnosis Codes

Chapter Review


Procedural Coding

5.1 Introduction to Procedure Codes in the CPT

5.2 Coding Steps

5.3 Coding Evaluation and Management Services

5.4 Coding Surgical Procedures

5.5 Coding Laboratory Procedures and Immunizations

5.6 HCPCS Codes

Chapter Review


Payment Methods and Checkout Procedures

6.1 Types of Health Plans

6.2 Methods for Setting Fees

6.3 Third-Party Contracts and Guidelines

6.4 Time-of-Service (TOS) Payments

6.5 Calculating TOS Payments

6.6 Checking Out Patients

Chapter Review


Health Care Claim Preparation and Transmission

7.1 Preparing Claims Using Practice Management Programs

7.2 Health Care Claims

7.3 Completing the CMS-1500 02/12 Claim

7.4 The HIPAA Claim

7.5 Health Care Claim Transmission

7.6 Billing Secondary Payers

Chapter Review


Private Payers/BlueCross and BlueShield

8.1 Private Insurance

8.2 Major Private Payers and the BlueCross BlueShield Association

8.3 Billing Guidelines Under Participation Contracts

8.4 Private Payer Claims

8.5 Capitation Management

Chapter Review



9.1 Medicare Overview

9.2 Part B Plans and Medigap Plans

9.3 Medicare Charges

9.4 Using the ABN

9.5 Medicare Secondary Payer

9.6 Claim Completion

Chapter Review



10.1 Introduction to Medicaid

10.2 Medicaid Coverage

10.3 Medicaid Eligibility and Plans

10.4 Filing Medicaid Claims

Chapter Review



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


Workers' Compensation and Automobile/Disability Insurance

12.1 Federal Workers' Compensation Plans

12.2 State Workers' Compensation Plans

12.3 Workers' Compensation Terminology

12.4 Claim Process

12.5 Automobile Insurance and Disability Compensation Programs

Chapter Review


Claim Processing, Payments, and Collections

13.1 Health Plan Claim Processing by Payers

13.2 Processing the Remittance Advice

13.3 Appeals

13.4 Patient Billing and Adjustments

13.5 Collecting Outstanding Patient Accounts

13.6 Writing Off Uncollectible Accounts

13.7 Terminating the Provider-Patient Relationship

Chapter Review


Hospital Insurance

14.1 Health Care Facilities: Inpatient Versus Outpatient

14.2 Hospital Billing Cycle

14.3 Inpatient (Hospital) Coding

14.4 Payers and Payment Methods

14.5 Claims and Follow Up

Chapter Review


Dental Insurance

15.1 Introduction to Dental Terms

15.2 Dental Insurance

15.3 Processing Dental Claims

Chapter Review


Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM

16.1 ICD-9-CM

16.2 Organization of ICD-9-CM

16.3 The Alphabetic Index

16.4 The Tabular List

16.5 Tabular List of Chapters

16.6 V Codes and E Codes

16.7 Coding Steps

16.8 Official Coding Guidelines

16.9 Introducing ICD-10-CM

Chapter Review

Appendix A Guide to Medisoft

Appendix B Guide to the Interactive Simulated CMS-1500 Form

Appendix C Professional Websites

Appendix D Forms




About the Author

Cynthia Newby

Cynthia Newby, CPC, CPC-P, is a long-serving author who works closely with McGraw-Hill Education instructional development staff to develop excellent MIBC programs. Cynthia is a graduate of Hood College and a trustee of that institution as well as her local animal shelter and library.

Nikita Carr