- Description
MEDICAL INSURANCE
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HCR 202 Entire Course Link
https://hwsell.com/category/hcr–202/
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HCR 202 Week 1 Health Care Payors Worksheet
Complete the University of Phoenix Material: Health Care Payors Worksheet.
Click the Assignment Files tab to submit your assignment.
Health Care Payors Worksheet
Complete Parts A and B of this worksheet.
Reference: Ch. 1 of Medical Insurance: An Integrated Claims Process Approach (6th ed.)
Part A
Complete the table by describing the health care payor listed. Be clear and concise, use complete sentences, and define them in your own words.
| Health Care Payors | Characteristics |
| Medicare | |
| Blue Cross | |
| Medicaid | |
| Aetna | |
| PPO | |
| HMO |
Part B
Write a 50- to 150-word response to each of the following prompts. Be clear and concise, use complete sentences, and use your own words.
Cite any outside sources. For additional information on how to properly cite your sources see the Reference and Citation Generator resource in the Center for Writing Excellence.
HCR 202 Week 2 Payment Systems Worksheet
Complete the Payment Systems Worksheet.
Click the Assignment Files tab to submit your assignment.
Payment System Worksheet
Complete Parts A and B of this worksheet.
Part A
Complete the table by describing the term. Be clear and concise, use complete sentences, and define them in your own words.
Cite any outside resources. For additional information on how to properly cite your sources see the Reference and Citation Generator resource in the Center for Writing Excellence.
| Term | Definition |
| Preauthorization | |
| Precertification | |
| Predetermination |
Part B
Write a 250- to 350-word response to each of the following questions. Be clear and concise, use complete sentences, and use your own words.
When are patient referrals needed?
How would you determine if a referral is required?
Cite any outside sources. For additional information on how to properly cite your sources see the Reference and Citation Generator resource in the Center for Writing Excellence.
HCR 202 Week 2 Health Care Reimbursement Worksheet
Complete the University of Phoenix Material: Health Care Reimbursement Worksheet.
Click the Assignment Files tab to submit your assignment.
Health Care Reimbursement Worksheet
Complete Parts A and B of this worksheet.
Reference: Ch. 1 and Ch. 17 of Medical Insurance
Part A
Pair the health care term from Column A with the appropriate definition from Column B. List the corresponding letter in Column C.
| Column A | Column C | Column B |
| co-pay | The amount owed for covered health care services before the health insurance plan begins to pay | |
| Deductible | The portion of charges an insured person must pay for health care services after payment of the deductible amount is met; usually stated as a percentage | |
| Out-of-pocket max | A patient who does not have insurance | |
| Self-pay patient | The most an insured person will have to pay for covered health care services in a policy period. Until this maximum amount is met, the health care plan and insured person share costs | |
| co-insurance | A set dollar amount a health plan requires an insured person to pay at the time of service for each health care encounter |
Part B
Resource: Table 1.2 in Ch. 1 of Medical Insurance
Describe three to four health plans by completing the following table. Be clear and concise, use complete sentences, and use in your own words.
Health Plans
| Plan type | Provider options | Payment methods | Features |
Write 50- to 150-word responses to the following question. Use your own words and provide examples to support your answer.
Cite any outside sources. For additional information on how to properly cite your sources see the Reference and Citation Generator resource in the Center for Writing Excellence.
How do provider options (network) impact reimbursement for patients?
Review the features of the plan types discussed in the table and identify what features are most important to a patient.
HCR 202 Week 3 Government Payors Worksheet
Complete the University of Phoenix Material: Government Payors Worksheet.
Click the Assignment Files tab to submit your assignment.
Government Payers Worksheet
Complete Parts A and B of this worksheet.
References: Ch. 9, 10, and 11 of Medical Insurance: An Integrated Claims Process Approach (6th ed.)
Part A
Fill in the missing information by completing the table.
Identify the payer type, eligibility, coverage, and patient responsibility for Medicare programs, Medicaid, CHAMPVA, and Tricare.
| Payer Type | Eligibility | Coverage | Patient Responsibility |
| Medicare Part A | First 60 days responsibility is the annual deductible.
For days 61 to 90 there is a per-day copay and another per-day copay after days 91 to 150.
Beyond day 150, Medicare Part A does not make a payment. | ||
| Individuals entitled to Medicare Part A are automatically qualified to enroll in Part B.
Needs to be a U.S. citizen and over the age of 65 (voluntary program). | Physician services, outpatient hospital services, medical equipment, and other supplies and services. | ||
| Private health insurance companies contract with the Centers for Medicare and Medicaid to offer Medicare Advantage plans. | |||
| Medicare Part D | Medicare prescription drug plan (private insurance plan). | ||
| Categorically needy | Administered at a state level. Each state determines the coverage and sets the payment rates.
Services include hospital, outpatient, physician services, laboratory, radiology. Some states include prescription services, vision care, vision, clinic services, and home and community based care. | Some may include a spend down program prior to reimbursement.
Individuals and families may be required to spend a portion of income or resources on health care, which is similar to a deductible. | |
| Tricare | Coinsurance for nonparticipating providers.
Annual enrollment and copays for retirees and families. | ||
| Government health insurance program for families of veterans with 100% services related to disability. | Includes most all treatment with the exception of unnecessary services and supplies.
Does not include experimental treatment, custodial care, or dental care. |
Part B
Write a 50- to 150-word response to each of the following questions. Use your own words and provide examples to support your answers.
Why is it important to understand the guidelines for timely claim filing from the date of treatment or discharge?
Why is it important to understand the different payer coverage and patient responsibility?
Cite any outside sources. For additional information on how to properly cite your sources see the Reference and Citation Generator resource in the Center for Writing Excellence.
HCR 202 Week 3 Government Payors Presentation
Create a 10- to 12-slide Microsoft® PowerPoint® presentation that discusses Medicare, Medicaid, the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), and TRICARE.
Include detailed speaker notes to explain the following topics in your presentation:
- Eligibility requirements
- Coverage provisions
- Participating and non-participating provider charges
Use a minimum of 1 reference. You may use your textbook as a reference.
Format your assignment according to APA guidelines.
Click the Assignment Files tab to submit your assignment.
HCR 202 Week 4 Features of Private Payor and Consumer-Driven Health Plans
Resources: Table 8.1 and Table 8.2 in Ch. 8 of Medical Insurance: An Integrated Claims Process Approach (6th ed.) and the U.S. Department of the Treasury website
Write a 350- to 700-word response to familiarize yourself with private payer plans and consumer-driven health plan (CDHP) account types. Briefly list two to three main features for the following nine items.
- Preferred Provider Organization (PPO)
- Health Maintenance Organization (HMO)
- Group HMO
- Association of Independent Healthcare Organisations (AIHO)
- Point-of-Service (POS)
- Indemnity
- CDHP
- Health Reimbursement Account (HRA)
- Flexible Savings Account (FSA)
Use a minimum of 3 references. You may use your textbook and the two websites provided.
Format your assignment according to APA guidelines.
Click the Assignment Files tab to submit your assignment.
HCR 202 Week 4 Characteristics of Workers’ Compensation Plans
Resources: Ch. 12 of Medical Insurance: An Integrated Claims Process Approach (6th ed.) and the U.S. Department of Labor website
Write a 350- to 700-word response to the following:
- In your own words, briefly describe the features of the four federal workers’ compensation plans and the two types of state workers’ compensation benefits.
- Why is it necessary to have both federal and state compensation plans?
Format your assignment according to APA guidelines.
Click the Assignment Files tab to submit your assignment.
HCR 202 Week 4 Benchmark Assignment—Reimbursement and Coverage Worksheet
Complete the Reimbursement and Coverage Worksheet.
Click the Assignment Files tab to submit your assignment.
Reimbursement and Coverage Worksheet
References: Ch. 8 and 12 of Medical Insurance: An Integrated Claims Process Approach (6th ed.)
Imagine you are a billing supervisor at a local health facility. You have been asked to determine the expected reimbursement and coverage determination on the following claims:
You reviewed the claim 1500 form for patient Kevin Luke. You realize it is a new calendar year and he had not met his deductible. You had an authorization on file for treatment. Total billed charge amount is $1,100.00. His benefits are as follows:
| PPO-Medical Care for diagnostic testing | In-network benefit preauthorization required. Pays at 100% after deductible is met. | Must meet deductible. Annual family deductible is $500. |
Calculate the expected reimbursement from insurance and what the patient will owe.
You review the claim form for Lisa Smith for treatment of hyperglycemia. You discover she received treatment from a non-network provider. She has met her annual deductible. Total charges for the date of service are $170. The plan pays at usual and customary, which is exactly what was billed. Her benefits are as follows:
| PPO-Medical care office visits | In-network benefit-Office visit copayment: $10.00 | Out-of-network deductible and coinsurance of 20%. |
Calculate the expected reimbursement from insurance and her coinsurance.
You are reviewing a claim for Maria Johnson, a 45-year-old who received a well check and flu shot from her in network provider. Her benefits are as follows:
| PPO-Medical Care office visits | In-network benefit- copayment: Office visit $10.00 and Injections $25.00 | Out-of-network Deductible and Coinsurance of 20%. |
Mrs. Johnson called the office because she thought she had overpaid during her visit. What was Mrs. Johnson’s copay the date of the visit?
You are reviewing the vision exam benefits for Zach Bergman. He presented for an eye exam stating he needed new glasses. He had an examination 13 months prior and notes he can have an exam every year. His benefits are as follows:
| PPO-Medical care office visits | In-network benefit-One vision exam every 2 calendar years. | Out-of-network Deductible and Coinsurance of 20%. Covered every 2 calendar years. |
What is Mr. Bergman’s benefit?
Lisa Smith called your office noting she had to be transported to the hospital by ambulance while on vacation for food poisoning. She was concerned about what she will need to pay out-of-pocket. She was not admitted. Her benefits for emergency treatment are as follows:
| PPO-Emergency treatment | In-network benefit-Copay $100. Waived if admitted. Ambulance services no charge. | Out-of-network Copay $100. Waived if admitted. Ambulance services no charge. |
What should Lisa Smith expect to pay out-of-pocket?
Part B: Insurance Process Discussion
Choose one of the above cases and imagine the following scenario:
You received a call from the patient concerning their bill, and they would like to discuss it with you. You were asked a series of questions concerning insurance processes and medical reimbursement by the patient. As the billing expert you have a conversation addressing the patient’s billing questions and explaining the insurance process and steps you take. In 175 to 350 words, create a conversational dialog with the patient explaining the insurance process and why their claim was paid the way it was paid. Your conversation should include:
Explain how and why the patient’s insurance is verified.
Explain how to interpret the patient’s benefits for reimbursement using details from your selected case.
Explain possible pending insurance or patient actions relevant to your selected case.
Apply a professional and customer-oriented introduction and closure to the dialog.
HCR 202 Week 5 Comparing Cost Control Strategies
Resource: Ch. 8 of Medical Insurance: An Integrated Claims Process Approach (6th ed.).
Write a 350- to 700-word response to the following:
- Compare cost control strategies of employer-sponsored health plans (when employers buy from insurance companies) to self-funded health plans (when employers cover costs of benefits).
Include the following factors:
- Riders
- Enrollment periods
- Provider networks
- Third-party administrators
Discuss how the following affect cost control within group health plans:
- Portability
- Creditable coverage
Click the Assignment Files tab to submit your assignment.
HCR 202 Week 5 Ramifications of Participation Contracts
Resource: Ch. 8 of Medical Insurance: An Integrated Claims Process Approach (6th ed.).
Write a 350- to 700-word paper that discusses how participation contracts represent financial opportunities for providers. What are positive and negative ramifications of discounted fee-for-service arrangements?
Format your paper according to APA guidelines.
Click the Assignment Files tab to submit your assignment.