vPrimary and secondary payer status depends mainly on whether the insurance policy that lists the patient as the subscriber, insured, or dependent on the primary insurance plan. Medicare secondary payer generally is used when the Medicare program does not have primary payment responsibilities. Primary payers are those that have primary responsibility for paying a claim. There are many types of secondary and primary payers. The types of primary payers would consider to available under the dependent or nondependent rule, the subscriber rule, the birthday rule, and also the custody rule. The types of primary payers can also be considered as secondary payers. The possible errors that can occur on claims as a primary and secondary payers are consisted …show more content…
As a billing specialist, I would have to correct and resubmit the claim in order to be paid if the claim is rejected. If the claim is denied the claim, the claim has been through the claim process and is usually determined by the insurance payer that it cannot be paid. The claims are usually require an appeal by submitting the required information or correcting and resubmitting the claim afterwards. Some claims will have to be required an appeal letter to be submitted. The letter should clearly state to the insurance payer why the denied charges should be reconsidered. It should include every last specific claim data and documentation. The claims data and documentation that it would include would be supporting notes, lab results, or some other source of document. The billing specialist may also try calling the insurance company first if possible. There are many representatives that can be very helpful in handling and resolving many types of claims that has errors that has been rejected or denied. Before filing an appeal on the claim with the insurance claim, check out the contract with provider with the insurance carrier to have a great and even better understanding of the appeals process. Many insurance payers have little criteria and way of a lesser time periods for appealing claims. If a claim need to be submitted due to a corrected claim, it would be the billing specialist job to make a note on it that is has been corrected when sending it through paper, or attach a letter stating what correction were made to the
Overall, the work performed to test the relevant financial statement assertions and the evidence gathered has led our audit team to conclude that the confirmation issues encountered may signify that a potential for material misstatement exists. For example, the existence of a line of credit in one of the Financial institutions indicates that we need to perform further investigation to assess the reliability of the findings.
& Torrens, page 205). As for as the hospital, Medicare and private insurance are the primary
One of the biggest contributors to health care costs that I have seen during my time in the healthcare industry is insurance fraud. One example of such fraud came about two months ago. I was taking a phone call from a provider that was upset that one of their claims had denied even though all of their previous claims had been paid. In researching with a partner plan it was determined that the claim denied because this medical provid...
Fraud is putting the wrong information or up codding the codes on the claim form. This can be done by the doctor, biller and coder, and the patient selling their insurance number to false company. The false company can bill the insurance company, for false information whether it is services, medication,
Medicare and Medicaid are one of important government programs. According to Medicaid.gov site, there are more than 4.6 million low-income seniors enrolled in Medicare and about 8.3 million people that are enrolled in both Medicare and Medicaid. Anyone that enrolled with Medicare and limited income and resources are eligible to get assistance paying for their premiums and out-of-pocket medical expenses from Medicaid. Not only does Medicaid cover additional services, but, services covered by both programs are first paid by Medicare with Medicaid in the difference up to the state’s payment limit (Medicaid.gov, 2015) .
Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities and people of any age with End-Stage Renal Disease. There are four subcategories of Medicare. Part A is for hospital stays or, with certain restrictions, at-home care for a limited number of days. Part B is more like regular medical insurance. It covers ambulatory care and physician fees. There is a deductible and are sometimes co-pays as well. Part C is presented as an alternative to parts A and B. It is where private insurance companies can contract with the federal government to offer Medicare benefits through their own policies. It can offer benefits not covered under original Medicare, although there might be a premium charged. Part D is the prescription plan for enrollees. (Centers for Medicare and Medicaid Services, 2010)
The second option is Medicare Advantage Prescription Drug Plans (MA-PDs). MA-PDs offer hospital, medical and prescription drug coverage under one policy, perhaps an HMO or PPO. “To join a Medicare Advantage plan, you must have Part A and Part B” (Medicare & You 2014).
There are four components to the Medicare program, part A, B, C and D. Part A of Medicare covers in patient hospital services; patients have a financial responsibility to cover a deductible that is equivalent to 1 day of hospitalization, thereafter cost is covered at 100 percent for a maximum of 60 days. This also includes nursing facilities, home and hospice care. Part B covers outpatient surgery and physician office visits. This is an elective component of Medicare in that there is a premium associated with this plan that is paid for directly through social security payments. Part C is know as Medicare Advantage and is a supplemental policy that is purchased directly from employers; one may be denied for health reasons depending one when the plan is acquired. Part D is prescription drug coverage that is eligible to all individuals that qualify for Medicare. Beneficiaries of the Medicare choose which prescription plan they want and pay a corresponding monthly premium.
Medicare and Medicaid together "are the single biggest contributor to [the United States] long term [budget] deficit." This idea was expressed by President Obama during his 2011 state of the Union Speech. After saying this, the president said that health care costs need to be reduced, including these two services. Medicare and Medicaid are beneficial to those who receive their services, and the criteria for eligibility currently allow many to qualify for either program. This is most likely the cause of the major deficit that the president spoke of. However, downsizing or eliminating these programs to lessen the deficit will affect many people and their ability to receive healthcare.
These requirements overlap between the two and some beneficiaries do qualify for both benefits. This means that Medicaid is sometimes used to help pay for Medicare premiums and those who do quality for both programs are considered to be “dual eligible” and will usually enroll in both programs in order to cut personal costs. Medicare and Medicaid both have their financial woes, each have their burdens, a...
Most people do not make enough income to afford healthcare services short of the help of third party payers. Third party payers supply the bulk of medical payments. There are three parties involved in Physician and hospital reimbursement: the patient, the provider, and the insurance company that compensates the providers on behalf of the patient. Third party payers can be very competitive and the terms can either be simple or complex when it involves contract negotiations between physicians, hospitals. Physicians and hospitals should be familiar with negotiations, terms, and payment schedules.
The three main types of health insurance in the United States are voluntary, social and welfare. These types on insurance a person possess sometimes determine the ability to seek care and how that care is given. Insurance types such as voluntary and social insurance can be very expensive and will make participants consider how important it is for them to see the doctor, while welfare medicine participants have trouble finding a doctor due to the limit number of physicians who are provider or are refusing to take on new patients. Some of the types of voluntary insurance are Blue Cross and Blue Shield (BCBS), private and commercial insurance, and health maintenance organizations. Voluntary insurance is not only limited to health care from physicians, but can also include dental, long-term, and life insurance. One of the most popular voluntary insurance companies is BCBS. Sometime people have trouble paying for insurance especially if is as it related to an on the job injury or because they have reached retirement age and can no longer work.
Medicare is a federally governed insurance program, primarily serving Americans over the age of 65, younger disabled meeting specific disability criteria, and dialysis patients having permanent kidney failure. Medicare is linked to Social Security, is not income based, and is available to every American meeting the requirements of the program. Those entitled to Medicare can select Original Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) paying co-insurance and deductibles or opt to add Part C (Medicare Advantage Plans) paying a monthly premium and co-payments normally less than the out-of-pocket expenses for Original Medicare.
In the case of Norton vs Argonaut Insurance Company there are many factors which impacted the court’s ruling as to the parties who were responsible resultant wrongful death of the infant Robyn Bernice Norton. The nurses, doctors(independent contractors) and the the hospital though not formally charged
Medicare is a national social insurance program, run by the U.S. federal government since 1966 that promises health insurance for Americans aged 65 and older and younger people with disabilities. Being the nation’s single largest health insurance program, covering a large population for a wide range of health services, Medicare's funding is a fundamental part of it sustainability. Medicare is comprised of several different parts, serving different purposes, some of which require separate funding. In general, people at the age of 65 and older who have been legal residents of the United States for at least 5 years are eligible for Medicare. Same is true with people that have disabilities under 65, if they receive Social Security Disability Insurance benefits. Medicare involves four parts: Part A is hospital insurance. Part B is additional medical insurance, that Part A doesn't cover. Part C health plans, also mostly known as Medicare Advantage, are another way for original Medicare beneficiaries to receive their Part A, B and D benefits. Medicare Part D covers many prescription drugs, some of which are covered by Part B. Medicare is a major operation, not only needing adequate administering but the necessary allocated funds to keep this massive system afloat.