To whom may concern, I am returning the bill # --- for $81,305.97 for the following reasons: First, our health insurance company already paid several of the services Carle is billing us, which means that Carle is billing us for services that are already covered by our insurance company. As the table below shows, Carle’s billing does not include all the payments from HCC Medical Insurance to Carle Foundation Hospital. This omission signifies you are wrongly charging us $5,375.03 that we totally rejected. According To Carle´s Billing Paid for HCC Medical Insurance Description Service Charge Amount Payments Insurance Patient Balance Due Payments Insurance Patient Balance Due Double Billing Emergency $2,683.20 $0.00 $2,683.20 $2,146.56 $536.64 $2,146.56 …show more content…
Champaign Surgicenter $4,977.28 $753.35 $4,223.93 $3,981.82 $995.46 $3,228.47 Orthopedics and Sport Medicine Radiology $1,084.00 $867.20 $216.80 $867.20 $216.80 $0.00 $8,744.48 $1,620.55 $7,123.93 $6,995.58 $1,748.90 $5,375.03 Please, find attached the explanations of benefits sent by HCC Medical Insurance.
Indeed, the documents provide the details of what services HCC has covered so far, the amount it has considered, the checks’ numbers, and their dates. Second, in the page 5/6 in the bill we have received from you, Carle Foundation Hospital suggests us to apply to the “Carle Financial Assistance” program. However, Carle Foundation Hospital already approved 100% of coverage under the program, as the letter we received from you in [date] states. Therefore, as the Carle Financial Assistance program has approved our application, we understand that the balance of $1,748.90 indicated in the table above should be covered by the CFA. So, we assume that your letter inviting us to apply to financial assistance is a mistake and not a bad joke. You can find attached the letters we have received from you showing you have approved our financial assistance between November 2016 and November …show more content…
2018. Third, as we diligently informed you through a letter [date], we appealed to the first decision of our insurance company denying coverage derived from our son’s medical expenses.
Indeed, we repeatedly have informed to Carle Foundation (by phone, by letter, and personally in their offices) that HCC rejected covering my son’s accident because it wrongly labeled as a sports injury when it was not. We want to clearly insist that this was the reason the company rejected the medical coverage and not our supposedly lack of diligence on providing HCC all the required information, as Carle Foundation several times has stated in our communications. On the contrary, since the same day of my son’s accident, we called, uploaded, and mailed all the information we had to both HCC and Carle Foundation in order to facilitate all the process as smoothly as it could be under circumstances such a son’s injury. Believe us: More than anybody, we want that our health insurance company provides the coverage it must, as sooner as it could
be. Our appeals are still in process, as you could check regarding the payments HCC has started to approve. However, there are still other expenses under review and HCC has not back to us yet with a decision. And even if the company reject covering medical services that they are still evaluating, we have the right to appeal to a state level, disputing any eventual rejection from our company. Therefore, there is no reason that Carle Foundation Hospital continues sending billings which coverage is still under revision and, overall, there is no reason that Carle Foundation Hospital is not applying the Carle Financial Assistance coverage regarding these expenses. Indeed, we sent a letter asking for reviewing the Carle’s decision of not applying the financial assistance, providing every single documentation that we had by that time. Nonetheless, Carle has not even replied to our letter. Even more: As we have mentioned, in the last billing we received, Carle is even suggesting we should apply to its financial assistance program.
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
The first step is to pre-register the patient's insurance information into the computer system and making a copy of their insurance cards. The patient's insurance information would then be verified. The patient would then be seen by a medical professional to examine the patient, discuss any test results or provide a diagnosis. Once the patient is ready to check out any payment due would be collected. The medical coder would then go over the patients' medical record and assign any diagnosis codes or procedural codes and then a claim form (CMS 1500) would be completed and submitted. The payment would also receive and posted at this time and document in the patient's record. The CMS 1500 will information from the patient, including the type of
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
Another downfall to HMO coverage is selective-contracting. This is a process where hospitals deny treatment to patients because their...
As a Medical Biller and Coder, you will submit claims to third-party payers for reimbursement of services rendered. Try to set up your claim to be payer specific because you want the claim to be paid after the first submission. There are remittance advices sent to the Medical Biller and Coder from the third-party payer that help to inform you if the claim has been denied, paid, or pending. If your claim has been denied or pending than you can begin your investigation to figure out the reason(s) for the nonpayment of services rendered.
There are numerous amounts of billing codes within the Medicare system. Many have the same codes to one medical piece of equipment. If a biller tries to make a claim for a device, such as a wheelchair and walker, and the claim was denied based on excessive usage of that particular code because of its geographic region, then the biller can easily resubmit the claim using an alternative code that will allow the claim to go through with minor alternations to the device (AGHAEGBNO, 2001). The biller can complete this task several times until the claim is satisfied. The biller can also bill for services that were not provided in order to receive higher payments from health care providers. These are forms of multiple, double and improper billing abuses that are defrauding the system tremendously. Health care claims are coming in quickly and some payments are even expedited and reused to medical provide...
In order for any health care system to be stable in their revenue cycle, it has to post charges for procedures and care provided. If these charges are not posted correctly, the payments may be affected, resulting in less income than what the system is actually owed. Clearly, without any service being provided, there is no revenue to begin with, but if the charges are not captured, a service can be provided and not billed for (Cleverley & Cameron 2007). This means the health care system provided free care or services to a patient. In order to capture care charges, health care organizations use codes for each type of procedure provided. Because the health care industry is so complex, capturing said charges is also complex and most charges are broken down in order to prevent complex bills. The way charges are broken down is by using codes for the services rendered. Each procedure has a special code and each code is assigned a price, making billing less complicated. Coding also allows health care systems to document each procedure in order to prevent payment denials or delays from the payer (Thompson & Barrett 1993).
This letter went to explain our mission statement and our goal requesting their help in the building of our skatepark which is located in the local community. We were seeking any type of donation these larger companies would provide us with following this letter. Once we meet the towns basic criteria and with an architect stamped design in hand, we began the process of having the recreation board vote on approving our skatepark. The recreation board would then present it to the town board requesting their approval. At this point, all we would be waiting upon would be the funds. Unfortunately, the application process for grants were much more intense requiring all the criteria we used for the towns approval plus more. Once we have all the necessary documentations we must wait for the application date to submit our request. We then await the foundations and answers to begin out
Through a series of laws, Louisiana has established a Patient’s Compensation Fund (PCF) that automatically covers all state health care providers. The fund is designed to compensate patients who suffered loss, damages and expense because of professional malpractice by a health care provider who is a member of the fund. Private providers may join the Fund as long as they meet few requirements. The revenue is generated through surcharges paid by private healthcare providers, including hospitals, physicians, nursing homes, chiropractors, optometrists, dentist, oral surgeons and nurses. Damage caps in medical malpractice cases are based on joining the PCF. Recovery against a health care provider is limited to $100,000 per patient plus interest per patient per incident. Anything in access of this cap is placed in the patient care fund. A total recovery in medical malpractice cases is limited to $500,000 plus the cost of any future medical expenses. The PCF pays for any future medical expenses directly (Dekaris, Mims,
Based on the documentation submitted, from 06/15/2017 through 07/04/2017 and 07/07/2017 through 08/28/2017, the claimant does not have functional impairments. As it relates to hypertension, fatigue, and hyponatremia, according to the provider, the physical findings were suggestive of a cerebrovascular disease affecting the left hemisphere which was a complication of her hypertension. However, there was insufficient objective evidence to substantiate a severe functional impairment during the period of review. Although she had an elevated blood pressure measurement (ranged from 152/90 to 190/110 mmHg), the report dated 07/19/2017 stated that she was feeling better overall. Her laboratory testing dated 08/04/2017 were within normal limits and the appropriate conservative options were provided (Amlodipine, Apresoline,Clonidine, Aspirin). As it relates to her hyperglycemia, the most recent laboratory testing revealed a glucose level of 88 (normal). As it relates to osteopenia, the Bone Density test only revealed mild bone thinning and according to the provider, her calcium level was just slightly elevated. As such, the claimant is not considered disabled from 06/15/2017 through 07/04/2017 and 07/07/2017 through 08/28/2017, strictly from the perspective of Internal
Analyzed account balances on patient accounts to determine if payments had been received and applied correctly based on the explanation of benefits that have been received from patients insurance.
Then, patients have the choice of paying at POS or paying later (Butcher, 2015). For uninsured patients, the estimation tool automatically raises the discount program. Baptist Health incorporates a 40 percent reduction from the full amount (Butcher, 2015). However, numerous patients cannot bear the high costs of health care services, even at a reduced rate. In this case, patients at Baptist Health are referred to a registrar who uses a four-question study to determine if a patient qualifies for Medicaid (Butcher, 2015). If a patient does not qualify for Medicaid and cannot bear the estimated costs, he or she is referred to a financial counselor to apply for charity care (Butcher,
Let’s briefly review the steps of the medical billing procedure leading up to the transmission of an insurance claim. When a patient receives services from a licensed provider, these services are recorded and assigned appropriate codes by the medical coder. ICD codes are used for diagnoses, while CPT codes are used for various treatments. The summary of services, communicated through these code sets, make
Submit your reimbursement claim in the Web office with all necessary documentation, make sure that you submit the correct receipt, or not submit the same receipt more than once.