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Introduction to Medical Billing and Coding for Interns and Residents - Part 1 - Medical Insurance

Mar 22, 2024
In this video series, I'm going to teach you the basics of

medical

billing

and

coding

for

interns

and

residents

, really important skills to have to make sure you get paid what you're worth and that your patients get the best care possible, by the way, I'm Victoria, I'm a

medical

coding

auditor educator and content creator, and on my channel I provide tips, tricks, and tutorials to help you succeed in a medical coding career now if you're not an intern or resident or maybe even an advanced practitioner who you did not gain any knowledge about medical

billing

and coding through your education and you are simply someone who is considering medical billing and coding as a career, go to my free medical coding masterclass at medicalcodingmasterclass.com and that will give you all the information about the boxes you need to check to start your career as a medical billing coder.
introduction to medical billing and coding for interns and residents   part 1   medical insurance
It will give you the complete roadmap of how to go from someone who has no experience in medical billing and coding to someone who is ready to work in medical billing and coding in as little as six months simply takes all that guesswork out and then tells you about the program that I found to be very tasteful and that will give you everything you need to be successful in a career. medical billing coding, it is self-paced and very affordable, so definitely check out the free masterclass at medicalcodingmasterclass.com. I'll also link it in the description below to understand medical billing and coding, one of the first concepts you'll learn about.
introduction to medical billing and coding for interns and residents   part 1   medical insurance

More Interesting Facts About,

introduction to medical billing and coding for interns and residents part 1 medical insurance...

We'll need to understand

insurance

, so let's first talk about the different types of

insurance

, and most importantly Medicare. Medicare is available to patients over the age of 65 and then there are certain qualifying medical conditions for which patients can have Medicare, such as stage kidney disease. It is funded by the federal government. It is highly regulated. There are many different audits and checks and balances. They are carried out in the Medicare program and there are four different

part

s of Medicare Part A, B, C and D. Medicare Part A covers your inpatient hospital stays, patients who are admitted to the hospital and pay for things like their room and board and use of staff and medications while they are in the hospital.
introduction to medical billing and coding for interns and residents   part 1   medical insurance
Medicare Part B is for your provider based services your preventive visits your office visits if you're having things like having a surgeon do surgery on you, it's all covered under Medicare

part

b. Medicare Part C are those replacement plans, those plans that, even though the patient is maybe 65 and qualifies for Medicare, they want you to know what I want, something that will cover it. a little more be a little more solid maybe you have a better network better coverage and they have chosen to pay for a replacement plan actually more than half of Medicare beneficiaries choose to enter a replacement plan and that number is expected to increase more or less over the years and it's because they get additional things that maybe Medicare doesn't cover like for example Medicare doesn't cover a traditional head to toe physical exam, they cover like a wellness exam but they don't really cover head to toe like that. physical exam of the toes that we traditionally think of, so more and more patients are choosing to buy a Geisinger gold or a senior blue or a Highmark Blue Journey or whatever some of these replacement plans are called these days and, Sometimes, they get these interesting benefits like silver slippers if you have ever heard of silver slippers?
introduction to medical billing and coding for interns and residents   part 1   medical insurance
It's a fitness program where maybe as part of their package they can go to their local YMCA and work out, and that's included in their Part C plan and then Medicare Part D is for prescription drug coverage. Now there's a There's a lot to manage with Medicare, so CMS CMS is the center for Medicare and Medicaid, which we'll talk about the Medicaid center for Medicare and Medicaid services, and they have these regional administrative contractors, what they call Max or Medicare, which help manage certain regions so that these Medicare contractors, these Macs take the Medicare regulations, maybe areas that are gray, and help interpret them and how they will implement them in that region, so it is possible You might see slight differences in policies by region and that's why it can be confusing if you go to, say, a big vendor conference and you meet someone who's in a different region, they might say, Hey, you know I built this in a certain way and it is covered and you may not get coverage for it in your area. either you may have to use a different diagnosis to cover it or you may be covered with a diagnosis that you don't cover it with because of some of those different regional differences and we see that with our commercial insurance programs.
Also what we're going to talk about now I mentioned Medicaid Medicaid is a program for people who don't meet a certain income threshold, they're usually low income patients and often state programs have Medicaid programs that will cover children who don't. They have Otherwise, insurance too and some patients qualify for Medicaid due to various disabilities they have. Medicaid is always the last payer, so if a patient has any other insurance that she can pay first, Medicaid will always pay last and unfortunately will also pay. At least that's why you see some providers who choose not to accept Medicaid patients because they don't receive good reimbursement for many of those services.
There's also Tricare Tricare is for military service members and their dependents and then we have what we call our commercial insurance plans, those are their Highmark Capital Cigna UHC Aetna programs and they include programs that you can purchase on the Health Care Law Marketplace Low Price but of course most of them are programs that patients get through their employers, some of these programs can have very high copays and deductibles so let's look at some of those terms so that a copay is a payment which is done when a service is provided and the patient is responsible for things like an office visit, which could be a 20 copay that the patient has to pay or if they are going for urgent care, it could be fifty dollars, if they go to the emergency room, it could be a hundred dollar copay, but then certain things, like preventive exams, insurance often wants you to have them so that it's a zero dollar copay if you have a preventive exam or an exam annual gynecological exam and the co-payment does not count towards the patient's deductible.
The deductible is the amount of money a patient has to pay each year before their insurance begins to pay for Services. Some patients have ridiculously high deductibles, like thousands of dollars each year. If you have ever visited the Insurance Marketplace, you can see that there are many different programs available and they often have very high deductibles because the patient does not have to. pay such a high premium for that insurance that it's like their monthly payment for having that insurance policy, so maybe they only have to pay eighty dollars a month, but they have a deductible of ten thousand dollars before their insurance pays anything else services or sometimes they work with an employer that just doesn't have great coverage, they spend little money on health insurance, so you know if that patient has a high deductible of five thousand dollars and you know their child falls out of a tree. and they think they have a broken bone and they go to the emergency room and get all kinds of year and then at the end of December your child has an accident or gets seriously ill and that happens again on January 1st maybe they have to go for follow-up tests they're going to owe them five thousand dollars December and then when that starts again in January, they hear that they will owe that other five thousand dollars again and then we have coinsurance, now coinsurance is very different than copayment or deductible, so coinsurance is a percentage that a patient is responsible for for a covered service once have paid their deductible, then let's say you go to an office visit, the office visit costs one hundred dollars and the patient's coinsurance is 20, then let's say a patient's health insurance pays one hundred dollars for an office visit and that the patient's coinsurance is 20 if you have already met your deductible, you will be responsible for 20 of that hundred dollars or twenty dollars, the insurance company will pay the rest, that 80 percent or eighty dollars of that hundred dollars, visit now If that patient has not yet paid their deductible that year, then that entire hundred dollars will be the patient's responsibility because it will go toward their annual deductible.
Now let's transition and talk a little bit about some of those special permissions that an insurance company looks for, let's start with the referral, so some insurance companies will say, "Hey, if you want to see a specialist, you first have to designate a specialist." primary care doctor and ask them to refer you to the specialist, so if a patient has some kind of problem with their sinus they can't just go directly to the ENT doctor, they have to go to their primary care doctor, they say they have problems and the primary care doctor has to refer them to an ENT and then we have prior authorization, we see this as a lot for things like if a patient has to have expensive surgery, the insurance company wants to know in advance, so they want to be told send all that information, what diagnosis this patient has, what service you plan to provide and then they'll look at it and say is it something we're going to cover or could they say, "Hey, have you tried maybe these less invasive, less expensive procedures before Let's go ahead and cover this really expensive surgery?" You may want to see some documentation that a patient had knee injections or tried physical therapy before going straight to a joint replacement, so someone will need to call or go online and submitting the diagnosis codes, the CPT codes and getting that prior authorization. and since insurance companies like to say that they don't deny the patient from having that procedure, they simply refuse to pay for that patient's procedure and it's worth noting that it also gets complicated if there is a change in the procedure planned, like maybe we sent everything with codes for a laparoscopic surgery but then the patient had adhesions or there was some kind of problem, we had to open them, that's a different CPT code, we'll talk about coding in the next video, which means that that prior authorization was for something different and that can cause a bit of a mess in the end trying to get it corrected and insurances also have coverage policies so just because a patient has insurance doesn't mean everything under the sun will be covered, and even if it were. covered, there may be certain stipulations, often you will see that they have covered diagnoses, so an insurance company might say we cover this procedure, but only if the patient has one of these diagnoses on this list.
An example could be if a patient has one eye. Eye lifts are often performed for cosmetic purposes, so health insurance will not cover a cosmetic procedure, but there are many non-cosmetic reasons why a patient might have a drooping eyelid if the skin droops toward the eye and causes it. obstructs your vision, often in those cases where there is a medical condition that is very well documented, we have done visual field testing, we have all the documentation that says, hey, you know this is not cosmetic, it is definitely medically necessary. Medicare, for example, will cover them if they qualify. those qualification criteria, but we need those formal evaluations, we need the documentation of the formal evaluations and that will have to go to them for review and approval because unfortunately there have been providers in the past and there will continue to be in the future.
They abuse the system and another thing to keep in mind about insurance companies is that they don't always necessarily cover exactly the same things across the board, so a patient may have a policy with insurance that covers something like bariatric surgery. , but another patient may have coverage. through the same insurance, but has a different policy where they exclude it and say we're not going to cover this. You know, we just don't want to have to pay for it and that could be because maybe his employer ripped him off. above they said hey we want a cheaper plan so let's eliminate this and this and this and we're not going to cover them so we can get the cheapest plan and even though maybe they both have Cigna or they both have a high rating because they have different policies, one of them may have coverage for a service, another may not.
Now, in the next video, we're going to talk about the different sets of medical codes and how they influence coverage documentation and payment, but in the main time. Don't forget that if you are interested in a careerin medical billing and coding, which is a very popular work from home job, I will tell you that you can attend my free master class at medicalcodingmasterclass.com to learn all about medical professional information. In the meantime, billing and coding, don't forget to like, share and subscribe. I'll see you in the next video and until then keep coding.

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