Legal Aspects of Health Care Administration 14th ed., 2023, Jones & Bartlett Learning, (ISBN: 9781284231526).
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Case 13.2 Calculating Insurance Math Patient ID Patient Name Plan Date of Service Procedure Provider Charge Allowed Amount Patient Payment (Coinsurance and Deductible) Claim Adjustment Reason Code PROV PAY 537-88-5267 Ramirez, Gloria B. R-1 02/13/2018–2/13/2018 99214 $105.60 $59.00 $8.85 2 $50.15 348-99-2537 Finucula, Betty R. R-1 01/15/2018–1/15/2018 99292 $88.00 $50.00 $7.50 2 $42.50 537-88-5267 Ramirez, Gloria B. R-1 02/14/2018–2/14/2018 90732 $38.00 0 $38.00 49 0 760-57-5372 Jugal, Kurt T. R-1 02/16/2018–2/16/2018 93975 99204 $580.00 $178.00 $261.00 $103.00 $139.15 $15.45 12 $121.85 $87.55 875-17-0098 Quan, Mary K. PPO-3 02/16/2018–2/16/2018 20005 $192.00 $156.00 $31.20 2 $124.80 TOTAL $426.85 The preceding RA has been received by a provider. A. LO 13.5 What is the patient coinsurance percentage required under plan R-1? B. LO 13.5 What is the patient coinsurance percentage required under plan PPO-3? C. LO 13.5 What is Gloria Ramirez’s balance due for the two dates of service listed? D. LO 13.5 Kurt Jugal’s first visit of the year is the encounter shown for DOS 2/16/2018. What is the patient’s deductible under plan R-1? (Hint: Because the deductible was satisfied by the patient’s payment for the first charge, that payment was made up of the deductible and the coinsurance under the plan.) Case 13.3 Using Insurance Terms Read this information from a Medicare carrier and answer the questions that follow. E&M services rendered in a private residence are correctly billed with CPT codes 99341–99345 (new patients) and CPT codes 99347–99350 (established patients), home services. These CPT codes are payable only in home settings, that is, place of service 12. National Government Services has seen many instances of providers billing outpatient/office codes in home settings. Home visits should not be reported with E&M codes 99201–99215, which represent office and outpatient services. A. LO 13.3 Based on Table 13.2, what claim adjustment reason code will result if this code is billed 99201, POS 12? B. LO 13.3 Which Remark Code would appear, N210 or N211?
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Case 4-7 Investigating Privacy Violations: There have been several potential privacy incidents reported to your facility in the past week. Your job is to investigate these incidents to determine if they are truly privacy violations. If there are violations, decide what should be done. Research each of the privacy incidents described in the following list. Determine which ones are privacy violations. Determine to whom the privacy violation should be reported to and the timing required for the notifications. Identify the specific action(s) appropriate to address the following situations. 1. Some alcohol and drug abuse records were inadvertently left accessible via the internet. Fifty patients were affected. 2. A patient overheard a physician telling another patient’s family that the cancer has spread to the surrounding lymph nodes. The physician was talking in a low voice in a corner of the hallway. 3. A hacker accessed the lab system and viewed multiple records. 4. A single form from a different patient was sent to the requesting patient. 5. A computer was not logged off and a visitor looked up his mother’s PHI. 6. A monitor is turned toward the reception desk so that anyone who is walking by can see it. 7. A patient complained that his ex-wife looked at his record and told his girlfriend that he had human immunodeficiency virus (HIV). 8. A patient’s lab test was left lying out on the counter of the staff workroom. Staff were in and out of the room all day. 9. A patient’s radiology report was left lying out on the counter of the nursing unit, patients and their families walked by this counter and also came to the counter to talk to staff.
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