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Learning Plan 2

Assignments

LP2.1 Assignment
COMPLETE the LP2.1 Assignment: Apply Third Party Guidelines.
Download the attached worksheet: Apply Third Party Guidelines.
Complete
worksheet based on Activities 1, 2, 3, 4, 7, and 12 in Chapter 4 of
your Guide to Medical Billing Text starting on page 65.  
NOTE—It is recommended
to complete activities in your textbook, then transfer the data to the
worksheet. This does not bind you to a computer.

Submit this
assignment to your instructor via the dropbox “LP2.1 Assignment: Apply
Third Party Guidelines.” This assignment is worth 113 points (1 pt.
each).

Scoring Guide (113 Points)

Rating Scale
113-101 Work meets or exceeds criterion at a high level of competence.
100-90 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
89-79 Criterion partially met, but one or more important concepts/skills are missing or flawed.
78-67 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
66-0 Criterion not met or work is absent.

 

Criteria
1. Completed Activity #1 (6 pts.)
2. Completed Activity #2 (15 pts.)
3. Completed Activity #3 (39 pts.)
4. Completed Activity #4 (14 pts.)
5. Completed Activity #7 (5 pts.)
6. Completed Activity #12 (34 pts.)

LP2.2 Assignment
COMPLETE LP2.2 Assignment: Medicare & Medicaid Guidelines.
Download the attached LP2.2 Assignment template for Medicare and Medicaid Guidelines.
In this assignment you are to use the readings from Chapter 5 in the
Guide to Medical Billing and prepare a typed, one (minimum) page paper
discussing the following points as if you are providing an overview for a
potential employer:
Include the following:

  • Compare and contrast Medicare and Medicaid.  Where does the money
    come from in order to support these plans?  Who governs each?  What is
    the purpose served by each? Are these plans “insurance” plans or do they
    fall under other categories?
  • For Medicare:
    • Define the eligibility requirements.
    • What is the difference between a Medigap plan, Supplemental plan, and Medicare replacement plan?
    • What are the guidelines for collecting from Medicare recipients?
    • What does it mean when a provider says she “accepts assignment?” 
      Can this effect how much the patient pays out of pocket?  Can a patient
      see a provider that is non-participating and have Medicare reimburse the
      patient directly? If so, under what circumstances?
    • Can Medicare be a primary payer if other commercial insurance is on
      file and be filed for reimbursement first or does this fall under the
      rule of Medicare as Secondary Payer (MSP)?
    • What time frame does a provider have to file a claim and have it deemed payable?  Are there exceptions?
    • Under an appeals process, what are the six levels?  Must they be followed in order?
  • For Medicaid:
    • Define the eligibility requirements.
    • What are the guidelines for collecting from Medicaid recipients?
    • What does it mean that Medicaid is the “payer of last choice?”
    • What are at least three services requiring a Treatment Authorization Request (TAR)?
    • What is the Early Periodic Screening Diagnosis and Treatment program (EPSDT) and what are the benefits?
    • What time frame does a provider have to file a claim and have it deemed payable? Are there exceptions?
    • How often are updated benefits/ eligibility cards sent to the recipients?
  • What are common reasons for claim denials for “medically
    unnecessary” and how does this affect the patient paying out of pocket
    for both Medicare and Medicaid recipients, i.e. Durable medical
    equipment like ace bandages or shoe lifts?

The paper will include the following guidelines:
1. Double spaced
2. 12 point font
3. 1 inch margins
4. Separate title page

Submit this assignment to your instructor via the dropbox “LP2.2
Assignment: Medicare and Medicaid Guidelines.” This assignment is worth
20 points.

Scoring Guide (20 Points)

Rating Scale
5 Work meets or exceeds criterion at a high level of competence.
4 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
3 Criterion partially met, but one or more important concepts/skills are missing or flawed.
2 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
1-0 Criterion not met or work is absent.

 

Criteria
1. Paper addresses guidelines for Medicare.
2. Paper addresses guidelines for Medicaid.
3. Paper addresses common reasons for claim denials for “medically unnecessary.”
4. Paper was submitted per guidelines: double-spaced, 12 pt. font, 1 inch margins, and separate title page.

LP2.3 Assignment
COMPLETE the LP2.3 Assignment: Complete Calculations for Participating Provider.
Download the attached worksheet for LP2.3 Assignment
to complete calculations for Deductible, Co-Insurance, and Allowables
for Participating Provider.  Complete the worksheet.  This assignment
will gauge your understanding of calculating differences based upon a Participating Medicare Provider

Submit this assignment to your instructor via the dropbox “LP2.3
Assignment: Complete Calculations for Participating Provider.” This
assignment is worth 5 points.

Scoring Guide (5 Points)

Rating Scale
5 Work meets or exceeds criterion at a high level of competence.
4 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
3 Criterion partially met, but one or more important concepts/skills are missing or flawed.
2 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
1-0 Criterion not met or work is absent.

 

Criteria
1. Completed Calculations for Participating Provider.

LP2.4 Assignment
COMPLETE the LP2.4 Assignment: Complete Calculations for Non-Participating Provider.
Download the attached worksheet for LP2.4 Assignment to
complete calculations for Deductible, Co-Insurance, and Allowables for
Non-Participating Provider.  Complete the worksheet.  This assignment
will gauge your understanding of calculating differences based upon a Non-Participating Medicare Provider.

Submit this assignment to your instructor via the dropbox “LP2.4
Assignment: Complete Calculations for Non-Participating Provider. This
assignment is worth 5 points.

Scoring Guide (5 Points)

Rating Scale
5 Work meets or exceeds criterion at a high level of competence.
4 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
3 Criterion partially met, but one or more important concepts/skills are missing or flawed.
2 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
1-0 Criterion not met or work is absent.

 

Criteria
1. Completed Calculations for Non-Participating Provider.

LP2.5 Assignment
COMPLETE the LP2.5 Assignment: Post Medicare and Medicaid payments.
Download the attached worksheet for LP2.5 Assignment
to Post Medicare and Medicaid payments to a ledger.  Complete the
Ledger based upon Medicare and Medicaid Remittances.  This assignment
will gauge your understanding of documenting within the ledger from
primary and secondary payers.

Submit this assignment to your instructor via the dropbox “LP2.5
Assignment: Post Medicare and Medicaid payments.” This assignment is
worth 20 points.

Scoring Guide (20 Points)

Rating Scale
20-18 Work meets or exceeds criterion at a high level of competence.
17-16 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
15-14 Criterion partially met, but one or more important concepts/skills are missing or flawed.
13-12 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
11-0 Criterion not met or work is absent.

 

Criteria
1. Completed Medicare and Medicaid payments postings to ledger.

LP2.6 Assignment
COMPLETE the LP2.6 Assignment: Complete Preauthorization/Precertification Form.
Download the attached worksheet for LP2.6 Assignment
to Complete the Preauthorization/Precertification Form.  Fill in all
HIGHLIGHTED areas by using Patient and Insurance info listed in Appendix
A (Make sure you sign and date as well).

Submit this assignment to your instructor via the dropbox “LP2.6
Assignment: Complete Preauthorization/Precertification Form.” This
assignment is worth 10 points.

Scoring Guide (10 Points)

Rating Scale
10-9 Work meets or exceeds criterion at a high level of competence.
8 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
7 Criterion partially met, but one or more important concepts/skills are missing or flawed.
6 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
5-0 Criterion not met or work is absent.

 

Criteria
1. Complete Preauthorization/Precertification Form.

LP2.7 Assignment
COMPLETE the LP2.7 Assignment: Workman’s Compensation Overview.
Download the attached worksheet for LP2.7 Assignment
template to complete the paper for Workman’s Compensation Overview. In
this assignment you are to use the readings from Chapter 6 over
Workman’s Compensation in the Guide to Medical Billing to prepare a
typed, one-half (minimum) page paper discussing the following points as
if you are providing an overview for a potential employer:
Include the following:

  • The form that the patient is responsible for presenting.
  • The reports the Treating Physician is responsible for presenting to whom, how often and how many.
  • How the medical record of an injured worker is maintained.
  • Who is the contract for services between?
  • What is a lien and what is its purpose?  What is the process for getting one?
  • What does it mean for a claim to be “adjudicated?”  What can cause delays in the process?
  • What is the process if the Workman’s Compensation claim is deemed not payable and reversed?
  • If the claim is denied, describe the sensitive nature of how to
    communicate with the patient to obtain additional information for
    billing purposes, either to the patient or other third party payer.

Submit this assignment to your instructor via the dropbox “LP2.7
Assignment: Workman’s Compensation Overview.”  This assignment is worth
10 points.

Scoring Guide (10 Points)

Rating Scale
5 Work meets or exceeds criterion at a high level of competence.
4 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
3 Criterion partially met, but one or more important concepts/skills are missing or flawed.
2 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
1-0 Criterion not met or work is absent.

 

Criteria
1. Paper addressed specific guidelines noted above for Workman’s Compensation Overview.
2. Paper was submitted per guidelines: double-spaced, 12 pt. font, 1 inch margins, and separate title page.

LP2.8 Assignment
COMPLETE the LP2.8 Assignment: Managed Care Overview.
Download the attached worksheet for LP2.8 Assignment
template to complete the paper for Managed Care Overview. In this
assignment you are to use the readings from Chapter 7 in the Guide to
Medical Billing and the Internet to prepare a typed, one (minimum) page
paper discussing the following points as if you are providing an
overview for a potential employer:
Include the following:

  • Describe the types of managed care organizations, functions and how
    they set their reimbursement schedules, their reasoning’s for doing so
    and specific services covered or not covered under the plans.
  • Describe what information is to be listed on the insurance card; how
    the insurance company receives the insured’s group enrollment
    information and updates.
  • What happens if the insured is under the care of a Primary Care
    Physician (PCP) who is their gatekeeper orchestrating all of the
    patients care-but the patient no longer wants to receive care by that
    provider-how does the member change providers? What documenting will be
    required to complete that process?
  • What if the patient has a complaint about their Physician, care,
    denials, etc.?  What is the process that patient will need to follow? 
    What if the patient wants a second opinion?
  • By the same token-a provider decides he wants to discontinue caring
    for individuals under a certain Managed Care Organization (MCO)-and no
    longer be a participating provider-what is the process for achieving
    that goal? 
    • Until the paperwork is processed, how will the physician get paid
      (stop loss reimbursement) for still providing care for those patients?
    • Discuss how you would communicate with the insurance plan the desire
      of your provider in not wanting to accept their guidelines, fee
      schedules, etc.
    • Discuss how you would facilitate and provide communication between
      the patient and the provider for continuing care and referrals to other
      providers in the interim.

The paper will include the following guidelines:
1. Double spaced
2. 12 point font
3. 1 inch margins
4. Separate title page

Submit this assignment to your instructor via the dropbox “LP2.8
Assignment: Managed Care Overview.”  This assignment is worth 20 points.

Scoring Guide (20 Points)

Rating Scale
10-9 Work meets or exceeds criterion at a high level of competence.
8 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
7 Criterion partially met, but one or more important concepts/skills are missing or flawed.
6 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
5-0 Criterion not met or work is absent.

 

Criteria
1. Paper addressed specific guidelines noted above for Managed Care Overview.
2. Paper was submitted per guidelines: double-spaced, 12 pt. font, 1 inch margins, and separate title page.

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