Reimbursement and Coverage Worksheet

References: Ch. 8 and 12 of Medical Insurance: An Integrated Claims Process Approach (6th ed.)

Imagine you are a billing supervisor at a local health facility. You have been asked to determine the expected reimbursement and coverage determination on the following claims:

1. You reviewed the claim 1500 form for patient Kevin Luke. You realize it is a new calendar year and he had not met his deductible. You had an authorization on file for treatment. Total billed charge amount is $1100.00. His benefits are as follows:

PPO-Medical Care for diagnostic testing

In-network benefit preauthorization required. Pays at 100% after deductible is met.

Must meet deductible. Annual family deductible is $500.

Calculate the expected reimbursement by insurance and what the patient will owe.

2. You review the claim form for Lisa Smith for treatment of hyperglycemia. You discover she received treatment from a non-network provider. She has met her annual deductible. Total charges for the date of service are $170. The plan pays at usual and customary which is exactly what was billed. Her benefits are as follows:

PPO-Medical Care office visits

In-network benefit-Office visit copayment: $10.00

Out-of-network Deductible and Coinsurance of 20%.

Calculate the expected reimbursement from insurance and her coinsurance.

3. You are reviewing a claim for Maria Johnson, a 45-year-old who received a well check and flu shot from her in network provider. Her benefits are as follows:

PPO-Medical Care office visits

In-network benefit- copayment: Office visit $10.00 and Injections $25.00

Out-of-network Deductible and Coinsurance of 20%.

Mrs. Johnson called the office because she thought she had overpaid during her visit. What was Mrs. Johnsons copay the date of the visit?

4. You are reviewing the vision exam benefits for Zach Bergman. He presented for an eye exam stating he needed new glasses. He had an examination 13 months prior and notes he can have an exam every year. His benefits are as follows:

PPO-Medical Care office visits

In-network benefit-One vision exam every 2 calendar years.

Out-of-network Deductible and Coinsurance of 20%. Covered every 2 calendar years.

What is Mr. Bergmans benefit?

5. Lisa Smith called your office noting she had to be transported to the hospital by ambulance while on vacation for food poisoning. She was concerned about what she will need to pay out-of-pocket. She was not admitted. Her benefits for emergency treatment are as follows:

PPO-Emergency treatment

In-network benefit-Copay $100. Waived if admitted. Ambulance services no charge.

Out-of-network Copay $100. Waived if admitted. Ambulance services no charge.

What should Lisa Smith expect to pay out-of-pocket?