Please complete all parts

Part 1 400-600 words

You are a new graduate, and you just started work at a medium-sized hospital with an attached clinic. You have been asked to review the five different types of health care insurance plans and the characteristics of each to make sure the central business office (CBO) is up-to-date on all the rules and regulations. It is important to be familiar with these plans and the characteristics of each because they play a vital role in the reimbursement process for your health care organization. Discuss the following:

  • List the five different types of health care plans and 2–3 characteristics of each.
  • Explain why it is important to understand the differences in these plans.
  • What are some of the similarities between the plans?
  • What are some of the differences?
  • Would an out-of-date policy from one of these plans affect the facilities reimbursement? If so, how?

Part 2- reply to this post with 150 words

The 5 health care plans and their characteristics:

HMO- A network of providers that agree to lower cost for services, but at a standard quality of care. Members don’t have to worry about duplicate fees for services already rendered.

PPO- Members are able to see any doctor that they choose. Members do not need a referral to see a specialist.

POS-Members have the flexibility when choosing a PCP. A balance of choosing a PCP and having lower premiums.

EPO-Less PCP choice for lower rates. Smaller co-pays with smaller network.

Fee for service-Members have more service control but at a higher rate. Members pay out of pocket and get file claims for reimbursement.

It is important to understand the difference between the type of healthcare plans. The skinny of it comes down to revenue. Each plan has a way of billing, and some have regulations that determine incentives. With an HMO, if the provider is able to treat the patient at a lower cost, and they get well; the government gives the provider an incentive. A PPO can allow a member to request duplicate diagnostic testing without it being denied. A POS combines an HMO and PPO where they have lower cost for care, but at a limit. With an EPO if the member has a service outside of the network, the cost will fall on the member. A fee for service plan only provides a service once it is paid for. Again, it all comes down to capital. The business of healthcare is costly. The burden is on the party that does not fully understand the operations of the plan.

The similarities between the plans are that the member has the choice of services. They can select a PCP, and have preventive health at low to no cost. They are able to select services within the network. The EPO combines the PPO and HMO benefits with a smaller network to receive health care. The difference between the plans are how billing will be handled. Some plans do not allow the member many options for services. The fee for service plan is a plan of its own. The member must pay prior to the service being provided. Unlike the other plans, where the member has an employer or they pay a premium.

If a medical office had an out of date policy for billing of each plan, that would directly affect the business. The service would not be reimbursed due to old ICD codes. The cost for healthcare has regulations and those that are not followed will come with penalties. This will snowball down and affect everything from employees to the office management. An office would need a skilled and knowledgeable manager to ensure that the policies are up to date and followed. To ensure that healthcare is a continued service.

Part 3- reply to this post with 150 words

PPO – Preferred Provider Organization

This type of plan has an annual deductible that must be met before the insurance company starts paying. You are encouraged to use a network provider but you don’t have to stay with one you have the freedom to choose also you can see a specialist without having a referral.

The good side to this is the freedom of finding someone you are happy with instead of being stuck with someone you don’t care for. The down side to this one is its all out of pocket until you meet your deductible.

HMO – Health Maintenance Organization

With this plan the employee has the least of flexibility when choosing providers and must have a referral before seeing a specialist. The insured has to pay a co pay.

POS – Point of Service

With this plan you have to choose a provider in the network. When being seen you must pay your co pay at time of visit.

EPOs – Exclusive Provider Organization

This plan requires you to choose a network provider, but in the case of an emergency you are able to go without being in jeopardy of insurance not paying. The insured will have a Primary Care Provider and will have to pay a co pay at time of service.

This is the plan we currently have through Tricare, We pay a yearly fee of apx. 500.00 bucks, and when I see my PCP I don’t have to pay anything, when I go to an Urgent Care or a specialist (with referral) I have to pay 30.00 bucks. This works for us due to the ongoing visits to a PCP.

Indemnity Health Insurance Plans

This is a fee for service plan, the member may be responsible for deductibles and co pays. The insured will pay everything out of pocket and then file a claim for reimbursement.

While researching this assignment I realized how important and also difficult it is to understand all the different plans and coverages out there. If I am sitting at a desk providing customer service or taking payments at a hospital payment window, I have go to be able to answer questions to the patients when I tell them how much I will need to collect from them for the treatment, hospital stay, medication etc. I can speak from experience because I have been on the other side of the counter asking “why am I having to pay such and such amount”

I think out of date policies would affect the patient due to higher costs, deductibles and less coverage. As far as to the clinic I think maybe a delay in payments, but there are so many programs and electronic means that may not even be an issue. There are a ton of steps when it comes to medical billing/coding and its important that when billing the coding is done correctly, if not this can cause delays in payment while going through the adjudication process.

Part 4 400-600 words

Accurate coding and billing are essential to a health care facility and to a physician’s financial survival. Coding is a complex task that ties to charges and revenue generation. Failure to capture all charges associated with a patient encounter can result in significant revenue loss. Medical necessity also plays a vital role in the contract with the facility or physician in terms of receiving payment from the third party payer (e.g., an insurance company).


For this Discussion Board, you will define medical necessity, and you will describe the criteria to determine it.


Once the patient has an established diagnosis and the services and procedures have been ordered, you will code out this information and place it on the claim for payment.

It is important for health care professionals to understand this process to receive accurate reimbursement.

For this part of the discussion, you will be identifying the coding systems that are utilized to support the diagnosis, services, and procedures.

List and discuss the coding system that is utilized to code out the patient’s conditions or diagnosis. Provide an example of a diagnosis with the appropriate code as an example, and respond to the following questions:

  • What is the coding system replacing the diagnostic system?
  • Will it be implemented this year? Explain your answer.

Next, identify what coding system is utilized to capture the services and procedures that the patient has received (both levels). List an example of a service or procedure with the appropriate code as an example, and respond to the following questions:

  • Why is it important to assign the correct codes to the diagnoses, services, and procedures that a patient has received?
  • What are the repercussions of submitting incorrect coding and billing errors to the third party payers?

Part 5- reply to this discussion with 150 words

Medical necessity is a service, procedure or tool that is required to treat a disease or condition. This does not include preventative care. There must be a diagnosis made in order for the treatment to be deemed a medical necessity.

The different coding systems are ICD -10 and HCPCS, which stands for Healthcare Common Procedure Coding System, codes.

ICD-10 is the coding language that is used to code diagnoses.There is an actual proposed ICD-11 that includes feeding and eating disorders and alcohol and cannabis dependence in the coding system. An example of code is C67.9 that stands for bladder cancer unspecified location.

HCPCS codes that is used to report procedures, products, supplies and services for a patient. It is divided into 2 levels, Level I and Level II. Level I are called CPT codes. CPT stands for Current Procedure Terminology. This language is maintained by American Medical Association. Level I codes are 5 numeric digits long. For example, 1 0021 through 69990 is used to code surgeries. Level II codes are used to identify services or equipment not covered in the CPT code. These are maintained by CMS (Center of Medicare and Medicaid) HCPCS workgroup. An example of a Level II code is A6209 which is a foam dressing used to cover a wound that is less than 16 square inches.

It is important to have the correct codes because it enables communication between all providers. It also ensures that proper repayment and billing. If there is incorrect coding, the billing of services will be wrong and may be over or under charged for services.

Part 6- reply to this discussion with 150 words

What is Medical Necessity? What I understand medical necessity is a United States legal doctrine, related to medical activities that are justified as reasonable, necessary and appropriate based on evidence based clinical standards of care. Other countries may have medical doctrines or legal rules covering broadly similar grounds.(Wikipedia). So here I understand there has to be rules set for our medical services it basically a set of legal guidelines that a physician or other medical workers must follow this keeps the patient safe from any unnecessary health care procedure that lacks such justification. Example is a woman that is pregnant should not be admitted for a cesarean section on this Monday because the doctor will be going on vacation. This keeps us from having medical treatment at the doctors convenience of the doctor. To protect against medical necessity denials, one must practice medicine that is reasonable, necessary and appropriate.

There are two common medical coding classification systems. The International Classification of Diseases (ICD). and the Current Procedural Terminology (CPT).

ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings. These classifications are developed, monitored, and copyrighted by the World Health Organization (WHO). In the U.S. the NCHS (National Center for Health Statistics) part of CMS (Centers for Medicare & Medicaid Services) oversees all changes modifications to the ICD codes, in cooperation with WHO.

CPT codes are published by the American Medical Association and there are approximately 10,000 CPT codes currently at use. THe U.S. and other countries use the fourth edition and they were designed to provide a uniform data set that could be used to describe medical, surgical, and diagnostic services rendered to patients. Without the correct coding there would be no reimbursement to any medical provider or patient.

The International Classification of Disease 10th Revision Procedure Coding System (ICD-10-PCS) has been developed as a replacement for Volume 3 of the International Classification of Diseases 9th Revision (ICD-9-CM). The development of the ICD-10-PCS was funded by the U.S. Centers for Medicare and Medicaid Services (CMS).

Part 7- reply to this discussion with 150 words a piece

The Revenue Cycle

While hospitals, small practices, and larger healthcare systems are known for saving lives and treating patients, every healthcare organization needs to develop successful processes and policies for staying financially healthy. That is where healthcare revenue cycle management comes in. Healthcare revenue cycle management is the financial process that facilities use to manage the administrative and clinical functions associated with claims processing, payment, and revenue generation. The process encompasses the identification, management, and collection of patient service revenue. Without this key financial process, healthcare organizations cannot keep their doors open to treat patients. Healthcare revenue cycle management is the strategy that healthcare organizations use to pay the bills. In simple terms, healthcare organizations must stay in the black and maintain profitability to be successful at healthcare revenue cycle management. Successful healthcare revenue cycle management strategies focus on front-end tasks to help claims move along. Many errors occur in the first stages of a patient’s account and these issues can carry through the revenue cycle to disrupt claims reimbursement. It is especially important that providers verify insurance eligibility during pre-registration to ensure that insurance companies will reimburse the healthcare organization for medical services provided. According to a Claim Remedi survey, the top reason for claim denials is eligibility issues.

The Chargemaster

The hospital charge description master, or hospital chargemaster, is at the heart of the healthcare revenue cycle, serving as the hospital’s starting point for billing patients and payers. A hospital chargemaster is a list of all the billable services and items to a patient or a patient’s health insurance provider. The chargemaster captures the costs of each procedure, service, supply, prescription drug, and diagnostic test provided at the hospital, as well as any fees associated with services, such as equipment fees and room charges. Charge capture through the chargemaster is an integral component of the hospital billing process. When a patient receives services from a hospital, providers document the encounter in the medical record and health information management staff or professional coders assign codes for reporting and claim submission. Those codes and documentation are translated via charge capture to chargemaster rates. The charges are then used to bill the patient and create a claim for payers. Maintaining an accurate hospital chargemaster is key to revenue integrity. An inadequate chargemaster can result in over payment or underpayment, as well as claim rejections, undercharging for services, and compliance violations.

Various Reimbursement Methods

1. Discount from Billed Charges –This offers the provider the lowest level of risk with the payer agreeing to reimburse at a negotiated discount using the provider’s standard Charge Description Master(CDM) which serves to track activity/usage and billing. Conceptually, this is the easiest to calculate, but payers often scrutinize the billed charges and there can be higher denial rates which can lead to additional audit/recovery work.

2. Fee-for-Service This model incorporates specific negotiated rates for each procedure and/or service performed, but overtime, additional cost-controls / care-management components have been included. For inpatient services, per-diems and defined or relative weight case-rates are used by the payer to promote shared cost/care management. Providers often negotiate stop-loss provisions, carve-outs for high-cost items as a means of balancing out the risk. For outpatient services, fee-for-service started with simple rate schedules for individual procedures but this has been expanded to broader grouping of codes under pre-defined ambulatory payment classifications (APC, APG, EAPG, etc.). Additional levels of cost/care controls are often incorporated in the negotiation process including lesser-of the charge or reimbursement, observation or minimum stay criteria, multiple-procedure discounting, and modifier & bundling logic, but there are often few controls on the number of procedures and/or preventative care strategies.

3. Value-Based Reimbursement In the newer value-based reimbursementmodel, providers are compensated under a fee-for-service model with a quality and efficiency component. By tying the quality benchmark metrics to reimbursement, there are additional incentives to help create positive outcomes, not just the volume of activity.

4. Bundled Payment – With bundled payments, healthcare providers are reimbursed for specific episodes of care. It is much broader in the coordination of care than the traditional case-rate reimbursement. CMS’ Comprehensive Joint Replacement (CJR) program is an example where the inpatient stay and all related providers are bundled under a single payment. This method encourages greater coordination of care and can prevent redundant or medically unnecessary services.

5. Shared Savings This model provides upside incentives and lowers risk for providers to improve the coordination of care and outcomes within an identified patient population. A pre-determined percentage of net savings may be further negotiated with the providers as an upside incentive. This approach is based on defining the methodologies and related benchmarks for determining the shared savings.

Federal Regulations That Impact Financial Management of Healthcare Organizations are HIPAA Privacy Rule, Human Subjects Research Protections, HITECH Act, Additional HHS Laws and Regulations, Complaints and Appeals, Regulatory Agenda, Regulatory Priorities.

Part 8- reply to this discussion with 150 words a piece

Under the evolution of managed care plans, Electronic Medical Records (EMR), and medical necessity, there has been a various amount of significant developments in the health care industry. Three major developments in healthcare history are the introduction of Telemedicine, The Patient Protection and Affordable Care Act (PPACA), and the Quality Payment Program (QPP). These developments have provided gainful insight on how beneficial rules and regulations impact the financial management of medical facilities around the world.

Event 1: Telemedicine

The concept of telemedicine was initially introduced in the late 1950s and early 1960s. The invention of telemedicine bridged the gap between communication and information technologies. It became most popular with military settings. In those times it was important for combat units to communicate with one another from a distance in the event an enemy was approaching. Telemedicine first uses were to send videos or medical data and now with the expansion of technology; providers are given the opportunity to evaluate, diagnose, and treat patients who are not located within the office. (Bashshur, Rashid., & Shannon, Gary, W.). The creation of telemedicine impacted the healthcare industry today by giving patients an alternative to accessing healthcare. Often times, patients come into barriers when seeking healthcare such as transportation and telemedicine allows those patients to continue receiving care from their home.

Event 2: The Patient Protection and Affordable Care Act (PPACA)

The Patient Protection and Affordable Care Act (PPACA) also referred as the Affordable Care Act (ACA) or “Obamacare” was enacted by President Obama March 23, 2010. The law was set in place to provide “affordable” insurance to those who were either uninsured or had little to no coverage at all. Primary goals of this act was to improve quality of care and reduce the cost of healthcare. It is no secret that individuals had insurance before the ACA was implemented; however coverage was provided through employers, private insurance companies, or government sponsored plans such as Tricare, Medicaid, Veterans Health, Peace Corps, etc. (Adams, Steve., Clark, Jules., Delorme, Luke F). The event of the ACA became impactful in the healthcare industry today because compared to other insurances, ACA coverage protects individuals from high premiums. Coverage is provided based upon income and the individual must fall between the Federal Poverty Line of 100-400 %.

Event 3: Quality Payment Program (QPP)

The Quality Payment Program (QPP) was developed January 2017 under the creation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA created this program with the intention to choose quality over quantity. Payment models found under the QPP are the Merit Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). (2018, December 17). MIPS allows for reimbursement under four critical components; quality, cost, interoperability, and improvement activities. (2019. February 01). APM details accountable care organizations (ACO), bundled payments, and pay for performance. (2018, December 17). The creation of QPP has impacted the healthcare industry today by driving value. This program suggests that patient outcomes and experiences are more of a priority than number figures.

Conclusion Statement:

In conclusion, it is imperative for medical professionals to understand the importance of providing efficient, reliable and cost effective care in order for the healthcare industry to continue growing in a beneficial way.

Week 9- reply to this discussion with 150 words a piece

Part One: Consequences of Current Codes

Two common coding systems used in the United States are the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT). In 2019, medical facilities currently utilize ICD-10-CM to code diagnosis and CPT-4 to code procedures. If a medical coder/biller was to not use the current year coding, multiple consequences can occur. Issues that can arise are decrease in provider reimbursement, claim denial, even fraud and abuse. (Matthews, 2018). Utilizing last year Charge Description Master (CDM) can affect this year bottom line and create a negative result for the healthcare facility. Reasoning for this is because the CDM provides current official charges and is used to generate bill slips to insurance carriers for provider reimbursement. (Jahn, 2017). Each year insurance policies and forms are updated. A 2018 bill slip may not incorporate all aspects of what insurance carriers are looking for in 2019. Facilities can ensure the current CDM is used by developing CDM governance. This action creates a specific department that will be responsible for reviewing the software every 3 to 6 months to ensure information is up to date. (Jahn, 2017).

Part Two: Review/Reflect

Throughout this course, the most compelling topic learned was the CDM. As long as I have been enrolled with CTU and working in the medical field, I have always understood the importance of billing and coding. This course was the first to introduce the CDM and actually explain its purpose.

Participating in Intellipaths are always my favorite part. It allows me to utilize information as a alternative resource to the Web and E-Book. Reading through Intellipaths provides me with more and clear knowledge of the topic at hand.

I truly enjoyed learning about all the coding systems and what forms are used for outpatient and inpatient settings. There’s nothing in the course I believe need additional approaches.


/@KaylaEMatthews. (2018, July 31). Medical Billing Errors Are Seriously Hurting Healthcare. Retrieved from

Jahn, Mark. Becker’s Hospital Review. (2017, September 13). Seven must-dos to ensure charge description master (CDM) success: If revenue is the lifeblood of any health care provider organization, the charge description master (CDM) is its financial heart. Retrieved from

Week 10- reply to this discussion with 150 words a piece

Part 1

Imagine you have a medical office and you have been hit with fines for improper bill coding. Tragic, right? The impact of not using the correct bill coding can be a matter of financial woes to a full shutdown of medical practice. “Miscoded claims could result in insurance companies refusing to pay for services provided,”(Berkely). This can lead to a snowball effect. Staffing not being paid, overhead for the business not being paid, and money put towards legal fees to clear up the miscoded billing. Upcoding is one of the most popular code frauds committed in the healthcare community.” In May 2000, Community Health Systems hospital chain paid out $31 million for systematically upcoding Medicare/Medicaid/Tricare throughout the mid-1990s”(Whistleblowers International).

This years CDM will affect the business of healthcare. “A CDM tool can also help you get the maximum reimbursement,” (Enrsdo,2007) This motto has not changed. Healthcare professionals are not only in the business for helping the community return to optimal health. They are also in the industry for reimbursement.

This will make for a positive reaction. In that the burden falls solely on the business and not the patient. The need for a well versed CDM vendor will be the best investment for a practice. This investment will do two things. One, the facility will have someone looking over the business to ensure that the right codes are being submitted for proper reimbursement. Two, the community can rest assured that they will not be charged for medical care. It’s a win win situation.

Part 2

For me, I found this course to be difficult to get excited about. I know it’s the topics. I do not have experience in bill coding, and I think the history of it all was too complex for me. I am a nurse at heart, and I guess I related to unit 1. I understand the insurance part, but as a nurse I do not touch that side of healthcare. The discussion boards helped me to understand the topics a little more. After I read the assignments, and read some of my peers postings I was able to connect the dots. I would say that I need some insight on the paring of ICD-10 codes and CPT codes. Will a claim be denied if there is only one code used? I was so lost on this. I think if I had attended the Live chats in real time, I would have been able to ask questions. My work did not permit it. I should have asked more questions through the messenger to the professor as well. In reflection, I think the topic matter was just unrelatable to me, because I don’t use it. However, without it I can not do what I do everyday. I will take my new found information and drill my DA to learn more of what is needed of me in my role.