MEDA 149 - Medical Insurance Procedures for Medical Assisting

Credits: 5
LEC hours per week: 5
This course provides a basic introduction to accurate billing and medical coding procedures used to obtain reimbursement for medical procedures or services. Billing topics include different types of health insurance, preparation of insurance claim forms, applying third-party payor guidelines and collection procedures. Coding topics will include the Healthcare Common Procedure and Diagnostic Coding Systems II (HCSPCS Level II).
Course Outcomes:

Interpret information on an insurance card
Verify eligibility for services
Identify:
- types of third-party plans
- steps for filing a third-party claim
Identify processes for:
- verification of eligibility for services
- precertification/preauthorization
- tracking unpaid claims
- claim denials and appeals
Obtain precertification or preauthorization with documentation.
Complete an insurance claim form.
Identify the purpose and components of the Explanation of Benefits (EOB) and Remittance Advice (RA) Statements.
Assist a patient in understanding an Explanation of Benefits (EOB).
Identify managed care requirements for patient referral.
Identify fraud and abuse as they relate to thirdparty reimbursement.
Define the following:
- bundling and unbundling code
- advanced beneficiary notice (ABN)
- allowed amount
- deductible
- co-insurance
- co-pay
Identify the current procedural and diagnostic coding systems, including Healthcare Common Procedure and Diagnostic Coding Systems II (HCSPCS Level II)
Perform Procedural and Diagnostic coding
Identify the effects of:
- upcoding
- downcoding
Define and utilize medical necessity guidelines.

Course Topics:

Insurance coverage and verification process
Submitting in third-party reimbursement claims
Explanation of Benefits
Procedural and diagnostic coding
Fraud and abuse related to third-party reimbursement
Managed care, Medicare, Medicaid and workmen’s comp and disability