Nichols case
Assignment Instructions
Students will complete the following scenario as an essay.
As you are completing your audits you observe Mary Johnson’s chart and notice the following:
Mary Johnson saw Dr. Nichols today for a well-woman exam. Total charges are $185.00. Mary has two insurance companies:
| Primary Insurance | Secondary Insurance |
| BCBS | Cigna Health Care |
| Copay: $25.00 | Deductible: $200.00 (already met) |
| 100% benefit after copay | 80% benefit after deductible |
| Allowed amount: $150.00 | Allowed amount: $125.00 |
Both claims were submitted at the same time in error.
Money collected from the patient: $0.00
- Complete the following questions providing rationales for your responses:
- How much money did Dr. Nichols receive?
- How much should BCBS have paid?
- How much should Cigna have paid?
- How much is this claim overpaid?
- Who overpaid on this claim?
- What would be your next steps?
- Address how this situation might be avoided in the future: be specific and provide steps.
- The well-woman exam showed this patient due to family history of cancer would benefit from BRCA genetic testing and both insurance companies denied this claim. Format a letter of appeal or BRCA testing.
This assignment is completed as an APA style paper, and should be at least 2-3 pages in length. Demonstrate your business knowledge and professional ethics in your response.
Assignment Expectations:
- Length:
- answers must thoroughly address each question in a clear, concise manner; complete answers will likely take 2-3 pages
- Structure:
- Title and reference page required
- address each question in a numbered list
- References:
- References required to be cited if used
SAMPLE ANSWER: Addressing Insurance Claim Errors
Money Dr. Nichols Received
The doctor received $25.00 as a copayment from Mary. The money is the fixed charge the patient is required to pay at the time of the visit.
Money BCBS Should Pay
The insurance company should have paid $125.00 for the claim because it covers 80% of the allowed amount, which is $150.00, and the deductible has already been met.
Money Cigna Should Pay
Cigna covers 80% of the allowed amount, which is $125.00, meaning that it should have paid $60.00.
Overpaid
The claim is overpaid by $35 (Cigna overpaid $25 and BCBS by $10).
Who Overpaid
The claim was overpaid by both Cigna and BCBS. Cigna overpaid $25 and BCBS by $10, which is higher than the amount they needed to pay.
Next Steps
Steps should be taken to ensure that health insurance programs overpay for claims. The next step to correct the program is to contact both Cigna and BCBS to notify them of the overpayment. Second, the companies would be requested for reimbursement. Third, the patients will be adjusted to reflect the correct payments received from Cigna and BCBS. The last step is informing the patient about the situation and how it has been resolved.
Avoiding the Situation in Future
The situation can be avoided in the future through the following steps. The first step is to ensure that the individual preparing claims obtains correct insurance information and verifies it before submitting claims (Gebert-Persson et al., 2019). The patient should be included in the data collection method to ensure that the correct information about their insurance plans is corrected. The information should also be verified with the patient and their insurers to ensure that it is correct. The second step is implementing the verification process. A verification process should be implemented to cross-check the secondary and insurance coverage plans and the terms of payments.
The billing officer submitting the claim should communicate with the insurance plans and the patients to understand the primary and secondary plans and how the insures and the patients agreed on how to pay for care services. The third step is training the staff members in the billing and insurance claims departments to diligently review and confirm the insurance data. Staff training can improve the accuracy of the claims submission process and ensure that staff members understand the complex issues in billing procedures and insurance claims (Johnson et al., 2021). Training also reduces the chances of billing staff making an error.
Training staff on coverage limitations, insurance policies, and claims submission guidelines improves the successfulness of the reimbursement process. Training also reduces the number of denials the hospital might experience after claims submission, as a result saving time and effort needed for resubmissions and rework and improving cash flow within the hospital (Johnson et al., 2021). Lastly, training will also ensure that the hospital receives payments for the services they rendered in a timely manner.
The last step is using electronic claim submission systems. Johnson et al. (2021) noted that electronic claim submission systems improve the accuracy of claims submission by allowing billing officers to identify inconsistencies and potential errors in real-time. Electronic systems will also reduce the costs of claims submission by eliminating the costly ways of manually submitting claims and errors.
Letter to BRCA Regarding Genetic Testing
J Claire,
Billing Officer,
ABC Hospital,
7640 University Road S, Jacksonville, FL 32286.
May 22, 2023.
BRCA Insurance Company,
Head of Appeals Department,
BCSBS Insurance Company,
27940 FL-85 N, Jacksonville, FL 3265,
Subject: Appeal for BRCA Genetic Testing
Dear Sir/Madam,
Hope you are fine. I am appealing your decision to deny the BRCA genetic testing claim for my patient, Mary Jonson. The patient is under coverage for both Cigna and BCBS Health Care. This testing is significant, considering her family history of cancer and her age. We believe that the test is highly important to her ongoing healthcare.
The test was recommended by Dr. Nichols after performing a comprehensive well-woman exam on Mary Jonson. The test is vital for determining the patient’s risk factors for certain types of cancer and potential genetic mutations, considering her family history of cancer. The results of the tests can be fundamental to the patient’s health as they can be used to develop treatment options and preventive care. According to the terms of coverage by the two companies, the test should be covered since it falls under the category of preventive care for high-risk persons. Here are the attached supporting documentation supporting the test, including well-woman exam results and doctor’s recommendations to show the medical necessity of the test.
We request you review the denied claim properly and reconsider the decision. We believe that the test is in the best interest of the patient. Do not hesitate to contact me at (904) 702-9990 to communicate your decision. We will highly appreciate it if you treat this request with the agency it needs. Thank you in advance.
Sincerely,
J Claire, Billion Officer, ABC Hospital (904) 702-9990).
References
Gebert-Persson, S., Gidhagen, M., Sallis, J. E., & Lundberg, H. (2019). Online insurance claims: when more than trust matters. International Journal of Bank Marketing, 37(2), 579-594. https://doi.org/10.1108/IJBM-02-2018-0024
Johnson, M., Albizri, A., & Harfouche, A. (2021). Responsible artificial intelligence in healthcare: Predicting and preventing insurance claim denials for economic and social wellbeing. Information Systems Frontiers, 1-17. https://doi.org/10.1007/s10796-021-10137-5
Jermaine Byrant
Nicole Johnson
OVER
RATING
YEARS
