Unit VII Case Study

In this unit, you were introduced to the most common third-party insurance payers, including government payers such as Medicare, Medicaid, and TRICARE. Additionally, you reviewed the process for accurate claim processing and the various stages for claim status. This included the importance of adhering to Health Insurance Portability and Accountability Act (HIPAA) standards and code set transactions during the electronic claim submission process.

First, please review the following video clip.

NBC News (Producer). (2004).  Private insurance carrier denies claims (Segment 9 of 12) [Video file]. Retrieved from https://libraryresources.columbiasouthern.edu/login?auth=CAS&url=http://fod.infobase.com/PortalPlaylists.aspx?wID=273866&xtid=39090&loid=57665

The transcript for this video can be found by clicking the “Transcript” tab to the right of the video in the Films on Demand database.

Once you have completed watching the video segment, use the Chapter 18 readings and research from the CSU Online Library to respond to the prompts below.

  • Identify the main reasons why insurance companies deny patient insurance claims.
  • When filing insurance claims, how do HIPAA transaction code set standards apply?
  • What remedies might the patient and provider have regarding reversal of an insurance company’s decision to pay a patient’s claim?
  • Describe the major differences between traditional Medicare and Medicare Advantage. Which appears to provide the best options for patients, and why?
  • Summarize the average timely filing claim limits for common third-party payers as well as for Medicare, Medicaid, and TRICARE.

Your response must be at least two pages in length, not counting the title page or references page. You are required to use at least two sources in your response. One must be found from the CSU Online Library, and the other can be your textbook. Any in-text citations and references need to be cited according to APA guidelines.