Explanation of Benefits, Payment Adjudication, Refunds, Follow-up, and Appeals
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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.
References: Vines, D., Braceland, A., Rollins, E., & Miller, S. (2017). Comprehensive Health Insurance (3rd ed.). Pearson Education (US). Read Chapters 15 & 16. https://bookshelf.vitalsource.com/books/9780134458878
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