A large number of healthcare consumers are perplexed by their medical bills. It is felt by many that their medical bills are overinflated and too expensive. Accurate and ethical medical billing, coding, and processing ensures that healthcare services are provided in an ethical manner and the services received are paid accurately (Vines et al., 2017). When interpreting claims, it is important to understand medical terminology and understanding the guidelines of Federal and private insurance companies including the coverage they provide (Vines et al., 2017). This consists of copayments, deductibles, reimbursement, and coverage provided. Insurance companies include Medicare, Medicaid, Private health insurance companies, PPOs, and HMOs (Vines et al., 2017). Those submitting claims must have adequate knowledge of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT) coding (Vines et al., 2017). Other useful skills and knowledge will be to understand how health insurance is managed, including the number of charges that providers are allowed for their services. In addition, knowledge of bookkeeping and accounting are also helpful. Understanding and compliance with the Health Insurance Portability and Accountability Act (HIPAA) laws ae required (Vines et al., 2017).
One of the duties we have as healthcare providers are to act as liaisons for patients and too assist with claims questions (Vines et al., 2017). The skills required to answer claims include communication skills, analytical skills, the ability to explain health policies, the ability to perform multiple tasks, and the ability to effectively discuss benefits interpretation (Vines et al., 2017). One should carefully assess contracts providers have with other healthcare providers, and specialists (Vines et al., 2017). You should be able to review claims and ensure amounts paid are correct (Vines et al., 2017). There are multiple steps which you must be knowledgeable to correctly complete and file a claim (Vines et al., 2017). This knowledge will help when a claims dispute or explanation is needed (Vines et al., 2017). These steps include the verification of the patient’s insurance benefits, military service, secondary insurance, if a release of information was obtained, all signatures were obtained, proper identification, correct demographics, completed encounter forms, followed by the submission of a clean claim (Vines et al., 2017). The Explanation of Benefits (EOB) statement will be sent to the patient to explain the cost and expenditure of receiving healthcare services (Vines et al., 2017). The Electronic Remittance Advice (ERA) is a collection of electronic data that provides a breakdown and explanation of medical insurance payments (Vines et al., 2017).
The Employee Retirement Income Security Act (ERISA) was founded in 1974 (Vines et al., 2017). ERISA is the federal tax and labor law of the United States (Vines et al., 2017). ERISA is jointly managed by the Treasury Department and the United States Department of Labor (Vines et al., 2017). ERISA establishes rules, regulations, and minimum standards for private industry retirement pension plans and private health insurance plans (Vines et al., 2017). This includes life insurance plans, apprenticeship plans, health plans, and welfare plans. The way an employer provides benefit plans is governed by ERISA (Vines et al., 2017). The applicable plans for ERISA are employee pension benefit plans and employee welfare benefit plans (Vines et al., 2017). Employee pension benefit plans include currency purchase plans, stock dividend plans, 401K plans, welfare, and profit-sharing retirement plans (Vines et al., 2017).
ERISA guards the funds and assets placed in retirement plans during the working years of individuals (Vines et al., 2017). People who benefit from ERISA include employees of private sector companies (Vines et al., 2017). ERISA protects the assets of employees and their families (Vines et al., 2017). ERISA was created to protect those employees who depend on long-term disability plans, retirement pensions, or other benefits (Vines et al., 2017). Other amendments expanded ERISA to protect workers and their families from health-related discrimination based on health-related factors, including factors related to mental, maternal, newborn, and cancer health-related needs (US Department of Labor, 2021). Furthermore, the Consolidation Omnibus Budget Reconciliation Act (COBRA) protected the rights for healthcare coverage to workers who lost their jobs for a limited period of time (United States Department of Labor, 2021).
The year 2021, $230,000 is the established annual maximum payable benefit (Retirement Plan Contribution and Benefit Limits | Pension Rights Center, 2021). $58,000 is the annual employee-employer combined contributions to a contribution plan (Retirement Plan Contribution and Benefit Limits | Pension Rights Center, 2021) The investment limit for individual retirement accounts is $6,000. Plans not covered by ERISA include group health plans, church employee plans, government-maintained plans, disability, unemployment, or workers’ compensation (retirement plan contributions and benefits limits | Pension Rights Center, 2021).
I am an employee of the Allegheny Health Network (AHN) in Pittsburgh, Pennsylvania. All employees are eligible for a 401(k) plan or 457 savings plan (Allegheny Health Network, 2020). The maximum annual contribution is $19,500 (Allegheny Health Network, 2020). The maximum annual benefit pension plan payable is $230,00 (Allegheny Health Network, 2020). There is a maximum $58,000 matched employer-employee contribution plan. $6000 is the maximum annual contribution an employee can contribute to an individual retirement account (Allegheny Health Network, 2020).
The Pension Guarantee Corporation ensures those in single employer plans at the age of 65 maximum of $6304 annually (Allegheny Health Network, 2020). Pension Guarantee Corporation ensures those employees of multiple employers with 30 years of service at the time of retirement with a maximum monthly $1072 amount (Allegheny Health Network, 2020).Transamerica is the AHN retirement plan provider AHNs plan is a no-qualified plan that falls outside of a majority of ERISA guidelines (Allegheny Health Network, 2020). My husband and I both have 401 (K) plans. Additionally, we took advantage of matching employer-employee contribution plans, life insurance policies, and my husband has a retirement plan. My husband is eligible for Social Security benefits. He loves his job and doesn’t want to retire. Currently strains are evident in the Social Security System, Medicaid, and Medicare (Barnes, 2021). The Baby Boomers are increasing in age and accessing Social Security, Medicaid, and Medicare benefits (Barnes, 2021). Medicare, Medicaid, and Social Security are open-ended entitlement programs that are obligated to provide services to all eligible citizens (Barnes, 2021). By 2030, the Social Security Administration will not be able to pay full benefits (Barnes, 2021).