{"id":33174,"date":"2023-09-07T00:57:17","date_gmt":"2023-09-07T00:57:17","guid":{"rendered":"https:\/\/www.goodacademic.com\/blog\/questions\/explanation-of-benefits-payment-adjudication-refunds-follow-ups-and-appeals\/"},"modified":"2023-09-07T00:57:17","modified_gmt":"2023-09-07T00:57:17","slug":"explanation-of-benefits-payment-adjudication-refunds-follow-ups-and-appeals","status":"publish","type":"questions","link":"https:\/\/www.goodacademic.com\/blog\/questions\/explanation-of-benefits-payment-adjudication-refunds-follow-ups-and-appeals\/","title":{"rendered":"Explanation of Benefits, Payment Adjudication, Refunds, Follow- Ups and Appeals"},"content":{"rendered":"

Assignment:<\/strong><\/span><\/p>\n

Students will complete the following scenario as an essay.<\/span><\/p>\n

As you are completing your audits you observe Mary Johnson\u2019s chart and notice the following:<\/span><\/p>\n

Mary Johnson saw Dr. Nichols today for a well-woman exam. Total charges are $185.00. Mary has two insurance companies:<\/span><\/p>\n


<\/span><\/p>\n

\n\n\n\n\n\n\n\n
\n

Primary Insurance<\/span><\/p>\n<\/td>\n

\n

Secondary Insurance<\/span><\/p>\n<\/td>\n<\/tr>\n

\n

BCBS<\/span><\/p>\n<\/td>\n

\n

Cigna Health Care<\/span><\/p>\n<\/td>\n<\/tr>\n

\n

Copay: $25.00<\/span><\/p>\n<\/td>\n

\n

Deductible: $200.00 (already met)<\/span><\/p>\n<\/td>\n<\/tr>\n

\n

100% benefit after copay<\/span><\/p>\n<\/td>\n

\n

80% benefit after deductible<\/span><\/p>\n<\/td>\n<\/tr>\n

\n

Allowed amount: $150.00<\/span><\/p>\n<\/td>\n

\n

Allowed amount: $125.00<\/span><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n


<\/span><\/p>\n

<\/div>\n


<\/p>\n\n\n\n<\/colgroup>\n\n\n
\n

Both claims were submitted at the same time in error.<\/span><\/p>\n

Money collected from the patient: $0.00<\/span><\/p>\n

    \n
  1. Complete the following questions providing rationales for your responses:<\/span>\n
      \n
    1. How much money did Dr. Nichols receive?<\/span><\/li>\n
    2. How much should BCBS have paid?<\/span><\/li>\n
    3. How much should Cigna have paid?<\/span><\/li>\n
    4. How much is this claim overpaid?<\/span><\/li>\n
    5. Who overpaid on this claim?<\/span><\/li>\n
    6. What would be your next steps?<\/span><\/li>\n<\/ol>\n<\/li>\n
    7. Address how this situation might be avoided in the future: Be specific and provide steps.<\/span><\/li>\n
    8. The well-woman exam showed this patient due to a 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.<\/span><\/li>\n<\/ol>\n

      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.<\/span><\/p>\n

      <\/span><\/i><\/span><\/p>\n



      <\/span><\/p>\n<\/td>\n

\n

<\/p>\n

<\/p>\n

<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"excerpt":{"rendered":"

Assignment: Students will complete the following scenario as an essay. As you are completing your audits you observe Mary Johnson\u2019s 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: […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","meta":[],"disciplines":[1110],"paper_types":[],"tagged":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/questions\/33174"}],"collection":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/questions"}],"about":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/types\/questions"}],"author":[{"embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/comments?post=33174"}],"version-history":[{"count":0,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/questions\/33174\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/media?parent=33174"}],"wp:term":[{"taxonomy":"disciplines","embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/disciplines?post=33174"},{"taxonomy":"paper_types","embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/paper_types?post=33174"},{"taxonomy":"tagged","embeddable":true,"href":"https:\/\/www.goodacademic.com\/blog\/wp-json\/wp\/v2\/tagged?post=33174"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}