HCA- 240
November 15, 2020
Professor Chip Coon
Biller / Benefits Coordinator Interview
In the healthcare sector, several functions are essential to a healthcare facility's
functioning, but medical agents and coders are most important. It is the primary duty of medical
coders and billers to examine patient medical notes and allocate the required diagnosis and
treatment codes, also known as procedural codes. is a medical coder and biller aged 39 years and
interviewed on November 12, 2020. Ann works for Northwestern Medicine Central DuPage
Hospital, Illinois. She also supervises the coding of health departments and specializes in E&M
codes for the emergency sector and also a medical co-coder (Personal Contact, November 12,
2020). The paper would also address the premiums variations between insurance funds, third-
party insurances and Medicare / Medicaid, medical fees, and pricing systems.
Payment System Variations
The mechanism for charging for health care for each patient is different, and the charge
for medical services is organized based on the status of the payment for each person as opposed
to other types of trade. Ann described that cash payers are the simplest since there is no third-
party insurance or subsidized insurance that the person must charge. The payment rate is also
base on the health facility's regular service rates (Personal Contact, November 12, 2020). Payers
from third parties are businesses that pay for a person's insurance expenses not funded by the
government, for example, Cigna, United Health Care, Blue Cross Blue Shield, Etc. Sommers,
, Gawande, Baicker says, "the private insurer works under special terms, whether or not claim
reimbursements are legitimate, which creates conflicting circumstances where a patient in a
hospital compensate by an insurer that does not pay at another hospital" (Sommer, Gawande,
Baicker, 2017). Additionally, a negotiated percentage of all charges based on a patient care plan
used as the price-relates basis (Cleverley, Song, Cleverley, 2011). The compensation
arrangement is base on a negotiated percentage of the overall charges. Finally, the government-
funded payer Medicaid and Medicare are payers who pay a fixed rate or fee schedule set by the
Medicaid and Medicare centers. Medicare / Medicaid also covers people who have minimal
income and resources at medical expenses and payments already made regardless of the service
costs rendered (the difference between Medicare and Medicaid, n.d.). It is also necessary for
medical billers to know the billing and coding variations for the services provided between
different payers.
Pricing of the Healthcare Sector
The medical industry produces an invoice of services and resources that include the costs
and the fees following medical services provision. The 'prize' on the price list of a healthcare
business is known as the CDM. Compared to other divisions, rates, or payments are the same for
all regardless of payment status, Medicare and Medicaid are included (Cleverley Music, &
Cleverley 2011, p.140). As described by Ann, the bill is comprehensive and includes
International Classification codes for diagnosis and care by medical professionals and treated by
billers and coders for diseases (ICD-10 codes). Billers and coders also must look at and check all
information that is right and registered.
November 15, 2020
Professor Chip Coon
Biller / Benefits Coordinator Interview
In the healthcare sector, several functions are essential to a healthcare facility's
functioning, but medical agents and coders are most important. It is the primary duty of medical
coders and billers to examine patient medical notes and allocate the required diagnosis and
treatment codes, also known as procedural codes. is a medical coder and biller aged 39 years and
interviewed on November 12, 2020. Ann works for Northwestern Medicine Central DuPage
Hospital, Illinois. She also supervises the coding of health departments and specializes in E&M
codes for the emergency sector and also a medical co-coder (Personal Contact, November 12,
2020). The paper would also address the premiums variations between insurance funds, third-
party insurances and Medicare / Medicaid, medical fees, and pricing systems.
Payment System Variations
The mechanism for charging for health care for each patient is different, and the charge
for medical services is organized based on the status of the payment for each person as opposed
to other types of trade. Ann described that cash payers are the simplest since there is no third-
party insurance or subsidized insurance that the person must charge. The payment rate is also
base on the health facility's regular service rates (Personal Contact, November 12, 2020). Payers
from third parties are businesses that pay for a person's insurance expenses not funded by the
government, for example, Cigna, United Health Care, Blue Cross Blue Shield, Etc. Sommers,
, Gawande, Baicker says, "the private insurer works under special terms, whether or not claim
reimbursements are legitimate, which creates conflicting circumstances where a patient in a
hospital compensate by an insurer that does not pay at another hospital" (Sommer, Gawande,
Baicker, 2017). Additionally, a negotiated percentage of all charges based on a patient care plan
used as the price-relates basis (Cleverley, Song, Cleverley, 2011). The compensation
arrangement is base on a negotiated percentage of the overall charges. Finally, the government-
funded payer Medicaid and Medicare are payers who pay a fixed rate or fee schedule set by the
Medicaid and Medicare centers. Medicare / Medicaid also covers people who have minimal
income and resources at medical expenses and payments already made regardless of the service
costs rendered (the difference between Medicare and Medicaid, n.d.). It is also necessary for
medical billers to know the billing and coding variations for the services provided between
different payers.
Pricing of the Healthcare Sector
The medical industry produces an invoice of services and resources that include the costs
and the fees following medical services provision. The 'prize' on the price list of a healthcare
business is known as the CDM. Compared to other divisions, rates, or payments are the same for
all regardless of payment status, Medicare and Medicaid are included (Cleverley Music, &
Cleverley 2011, p.140). As described by Ann, the bill is comprehensive and includes
International Classification codes for diagnosis and care by medical professionals and treated by
billers and coders for diseases (ICD-10 codes). Billers and coders also must look at and check all
information that is right and registered.
