Transcript NOT a quiz!!

1.3 Health Care Plans (Continued)
1-14
• Managed care offers a more restricted choice
of providers and treatments in exchange for
lower premiums, deductibles, and other
charges
• Managed care organizations (MCOs) establish
links between provider, patient, and payer
– How many MCOs may a doctor choose to
participate in?
• Thinking it Through, page 10
1-15
1.4 Health Maintenance Organizations
• A health maintenance organization (HMO)
combines coverage of medical costs and delivery
of health care for a prepaid premium
• Participation means that a provider has
contracted with a health plan to provide services
to the plan’s beneficiaries
• Capitation is a fixed prepayment to a provider for
all necessary contracted services provided to
each plan member
– Per member per month (PMPM) is the capitated rate
– Figure 1.3, page 11
1.4 Health Maintenance Organizations1-16
(Continued)
• A network is a group of providers having participation
agreements with a health plan
– Visits to out of-network providers are not covered
• HMOs…
– Health Maintenance Organization…
• often require preauthorization before the patient
receives many types of services
• When HMO members see a provider, they pay a
specified charge called a copayment
• HMO members choose a primary care physician (PCP),
who directs all aspects of their care
1.4 Health Maintenance Organizations1-17
(Continued)
• Open-access plans are those HMOs…
– Health Maintenance Organization…
• that allow visits to specialists in the plan’s
network without a referral
• A point-of-service (POS) plan permits patients
to receive medical services from non-network
providers for a greater charge
• Thinking it Through, page 14
1.5 Preferred Provider Organizations
1-18
• A preferred provider organization (PPO) is an MCO…
– Managed Care Organization…
• where a network of providers supply discounted
treatment for plan members
– Most popular type of health plan
– Creates a network of physicians, hospitals, and other
providers with negotiated discounts
– Requires payment of a premium and often of a copayment
for visits
– Does NOT require referrals or PCPs…
• Primary Care Physicians
• Thinking it Through, page 16
1.6 Consumer-Driven Health Plans
1-19
• A consumer-driven health plan (CDHP)
combines a high-deductible health plan with a
medical savings plan
– The health plan is usually a PPO…
• Preferred Provider Organization…
– with a high deductible and low premiums
– The savings account is used to pay medical bills
before the deductible has been met
1.7 Medical Insurance Payers
• Three major types of medical insurance payers:
1. Private payers—dominated by large insurance
companies
2. Self-funded (self-insured) health plans—
organizations that pay for health insurance directly
and set up a fund from which to pay
3. Government-sponsored health care programs—
includes Medicare, Medicaid, TRICARE, and
CHAMPVA
• The Patient Protection and Affordable Care Act
(PPACA) is health system reform legislation that
introduced significant benefits for patients
1-20
1.8 The Medical Billing Cycle
• A medical insurance specialist is a staff
member who handles billing, checks
insurance, and processes payments
• To complete their duties, medical insurance
specialists follow a 10-step medical billing
cycle
– This cycle is a series of steps that leads to
maximum, appropriate, timely payment
1-21
1-22
1.8 The Medical Billing Cycle (Continued)
• Step 1 – Preregister patients
• Step 2 – Establish financial responsibility for
visits
– Who is primary payer?
• Step 3 – Check in patients
• Step 4 – Check out patients
– A medical coder is a staff member with specialized
training who handles diagnostic and procedural
coding
– The patient’s primary illness is assigned a diagnosis
code
1-23
1.8 The Medical Billing Cycle (Continued)
• Step 4 – Check out patients (continued)
– Each procedure the physician performs is assigned a
procedure code
– Transactions are entered in a patient ledger—a record
of a patient’s financial transactions
• Step 5 – Review coding compliance
– Compliance means actions that satisfy official
requirements
• Step 6 – Check billing compliance
• Step 7 – Prepare and transmit claims
1-24
1.8 The Medical Billing Cycle (Continued)
• Step 8 – Monitor payer adjudication
– Accounts receivable (A/R) is the monies owed to a
medical practice
– Adjudication is the process of examining claims and
determining benefits
• Step 9 – Generate patient statements
• Step 10 – Follow up patient payments and
handle collections
• A practice management program (PMP) is
business software that organizes and stores a
medical practice’s financial information
1.9 Working Successfully
• Professionalism is acting for the good of the
public and the medical practice
• Medical ethics are standards of behavior
requiring truthfulness, honesty, and integrity
– Thinking it Through, page 29
• Etiquette is comprised of the standards of
professional behavior
1-25
1.10 Moving Ahead
1-26
• Certification is the recognition of a superior
level of skill by an official organization
– Provides evidence to prospective employers that
the applicant has demonstrated a superior level of
skill on a national test