Transcript This would be title slide - University of Mississippi

CHAA Examination
Preparation
Pre-Encounter - Session V
Pages 62-69
University of Mississippi Medical Center
What to Expect…
• This module covers various aspects of
Patient Access knowledge found in pages 6269 of the Pre-Encounter section of the 2010
CHAA Study Guide.
• A quiz at the end will measure your
understanding of the content covered.
Medicaid
• Medicaid was established by federal
legislation in 1965 to provide health care
coverage for categories of low-income
people.
• States have the freedom to design their
program and decide:
– Eligibility standards
– What benefits and services to cover
– What payment rates to charge
Medicaid Qualifications
Medicaid Qualifications Include:
• Certain low income families with children
• Aged, blind or disabled people on Supplemental
Security Income
• Certain low income pregnant women and children
• Certain people who would not otherwise be eligible
but qualify as the result of catastrophic medical
expenses
Medicaid Miscellaneous
• Qualifying for Medicaid coverage is determined by
the patient MEETING SPECIFIC FINANCIAL
CRITERIA. Therefore, after eligibility is granted,
the beneficiary’s FINANCIAL STATUS is EVALUATED
on a REGULAR BASIS.
• Medicaid can contract with HMOs as determined by
each individual State.
MEDICAID IS A SECONDARY PAYER WITH RESPECT TO
MEDICARE
Worker’s Compensation
• This insurance coverage is for services
needed as a result of a work related
accident or injury.
• It is paid by the patient’s employer or their
Workers Compensation insurance company.
• The EMPLOYER MUST AUTHORIZE worker’s
compensation services.
Worker’s Compensation
Key Information
When registering a patient with a work related
injury/illness, be sure to obtain:
-Time and Date of Injury
-Type of Injury
-Name of employer and contact person
-Immediate Supervisor
-Employee Insurance Info (in case injury is deemed not
work-related)
Classify patient as ‘Workers Compensation’ and note who
should receive the bill.
Auto Insurance
• This is coverage for injuries that are the
result of an auto accident.
• If injuries are auto-related and patient has
Medicare or Medicaid as their primary
insurance, the AUTO INSURANCE would be
primary.
Liability Insurance
• Liability insurance is for injuries resulting from the
NEGLIGENCE of another party.
• If a patient slips and falls on a wet floor that WASN’T
POSTED WITH A SIGN, then the business could be
determined ‘liable’ for the accident and therefore
responsible for the medical bills.
• For Medicare Patients, liability should be IDENTIFIED by the
MEDICARE SECONDARY PAYER QUESTIONNAIRE.
• Liability Insurance should be billed PRIOR TO BILLING
MEDICARE.
COMMERCIAL INSURANCE
This is any insurance that IS NOT:
Medicare/Medicaid
Federal, State, or County Programs
Workers Compensation
BLUE CROSS
Auto
PPO or HMO
Patients with commercial insurance are NOT REQUIRED to
select a PRIMARY CARE PHYSICIAN or go to a SPECIFIC
PROVIDER.
Preferred PROVIDER
Organization (PPOs)
PPOs are contracts between EMPLOYERS, DOCTORS,
and HOSPITALS.
For PPOs:
• Doctors and hospitals agree to provide their services
at a discount in return for getting a large volume of
patients who are PPO members.
• Members are NOT REQUIRED to select a Primary
Care Physician.
• However, they MUST use a PARTICIPATING PROVIDER
to obtain FULL COVERAGE.
Health MAINTENANCE
Organization (HMOs)
HMOs are insurance plans that strive to control health
care costs by requiring members to receive services
at DESIGNATED FACILITIES.
For HMOs:
• Typically, patients must choose a PRIMARY CARE
PHYSICIAN (PCP) who will be responsible for the
oversight of all the patient’s healthcare.
• All services, except those in life threatening
situations, must be approved by the PCP.
• Most HMOs identify the policy holder with a suffix of
-00, the spouse as -01, and subsequent dependants
as -02, -03, etc.
PPO vs. HMO
PPO
HMO
• Between employers, • Strive to control
doctors, and
health care costs by
hospitals
using Designated
Facilities
• Beneficiaries must
use Participating
• Members must
Providers to obtain
choose a PCP
full coverage
• Use suffix -00, -01,
-02, etc.
Tricare
•
•
•
•
•
Tricare is a health care program overseen by the
Department of Defense.
Tricare Prime – all active duty service members are
enrolled in this program which is similar to an HMO.
Tricare Extra – Similar to a PPO
Tricare Standard – Fee for service option
Tricare for Life – Provides expanded coverage for
Medicare eligible beneficiaries
CHAMPVA – Health coverage for families of veterans
with 100% service connected disability and the
surviving spouse or children of a veteran who dies
from service related disability
Payer Websites
It’s acceptable to verify only basic information via
website. Information such as:
-Date coverage began
-Is the policy active or inactive
-Is patient the policy holder or a dependant
-Deductible and co-pay information
It’s preferable to speak to a representative for
accurate coverage information regarding specific
service coverage and if precertification/authorization is needed.
Common Working File (CWF)
This verification system is LINKED TO MEDICARE and is a
tool for verifying:
• Part A and B status and effective dates
• If the patient has Medicare Advantage Plan (Part C)
• If the patient or spouse is employed and/or covered by
employee insurance
• If a case is open for a patient where they were involved
in an accident where a third party may be responsible for
payment
• Number of full/partial days remaining in the benefit
period or the number of SNF days remaining
• If the patient is on Hospice care
Verifying Medicaid
Medicaid can be verified through your State’s
website and/or their Common Working File
Verification System
Verification of Benefits
The first step in verifying benefits is calling the
insurance company to confirm eligibility. The
insurance company will tell you what services are
covered and if the member is currently eligible.
The following items need to be confirmed:
1. PRE-CERTIFICATON/PRE-AUTHORIZATION – some
insurance companies require this from the PCP prior
to services.
Verification of Benefits
2. OUT-OF-POCKET MAXIMUM – the maximum amount of
money toward eligible expenses that A COVERED
PERSON MUST PAY for themselves and/or dependants in
a year. Once this limit is reached, benefits will
increase to 100%.
3. DEDUCTIBLE – the amount of eligible expenses a covered
person must pay each year from their own pocket
before the plan begins paying for eligible expenses.
4. CO-PAYMENT – A predetermined payment that must be
made by the covered beneficiary at the time of service.
Verification of Benefits
5. CARVE OUT – this is where certain benefits are
offered by a specialized vendor on a stand-alone,
as needed basis.
6. LIFETIME MAXIMUM – Many payers have a calendar
year and lifetime maximum on benefits paid. Once
maximum is reached, benefits are exhausted.
7. VERIFICATION OF PHYSICIAN – This is making sure
the attending physician is on the panel for the
patient’s insurance. If not, patient may have to
pay more.
Coordination of Benefits
(COB)
• COORDINATION OF BENEFITS is the term used
to describe determining the order in which
benefits are paid, and the amounts that are
payable WHEN A PATIENT IS COVERED BY
MORE THAN ONE HEALTH INSURANCE
PLAN.
• It’s intention is to prevent DUPLICATION OF
PAYMENTS.
Coordination of Benefits
(COB)
• When children are covered under both
parents’ insurance plans, you apply the
BIRTHDAY RULE.
• That is, the plan of the parent whose
birthday (using both month and day) occurs
earlier in the year is primary.
Coordination of Benefits
(COB)
Regarding children when parents are not together,
you ALWAYS OBEY THE COURT DECREE.
When no court decree exists, follow this order:
• The plan of the parent with custody is Primary
• The plan of the stepparent with custody is
Primary
• The plan of the parent who does not have
custody is Primary
• The plan of the non-custodial parent is Primary
Authorization &
Medical Necessity
• AUTHORIZATION means that, “based on the
information provided, all the requirements are
satisfied under the benefits health plan for medical
necessity,” and the payer will pay for the service.
• MEDICAL NECESSITY describes a health care service
that a provider, EXCERCISING PRUDENT CLINICAL
JUDGEMENT, would provide to a covered person for
the purpose of evaluating, diagnosing, or treating an
illness, injury, disease or its symptoms.
– In other words, the treatment is appropriate and
necessary.