Transcript Behavioral Emergencies - Vista Unified School District

Medical Office Administration
2nd edition
Brenda A. Potter, CPC
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Chapter 11
Health Insurance and Health
Benefits Programs
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Important Information about
Insurance Processing
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Regulations constantly change
Obtain most current information direct from
insurance plan or program
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3
Insurance Terminology
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Contract, policy
Insurer
Premium
Insured,
policyholder,
subscriber
Beneficiary
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Copayment
Coinsurance
Claim
Deductible
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4
Centers for Medicare and Medicaid
Services (CMS)
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Agency of federal government
Oversees Medicare, Medicaid, State
Children’s Health Insurance Program
Programs service more than 90 million
people
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5
CMS-1500 Claim Form
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Form used for most insurance claims
Used by both public and private insurance
Each insurance plan develops its own
requirements for completion of CMS-1500
Used for paper claims
OCR equipment used to process claims
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Electronic Claims Processing
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Preferred method of filing insurance claims
Process can speed up payments and save
mailing costs
Errors corrected easily
Claim status available online
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7
Life Cycle of a Claim
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Necessary insurance information gathered at
registration
Superbill generated and completed
Claim created and sent to insurance plan
Insurer checks patient and provider
information and coverage
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8
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Insurer determines UCR fee
EOB completed and sent to patient and
insurer
Payment made to appropriate party
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9
Coordination of Benefits
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Ensures that health expenses are not paid
twice
Determines the primary and secondary
insurer
Birthday rule

determines primary insurance for dependents
covered by two policies
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10
Troubleshooting Claims
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Mistakes anywhere in the claims process can
cause an error on a claim
Mistakes delay receipt of payments
Mistakes often corrected by verifying
information in patient’s medical record
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11
Timelines for Filing
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Each plan sets deadlines for filing claims
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12
Filing an Appeal
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Insured may appeal decision of an insurance
plan
Amounts paid or denials can be appealed
Time limits usually apply for appeals
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13
Managed Care
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Restricts healthcare choices for patients
Limits referrals and services without approval
Patients usually required to use certain
providers in a particular network
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14
Fee-for-Service
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Insurance plan pays only when patient
receives services
If patient is not seen, insurance company
pays nothing
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15
Health Maintenance Organization (HMO)
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Prepaid health care
Insurance company pays flat fee every month
Patients may be required to choose primary
clinic or physician
Referrals often required for services from a
specialist
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16
Preferred Provider Organization (PPO)
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Network of healthcare providers
Contract with PPO to provide healthcare
services at a discount
Patients may be required to choose primary
clinic or physician
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17
Medicare
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Largest health insurance program in U.S.
Provides health benefits for individuals

65 and over or
 Permanently disabled or
 End-stage renal disease
 Amyotrophic lateral sclerosis (ALS; Lou Gehrig’s
disease)
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18
Medicare Coverage and Enrollment
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Part A – Hospital
Part B – Medical Insurance
Part C – Medicare Advantage plans
Part D – Prescription drug coverage
Enrollment in some parts is automatic; some
is not
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19
Medicare Part A
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Covers inpatient care, skilled nursing facility,
hospice, home health care
Premium = most people do not pay for part A
coverage
Deductible = $1024 per benefit period (in
2008)
coinsurance applies to some hospital and
nursing home stays
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20
Medicare Part B
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Covers physician’s services, outpatient care,
some preventative care, immunizations,
ambulance
Premium = $96.40 (in 2008)
Individuals must enroll (not automatic)
A coverage
Deductible = $135 per year (in 2008)
Coinsurance = 20% of Medicare approved
amount (less deductible)
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21
Medicare Part C
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Provides HMO, PPO coverage
Different plans available
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22
Medicare Part D
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Prescription drug coverage
Individuals must enroll (not automatic)
Premium, deductible, coinsurance vary from
plan to plan
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23
Processing Medicare Claims
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Fiscal intermediary – insurance plan
processing Part A claims
Carrier – insurance plan processing Part B
claims
Intermediary or carrier answers questions
pertaining to a claim
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24
Medicare Assignment
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PAR – participating provider
A PAR agrees to accept what Medicare
approves as payment in full
PAR may not charge a patient more than the
approved amount
If provider is not a PAR, limiting charge may
apply
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25
Advance Beneficiary Notice (ABN)
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Medicare document
Patient must sign if Medicare may not cover
care
Purpose is to inform patient
that Medicare may deny
claim for services
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26
Medigap
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Policy to help cover costs Medicare doesn’t
cover
Must be purchased by patient
Twelve different plans
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27
Medicaid
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Medical assistance
Federal program providing benefits for lowincome families and medically needy
individuals
Supported by federal and state dollars
Physicians must accept Medicaid payments
as payment in full
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28
Medicaid Eligibility
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Low income
SSI recipients
Medically needy
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29
Medicaid Coverage
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Federal government mandates minimum
coverage
Basic coverage must be provided in each
state
State may add additional coverage
Medicaid restriction program
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30
Medicaid Payments
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Benefits paid directly to provider
Some states have small deductible or
copayments
Dual eligibles – patients covered by Medicare
and Medicaid
Medicaid – payer of last resort
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31
State Children’s Health Insurance
Program (SCHIP)
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Provides health insurance to uninsured
children
Children don’t qualify for Medicaid because
income is above limit
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32
TRICARE
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Health benefits for active duty service
members, retired military, families, survivors
Beneficiaries registered in Defense
Enrollment Eligibility Reporting System
(DEERS)
Several health and dental plans available
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33
CHAMPVA
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Civilian Health and Medical Program of the
Department of Veterans Affairs
Health coverage for dependents of veterans
who have total, permanent disability, or
survivors of persons who died in the line of
duty
Sponsor – military member on which eligibility
is based
Beneficiary – individual receiving benefits
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34
Workers’ Compensation
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Covers persons suffering from work-related
injuries
Each state responsible for structuring
workers’ compensation
Can be state funded, self-insured, private
insurance or combination
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35
Claim Processing for Workers’
Compensation
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Injured worker must complete first report of
injury in timely manner
Time limits apply for reporting injury
Providers required to file periodic reports for
patients requiring extended treatment
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36
Private Health Insurance
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Group insurance
Obtained through employer
Basic coverage – hospital
Major medical – office visits
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37
Blue Cross/Blue Shield (BCBS)
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National association
Composed of independently owned and
operated plans in each state
Blue Cross – hospital coverage
Blue Shield – physician services
Providers may agree to be participating
UCR – usual, customary, reasonable fees
may be applied
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
38
Disability Insurance
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Partial income replacement for individuals
Does not cover medical care
Provides payments if individuals can’t work
Physicians may be required to document
patient’s disability
Patient will need to provide form for
documentation
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39
Long-Term Care Insurance
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Helps cover cost of nursing home care
Nursing home patients may need to apply for
Medicaid
Healthy spouse protected from losing
everything in order to care for ill spouse in
nursing home
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40
Insurance Resources
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Internet resources provide valuable up-todate information
Regional CMS office can provide information
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
41
Insurance Fraud and Abuse
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Fraud – willful act to deceive
Abuse – more difficult to determine because
not as blatant
Example:
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Billing for services never performed
 Billing for unnecessary items
 Inflating charges
 Misrepresenting patient’s diagnosis for higher
payment of benefits
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Reporting fraud or abuse is encouraged
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
42
Confidentiality
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
Patient’s bill contains diagnosis and
procedure information
Bill information cannot be released without
permission
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43
COBRA
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Consolidated Omnibus Budget Reconciliation
Act
Allows employees to keep health insurance
coverage for a limited time after leaving a job
Employee must pay for coverage; employer
not expected to pay
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44
Insurance Industry Statistics
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In 2006, 15.8% of people in U.S. (47 million)
did not have health insurance
In 2006, 30% of remaining were covered
under Medicare, Medicaid, or military health
care
Remaining 54% covered by some type of
health insurance
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45