Medical Insurance Chapter 18 ICBS 120

Understanding the Role of Health Insurance Designed to help individuals and families compensate for high costs of medical care. Consists of diagnoses of diseases/disorders and care/treatment. Includes preventative services. Contract between a policyholder and a third-party government program May not cover sufficiently proven procedures.

Medical Insurance Terminology Beneficiary – person covered under the terms of the policy. Coinsurance – percentage paid by insurance company or the insured (can vary 50% – 100%) Deductible – an amount of money that the insured must incur before medical services for the policy begin to pay. Co-payment – a payment made at the time of service; $5 to $20.

Medical Insurance Terminology Preexisting Condition – if a person had an illness, disease, or injury before the inception of insurance. Exclusions – non-covered services such as cosmetic surgery, elective procedures, dental or chiropractic services, or routine eye exams. Birthday Rule – when children of married parents are covered under both policies, the birthday of the parent falling earlier in the year is primary. If parents share the same birthday, then the policy with the earlier inception date is primary.

Terminology Billing Insurance Carriers Preauthorization – obtaining an insurance carrier’s consent to provide care and treatment to patient prior to doing so Claim – demand for payment, submitted to the insurance carrier on behalf of the patient Contains all identification information necessary to process/analyze the claim for payment Name, address, telephone number, group number and identification number, diagnosis code(s), CPT code(s), charges, and provider of service

Types of Medical Insurance Traditional Basic insurance – covers a specific dollar amount for physician fees, hospital care, surgery, and anesthesia Major medical insurance – developed to cover the costs of catastrophic expenses from illness or injury Many traditional policies require the patient have a primary care physician (PCP) and coordinate all their care through that physician

Types of Medical Insurance Managed Care Patients must stay inside physician network Co-pay at each visit No annual deductible Preventative treatment, as well as injury and illness Premium paid monthly by employer or subscriber Physician paid by capitation (a fixed fee for each patient no matter the number of times that patient is seen)

Types of Medical Insurance Traditional Care Patients can go outside physician network Coinsurance Annual deductible Illness or injury only Premium paid by employer or subscriber MD paid by fee for service

Six Primary MCO Models (Managed Care Organizations) EPOs (Exclusive Provider Organization) IDSs (Integrated delivery systems) HMOs (Health Maintenance Organization) POS (Point-of-Service Plan) PPO (Preferred Provider Organization) Triple Option Plan

Medicare Largest medical insurance program for individuals 65 years and older, individuals with a disability and chronic kidney disease. Medicare has two parts of coverage Part A – covers hospitalization, home health care, and hospice care Part B – covers outpatient services, including physician services, physical therapy, occupational therapy, diagnostic tests, lab tests, radiological studies, ambulance services, and durable medical equipment

Medicaid Covers medical care for certain qualified low-income individuals Not all physicians accept Medicaid patients. Medicaid is secondary to any supplemental insurance and is billed second.

CHAMPUS AND CHAMPVA TRICARE, formerly CHAMPUS (Civilian Health and Medical Program for Uniformed Services) Covers dependents of active duty personnel, retired military personnel, dependents of retired personnel, and dependents of personnel who died while on active duty. Three TRICARE options are available: HMO, PPO, and fee for service

CHAMPUS AND CHAMPVA CHAMPVA (Civilian Health and Medical Program of the Veteran’s Administration) Medical insurance for spouses and unmarried dependent children of a veteran with a permanent total disability resulting from a service-related injury. The surviving spouse and children of a veteran who died of a service-related disability.

CHAMPUS AND CHAMPVA CHAMPUS and CHAMPVA are billed after all insurance coverage except Medicaid. Preauthorization is required for patients living within a catchment area for treatment. Catchment – 40 mile radius of a military base where medical care is available to military dependents

Worker’s Compensation State Industrial Insurance Is medical and paycheck for workers who sustain injuries associated with their employment Employer usually pays the premium to the state or an insurance carrier Covers 100% of associated medical expenses The injured worker receives no bills, pays no deductible or coinsurance, and is covered 100 percent for medical expenses related specifically to that injury.

Screening for Insurance Some physicians may see patients regardless of ability to pay for the services Mandatory treatment Certain qualifying conditions Financial screening Some situations may include the patient who is eligible for Medicaid but has not yet applied, or the patient who has applied for Medicaid but has not yet received notification of qualification.

Screening for Insurance Be sure to obtain insurance information, verify coverage, obtain referral and any needed authorizations BEFORE providing treatment Always ask: Is the patient covered by insurance? Is this procedure covered by the insurance? Is the primary care provider performing that procedure? Is a referral required? Is an authorization number or authorization code required?