1. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Basics of Health Insurance Chapter 6

2. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 2 This chapter will examine: The purpose of health insurance Types of insurance policies How insurance benefits are determined Types of and use of fee schedules Preauthorizations and precertifications Major third-party payors

3. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Definition of 'Health Insurance' A type of insurance coverage that pays for medical and surgical expenses that are incurred by the insured. Health insurance can either reimburse the insured for expenses incurred from illness or injury or pay the care provider directly. Health insurance is often included in employer benefit packages as a means of enticing quality employees.

4. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 4 Introduction Health Insurance is designed to help individuals and families offset the cost of medical care. There are many types of health insurance available, but many individuals in the United States are not covered by any type of health insurance plan.

5. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 5 Cycle of Health Insurance The medical assistant plays a part in the provider’s reimbursement by providing accurate information on claim forms. Follow-up is sometimes necessary to make certain that claimsالمطالبات are paid correctly and in a timely manner.

6. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 6 Cycle of Health Insurance Obtain information from the patient and insured. Verify the patient’s eligibility and benefits. Perform diagnostic and procedural coding Calculate deductibles and co-insurance amounts.

7. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 7 Cycle of Health Insurance Obtain preauthorization or permission, if applicable, for referral if advance permissions is needed. Complete the insurance claim form and submit it to the third-party payor. Post payments sent by insurance carriers. Bill the patient for remaining balances. Follow up on rejected or unpaid claims.

8. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 8 Cost of Coverage Patients may have to pay certain expenses related to their health coverage. Deductibles – Amounts paid out of pocket before insurance will pay on a health claim Copayments – Amount paid at the time of service Co-insurances – Percentage paid by insured before insurance pays on a claim

9. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 9 Types of Health Insurance Group policies These policies cover a number of people under a single master contract issued to an employer or other association of individuals.

10. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 10 Types of Health Insurance Individual policies Usually more expensive than group policies, these are usually purchased by individuals who do not have access to any other type of health insurance.

11. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 11 Types of Health Insurance Government plans Sometimes called entitlement programs, these plans are sponsored by some branch or division of the government; examples include Medicare, Medicaid, TRICARE, and CHAMPVA.

12. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 12 Types of Health Insurance Medicaid A government program designed for medically indigent individuals who meet specific eligibility criteria

13. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 13 Types of Health Insurance Medicare A program established by the federal government for persons 65 and older, as well as persons with certain disabilities

14. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 14 Types of Health Insurance Workers’ compensation Laws that protect workers against the loss of wages and cost of medical care resulting from an occupational accident or disease

15. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 15 Types of Health Insurance Self-insured plans Often offered by large employers, which put a certain amount of money in an account per month, per employee; eligible medical bills are paid from that account.

16. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 16 Types of Health Insurance Medical savings accounts Tax-free accounts that allow the individual to make tax- free deposits into the account; the money is in turn used for medically related expenses

17. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 17 Health Insurance Providers Managed care plans Provide healthcare in return for preset scheduled payments. Care is coordinated through a network of contracted physicians and hospitals.

18. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 18 Advantages of Managed Care Costs are usually contained. Fee schedules are established. Authorized services are usually paid. Preventative treatment is usually covered. Patient out-of-pocket expenses are usually minimal.

19. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 19 Disadvantages of Managed Care Access to specialized care and referrals can be limited. Physician choices may be limited. Paperwork may increase. Treatment may be delayed because of preauthorization requirements. Reimbursement is historically less than through traditional insurance.

20. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 20 Models of Managed Care Health Maintenance Organization (HMO) Preferred Provider Organization (PPO)

21. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 21 HMO Contracts with a medical center or group of physicians to provide preventative and acute care for the insured Regulated by HMO laws Always require referrals to specialists

22. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 22 PPO (Preferred Provider Organization) Preserves the fee-for-service concept. Predetermined list of charges is contracted with providers. No capitations or prepaid care. Usually has deductibles and/or copays. Rates for services usually lower than for non-PPO patients.

23. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 23 Capitation Plans Found in HMOs. Providers are paid per member, per month. Patients may not even see the provider, yet he or she is paid a fee for that month.

24. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 24 Exclusive Provider Organization Employers agree not to contract with any other plan. Members must choose from a list of network providers. Exceptions are made for emergency and out-of-town care.

25. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 25 Medicaid Federal government assists states in providing healthcare services. States individually elect to provide funds for extension of benefits. Physicians may decide whether to treat patients with Medicaid coverage.

26. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 26 Medicaid ID Card

27. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 27 Qualifiers for Medicaid Medically needy Recipients of Aid to Families with Dependent Children Recipients of Supplemental Security Income (SSI) Persons receiving certain types of state aid Some Medicare qualifiers Persons in institutions or receiving long-term care in nursing facilities and intermediate care facilities

28. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 28 Medicare Qualifiers include: People 65 or older People who are permanently disabled or blind People receiving dialysis for permanent kidney failure or who have had a kidney transplant

29. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 29 Medicare Administration Medicare is administered by the Centers for Medicare and Medicaid Services Formerly known as the Healthcare Financing Administration (HCFA) Division of the Department of Health and Human Services

30. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 30 Medicare Parts A and B Part A Inpatient hospital care Skilled nursing facilities Home healthcare Hospice services Part B Outpatient hospital care Durable medical equipment Physician’s services Other medical services

31. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 31 Medicare Part “C” Medicare + Choice Expanded benefits similar to those of HMOs and PPOs

32. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 32 Medicare Part D Drug and prescription benefits. Drug plan is chosen at a reduced cost. Usually a small copayment is required.

33. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 33 Medicare ID Card

34. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 34 TRICARE Formerly CHAMPUS. Comprehensive healthcare program for military dependents and retirees. Expands access to healthcare. All military hospitals and clinics are a part of TRICARE.

35. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 35 TRICARE Choices Prime – similar to a civilian HMO Extra – similar to a civilian PPO Standard – traditional fee-for-service option

36. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 36 CHAMP VAشؤون المحاربين القدامى( Veterans Affairs Veterans Affairs Similar to TRICARE. Established for spouses and dependent children of veterans who have total, permanent, service-related disabilities. Most participants receive services at VA hospitals. Va : Veterans Affairsشؤون المحاربين القدامىVeterans Affairs

37. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 37 Worker’s Compensation Protects wage earners against the loss of wages and the cost of medical care after an occupational accident or illness. Always check for coverage when the patient mentions a work-related illness. Benefits include medical care, weekly income replacement benefits, permanent disability settlements, and more.

38. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 38 Disability Programs Form of health insurance Provide periodic payments to replace income Can be obtained through employer-sponsored and/or government-funded programs

39. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 39 Commercial Insurance Issued by private companies Secured through employers or individually Payment usually made to subscribers unless authorization is given to pay providers

40. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 40 Verification اثباتof Insurance Benefits Identify type of insurance coverage when the patient first calls the office. Photocopy both sides of the insurance ID card. Contact the insurance carrier to verify coverage and eligibility.

41. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 41 Verification of Insurance Benefits Document information in the patient’s medical record. Explain covered and noncovered procedures and services to the patient, if necessary. Explain the referral procedure to the patient. Collect copayments and/or deductibles.

42. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 42 Precertification or Preauthorization Information needed: Patient name, address, phone number Patient ID number Provider name and information Plan name and address Preliminary diagnosis Planned procedures and treatments Facility addresses and phone numbers Copayments and deductibles Hospital benefits Participating facilities

43. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 43 Referrals Can take a few moments or a few days. Urgent referrals usually are done within 24 hours. Regular referrals most common.

44. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 44 Utilization Management Making certain that medical care is necessary for the patient Utilization review committees determine whether certain procedures are medically necessary, which may influence reimbursement amounts

45. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 45 The Federal Register Official daily publication for rules, proposed rules, and notices of federal agencies and organizations Sponsored by the Office of the Federal Register (OFR)