Health Insurance Systems

Health Insurance Systems
Chapter 16 Health Insurance Systems

Objectives Review the learning and performance objectives for this chapter By the end of this chapter, demonstrate the procedures in the textbook and the job skills in the workbook

Heart of the Health Care Professional
Service By taking care of insurance requests or problems in an efficient and expedient manner, you will serve patients’ needs.

Introduction to Insurance
Claims processing Basic format Input requirements Time limits Deductible, coinsurance, copayment Insurance terminology

Third-Party Payers Three entities Patient Provider
Receives medical care Provider Supplies medical care Public or private payer Bears the cost of medical care

Third-Party Payers Types of insurance Commercial Insurance
Owned and run by private companies Indemnity insurance Protection against injury or loss of health Pays when individual is ill or injured

Third-Party Payers Types of insurance Group insurance Self-insurance
Obtained through employer or club Conversion privilege Self-insurance Employer or group assumes risk Funds their own plan

Third-Party Payers Insurance benefits The Insurance Policy
Major medical The Insurance Policy Waiting period Dependents Preexisting conditions Exclusions

Third-Party Payers Coordination of benefits Nonduplication of benefits
If insured has more than one policy Benefit cannot be more than fee charged

Third-Party Payers Methods of payment Fee schedule Capitation
Usual, Customary, and Reasonable (UCR) Relative Value Studies (RVS) Capitation Managed care plans Prepaid per capita

Third-Party Payers Physician's Fee Profile Computerized records
Payment data Statistical summary/fee pattern

Insurance Plans and Programs
Managed Care Plans Primary Care Physician Gatekeeper Referrals Formal Direct Verbal Self

Managed Care Plans Precertification Is the service covered? Predetermination How much will insurance pay? Preauthorization Is the service medically necessary?

Managed Care Plans Medical Review Professional Review Organizations (PRO) Evaluate quality of professional care Settle fee disputes

Managed Care Plans Types of managed care organizations Health Maintenance Organizations Preferred Provider Organizations Independent Practice Association Physician Provider Groups Point-of-Service Plans

Managed Care Organizations
Different Types of Health Maintenance Organizations

Medicaid Eligibility Low income, blind, disabled Claim Submission Use of CMS-1500 form Time Limit Varies by state

Medicare Eligibility Age 65 Blind or disabled Chronic or end-stage kidney disease Kidney donors

Medicare Part A – Hospital Insurance Benefits Part B – Supplementary (Outpatient) Part C – Managed Care Part D – Prescription Drugs

Medicare Medicare fee schedule Participating amount Nonparticipating amount Limiting charge

Medicare Participating Physician Accept assignment Payment sent to physician

Medicare Nonparticipating Physician Does not accept assignment Payment sent to patient Patient pays physician

Medicare Claim Submission Time limit CMS-1500 form Cannot charge for completion of form

Medicare Remittance Advice Explains payment Accompanies payment check Medicare Summary Notice Sent to patient

Medicare Medicare Cost Containment Tax Equity and Fiscal Responsibility Act Peer Review Organizations Civil Monetary Penalties Law Deficit Reduction Act Stark I and II Regulations

Medicare Medicare-Medicaid Medicare is primary Medicaid is secondary Crossover claim Time limit

Medicare Medicare/Medigap Covers deductible and copayments Medicare Secondary Payer (MSP) Individual still employed Insurance through employer is primary Medicare is secondary

TRICARE Dependents of military personnel TRICARE Standard Eligibility Defense Enrollment Eligibility Reporting System Benefits Tables 16-7 and 16-8

TRICARE TRICARE Extra Preferred Provider Organization TRICARE Prime Managed care option Annual fee per person/family Nonavailability statement

TRICARE TRICARE for life Supplement to medicare Eligibility Payment guidelines TRICARE Plus Eligible for care in MTF Not enrolled in prime or commercial HMO

TRICARE TRICARE claims submission Provider submits claim CMS-1500 form 60 day time limit

CHAMPVA Eligibility Veterans and dependents Total, permanent, service-connected disability Claims submission and time limit VA Form A 60 day time limit

State Disability Insurance Off-the-job injury or illness Only in five states and Puerto Rico Claims submission Time limit varies by state

Workers’ Compensation Illness or injury at work Covers medical bills and lost wages Workers’ Compensation Laws Mandatory in all states

Workers’ Compensation Types of disability Nondisability Temporary disability Permanent disability

Workers’ Compensation Reports Initial report must be filed Figure 16-10 Report from each subsequent visit

Workers’ Compensation Fee Schedule Example 16-3 Bills to insurance carrier Claims Submission Time limit varies by state

General Guidelines for Handling Insurance Claims
Insurance Identification Card Copy both sides and keep on file Figure 16-11 Patient Registration Form Verify current information at each visit

Assignments and consent/authorization Two forms to sign Assignment of benefits statement Consent to release information to insurance Keep on file

Completing the claim Use new revised CMS-1500 Form (08/05) Proofreading Proofread every claim Signatures Sign every claim

Posting to the account Indicate insurance has been billed Provider Identification Numbers National Provider Identification (NPI) Replaces UPIN, PIN, local insurance numbers Implementation date: Electronic submission 5/23/07; small health plans 5/23/08 Mandate of HIPAA

Claims submission Paper Subject to increasing delays Electronic Provider’s signature filed with carrier Patient’s signature filed with provider

Insurance Claims and Accurate Coding
Watch the video clips: CMS-1500 form and accurate coding MA Testimonial – CPT Coding The Coding Process

Coding for Professional Services
CPT Code Book Procedure Codes HCPCS Level II Codebook Those not fully described in CPT RVS Code Book Workers’ Compensation

Terminology Codebook Terms Accurate description of professional services New patient Established patient Concurrent care

Terminology Codebook Terms Critical care Emergency care Counseling Consultation Referral

Terminology Codebook Symbols Indicate new code and description changes Figure 16-13 Key Terms in Documentation Technical descriptors that change code or determine need for modifier

Terminology Reimbursement Terminology Downcoding Upcoding Bundled Codes Unbundling

Codebook Sections - Table 16-4 Evaluation and Management Section Includes preventive medicine Table 16-5 Anesthesia Section Anatomic site Type of anesthetic

Codebook sections Surgery How to code from the surgery section Surgical supplies Surgical package rules Follow-up days Medicare global package

Codebook sections Radiology Body part Number of views Type of view

Codebook sections Pathology and laboratory Type of test Medicine Services not surgically invasive Injections Vision and hearing

Code modifiers Table 16-7 More accurate description Codebook appendices 13 Appendices

Unlisted procedures Check Category III Temporary codes Select correct procedure codes Procedure 16-1

Diagnostic Coding ICD-9-CM International Classification of Diseases
Final diagnosis Sign or symptom Table 16-8

Diagnostic Coding Terminology Abbreviations Punctuation Symbols
NEC, NOS Punctuation Example 16-10 Symbols

Diagnostic Coding Volumes I and II Start in Volume II Go to Volume I
Alphabetic Index Go to Volume I Tabular List

Diagnostic Coding V Codes E Codes Supplementary codes
Known condition/disease Not currently sick E Codes Index of external causes

Diagnostic Coding Select correct diagnostic codes ICD-10-CM
Procedure 16-2 ICD-10-CM 10th Revision Expected in 2010

Health Insurance Claim Form CMS-1500
Most widely used and accepted For outpatient services Complete the health insurance claim form CMS-1500 using OCR guidelines Procedure 16-3

Tracing Insurance Claims
Have a follow-up procedure Pending claims File in chronological order Unprocessed/unpaid claims Follow-up Resubmit if necessary

Tracing Insurance Claims
Appeals Guidelines set by carrier Medicare has five levels Redetermination Reconsideration Administrative Law Judge Department Appeals Board Review Federal Court Review

Stop and Think Determination of benefits Review the scenario
Consider which process is necessary for each question

Stop and Think Submission of a late medicare claim Review the scenario
Using the date November 22, 2007, is it too late to submit this claim? What is the deadline date by which the claim must be submitted?

Stop and Think Determine TRICARE coverage and benefits
Review the scenario Answer the questions the patient asks about how the claim will be processed and what her payment responsibilities will be

Stop and Think Determine the responsible party in an injury case
Review the scenario What questions should you ask the patient (or person accompanying the patient) to determine who will be paying the medical bill?

Health Insurance Systems

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