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Published byMyles Willis Modified over 9 years ago
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Insurance Lori Howard
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Terms n Claim n Premium n Deductible n Benefits n Primary Coverage n Secondary Coverage n Rider n Exclusions n Provider n Co-pay n EOB n UCR n HCFA 1500 n Itemized Bill n UB 92 n CPT code
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TYPES OF INSURANCE n Health »HMO »PPO »POS »Indemnity
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TYPES OF INSURANCE Hospitalization Accident Athletic Insurance Accidental Self Insurance
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TYPES OF INSURANCE n Catastrophic Insurance –NCAA »Benefits start after $50,000 and pay for lifetime »www.ncaa.org
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n NFSHSA Membership benefits Benefits start after $25,000 www.nfhs.org
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COORDINATE INSURANCE n (Ed Setting) –philosophy of administration –philosophy of physician –be familiar with your policy (exclusions)
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–know NCAA rules –get to know insurance coordinators at your provider’s offices –Consider buying a CPT code book
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COORDINATE INSURANCE –Be organized, have a system –Utilize time management –Get to know CSR at your insurance company
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CLAIM PROCESSING (Ed) n get insurance info prior to athletic participation n keep insurance files separate from medical files
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n Managed Care: find out how many athletes have it contact each one, speak to a manager, find out if athlete can see team MD, if he accepts UCR Coverage under Athletics Dept. policy
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CLAIM PROCESSING (Ed) –Try to have local PC physician assigned –Mark the files of athletes with managed care –Have a follow up system for checking the status of claims
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DO NOTS n wait until claim to get primary insurance information n say the institution will pay the claim n take responsibility for filing the primary claims n pre-pay from the athletic budget n wait to file the claim
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DO NOTS n assume CPT codes are correct n fail to check claims carefully
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IF A CLAIM IS DENIED n find out why n get statement from M.D. saying treatment was necessary n provide evidence from clinical studies n convince M.D. to waive fees above UCR n contact the state insurance commission and challenge denial
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INS. BILLING (Clinic) n services are dictated by a physician (must have a script) n paid directly from insurance companies n wait until have authorization from insurance company before initiating treatment
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CLAIM PROCESSING (Clinic) n fill out charge slip (super bill) n find out CPT codes n list charges & procedures daily n file claim on HCFA 1500 form n Have PT sign claim (not nec. In GA) n keep copy of pt claim in chart n enter claim into registry in patient chart
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CLAIM PROCESSING (Clinic) n mail claim to insurance company n make a note of date submitted n have a follow up system for checking the status n usually takes 4-6 weeks to receive payment n New year = new deductible
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PURCHASING INSURANCE n contact agents n get bids
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n TO SELECT & PURCHASE n monetary limits n exclusions/riders n primary/secondary/HMO’s n deductible n co-payments n who is covered n out of season injury
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TO SELECT & PURCHASE n annual premium n how to file claims
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