1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 3 Understanding Managed Care: Medical Contracts and Ethics

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Compensation and Billing Guidelines  The contract should clearly state how and when provider is to be paid.  The forms used for claims submission should be clearly stated.

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Compensation and Billing Guidelines  All arrangements with regard to coordination of benefits and late payments should be clearly spelled out.  Be aware of any “rebundle,” which means to cover services in a single bundled fee.

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care Contracts Should List the Following:  Schedule of benefits: A list of medical services covered under the contract  Preventative medical services and types of office visits  Capitated procedures: Which office procedures are, and are not, covered

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care Contracts Should List the Following:  CPT codes: Procedure codes and rates for each service  Time limit for submitting claims  Which form to use for submitting claim  Time limit for receiving payment and what reimbursement charges for late payment

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Clinton Administration Attempts to Change Healthcare  The need for change was widely agreed upon.  The type and scope of changes was widely disagreed upon.  They advocated a strong governmental role.  Proposal was soundly defeated by general populace.

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care and Business Principles  Corporate business values are influencing the traditional medical ethics and values of the solo practitioner: the one-on-one doctor-patient relationship and fee-for- service payment –Efficiency –Cost reduction –Inventory management –Competition –Profit

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Healthcare Limits  System cannot support unlimited demands for care.  Providers no longer manage practices.  Practices are managed by accountants and managers.  Medical and business values are merging.

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care Plan Credentialing  Governed by National Committee for Quality Assurance  MCO reviews providers’ background for fraud, criminal activity, disciplinary actions, and malpractice history.  There is no guarantee that one provider is better than another.  The MCO grades physicians on services rendered.

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Ethics of Medical Office Specialist  Ethics are rules or standards governing the conduct of a person or members of a profession.  The medical office specialist is the liaison between patient and provider, and provider and carrier.  The specialist must know the Patient’s Bill of Rights and the MCO’s contractual guidelines.

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Fraudulent Behavior  The medical office specialist can be held liable for fraudulent billing.  The provider and medical office specialist can both be prosecuted for fraudulent behavior.

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Benefit plan: Contract issued by a payer, the plan document, or any other legally enforceable instrument under which a covered person may be entitled to covered services and which is in force with respect to such covered person.

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Contracted services: Covered services provided by the physician that are consistent with the physician’s training, licensure, and scope of practice  Coordination of benefits (COB): Determination as to which of two or more health benefit plans will provide health benefits for a covered person as primary or secondary payers

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Copayment: Charge the covered person is required to pay at the time of service  Covered person: An individual who is an insured, enrolled participant or enrolled dependent under a benefit plan.

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Emergency Services: –Services provided after a sudden onset of a medical condition –The absence of service would result in:  Placing the person’s health in serious jeopardy  Serious impairment to bodily functions  Serious dysfunction of any bodily organ or part

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Fee maximum: Maximum allowable fee payable by the corporation or payer for the provision of a given contracted service by a physician to a covered person  Medical director: The physician specified by the corporation as its medical director.

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Medically Necessary: Refers to the use of services or supplies (or both) that: –Are accepted as appropriate and effective treatment for condition –Are based on recognized standards of healthcare specialty involved –Are not investigative, experimental, or unproven

18. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Medically Necessary: Refers to the use of services or supplies (or both) that: –Are not solely for the convenience of covered person or healthcare provider –Do not involve greater resources than required for adequate care

19. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts  Participating hospital: State-licensed hospital designated as a participating provider  Participating provider: A licensed healthcare provider, including a physician or a facility  Payer: An insurance company, third-party administrator, or self-insured benefit plan that is contractually obligated to pay for services

20. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient’s Bill of Rights  Information Disclosure: Right to accurate and easily understood information  Choice of Providers and Plans: Right to choose healthcare provider  Access to Emergency Services: If you are convinced your health is in jeopardy due to sudden onset of pain, accident, or illness, you may be treated without prior authorization and with financial penalty

21. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient’s Bill of Rights  Participation in Treatment Decisions: The right to know your treatment options  Respect and Nondiscrimination: The right to receive respectful, considerate, and nondiscriminatory care

22. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient’s Bill of Rights  Confidentiality of Health Information: The right to talk in confidence with your physician, and to have your healthcare information protected  Complaints and Appeals: The right to a fair, fast, objective review of your complaint