rma health insurance

What is health insurance?

a contract requiring the insurer to pay some or all of the insured's healthcare costs

What is a premium?

monthly fee paid in order to have medical insurance

What should you ask yourself as a MA before verifying a pt's insurance plan?

Do I need to collect a co-payment?, Is a referral required?, Is the policy active?, What kind of plan is it?

co-payment

fixed dollar amount the pt pays for a covered service. Amount can vary by type of service

co-insurance

pt's share of costs, calculated as a percentage of the allowable amount for the service

deductible

specified annual dollar amount the pt must pay for healthcare before the insurance plan begins to pay

referral

written order from a provider to get care from a specialist or specific healthcare facility

What are the different types of insurance payers?

private, government, supplemental

types of private health insurance

HMO, PPO, EPO, Indemnity, Open Access

HMO (Health Maintenance Organization)

Limited network of providers, no coverage outside of network except for emergencies, requires PCP and referrals

PPO (Preferred Provider Organization)

more flexibility to see providers that work best for pt, can see providers outside of network for a higher price, does not require PCP or referrals

EPO (Exclusive Provider Organization)

locally managed care plan, requires in network providers except for emergencies, often requires PCP but not always, does not require referrals

Indemnity (fee for service plan)

Gives the pt the ability to direct their own care, plan pays set portion of charges. No network, PCP, or referral required

Open Access

Pt can choose a provider from a 3 tier category, no out of network coverage except for emergencies, does not require PCP or referrals

What are the government health insurances?

Medicare, Medicaid, TRICARE, TRICARE for Life, CHAMPVA

Medicare

federal program for eligible individuals who are 65 years or older, younger with disabilities, or have end stage renal disease

Medicare Part A

covers inpatient services

Medicare Part B

covers outpatient services

Medicare Part C

medicare advantage, supplemental coverage for left over costs from parts A and B

Medicare Part D

covers prescription drugs

what part of medicare would cover hospital visits, nursing facilities, or hospice?

Part A

What part of medicare would cover a doctor's office visit, medical supplies, or preventative services?

Part B

Medicaid

coverage for eligible low income adults, children, pregnant women, elderly adults, and people with disabilities

What are different types of supplemental health insurance?

disability, dental, accident

Disability insurance

supports those medically unable to perform certain duties due to injury or disability. can be short or long term

dental insurance

covers dental care, cannot be combined with medical insurance

accidental insurance

pays the policyholder directly in the event of an accident resulting in injury

what is an insurance claim?

specific request for the insurance company to pay for a service

ways to submit an insurance claim

mailing completed CMS1500 form, electronically completing an 837P form, or submitting paperwork via EHR

Why does HIPAA require patients to sign an insurance claim consent form?

to allow their medical information to be sent to the insurance company for payment purposes

What is an explanation of benefits (EOB)?

statement generated by insurance company that includes cost of services, amount paid, amount not covered, and outstanding payments. EOB is not a bill

What is insurance coding?

assigning a code to identify the reason to why the procedure was performed

What is the purpose of insurance coding?

allows for reimbursement to providers for services rendered

CPT (Current Procedural Terminology)

describes tests, surgeries, evaluations, and other procedures with a 5 character code that can be modified with a 2 character modifier

what is a modifier?

addition to a procedure code which indicates special circumstances

ICD-10 (international classification of diseases)

diagnoses codes that use 3-7 alphanumerical characters.

ICD-10-CPT

outpatient

ICD-10-PCS

inpatient

HCPCS (Healthcare Common Procedure Coding System)

identifies procedures, supplies, products, and services. may be provided to medicare beneficiaries and those with private health insurance

NDC (national drug code)

directory with finished drug products, unfinished drugs, and compound drug products. Inclusion in NDC doesn't indicate FDA verification or approval, doesn't contain all listed drugs.

dependent

person eligible for coverage under the policyholder's insurance (kids, spouse, etc.)

policyholder

A person who buys an insurance plan; the insured, subscriber, or guarantor.

birthday rule

The method of determining primary coverage for a dependent child, the plan of the parent whose birthday occurs first in the calendar year is designated as primary.

exclusions

treatments not considered medically necessary like fertility treatment or cosmetic surgery are not typically covered by insurance

formulary

list of generic and brand name drugs covered by an insurance plan, helps providers prescribe medications that will be covered by the pt's insurance

prior authorization

the need to obtain permission from the insurance company before a procedure or service

TRICARE

government health insurance for all active duty or retired military personnel and their families

TRICARE for Life

Program for beneficiaries who are both Medicare and TRICARE eligible.

CHAMPVA

covers surviving spouses and dependent children of disabled veterans or veterans who died as a result of service-related disabilities