Financial/Reimbursement/Resources for Patients

providers

• provide healthcare services

• bill payors (insurerers)

• bill patients for services

payors

• health insurers

• reimburse providers providers for services

patients

• seek healthcare

• pay both payors and providers for services rendered

prior authorization

• determines if test is medically necessary

• does NOT address amount owed

Medicare Incident-To

• patient must have been previously seen (no initial visits)

• has established care plan

• physician is present in the office suite

cost sharing

costs of healthcare that are shared between patient and insurance company

capacitated payment

providers paid a set fee per month to incentivize lowering of service costs

balance billing

bill for the remaining difference between total charged fee and the amount the health insurance company approves and pays

adverse selection

person waits until they are sick and in need of healthcare before applying to health insurance policy

institutional billing

hospital or healthcare facility acts as the billing provider

Non-institutional/Laboratory Billing

laboratory bills the patient’s insurance

Self Pay

patient pays the lab directly for the test

GC certification

provided by ABGC, certifies that GC passed board exam and graduated from established program - verifies knowledge and skills

state licensure

grants state-level permission to practice (for states with licensure)

credentialing

insurance credentialing in which an insurance company verifies a provider’s qualifications and approves them to bill for services

ICD-10 codes

• international classification of diseases

• used for diagnosis and in public health surveillance

CPT codes

• current procedural terminology

• used for billing purposes

LOINC

• logical observation identifiers names and codes

• mainly used for laboratory tests

relative value units (RVU)

measure of amount worked, used to reimburse providers

CPT 96041

bills for total time provided by the GC on the fate of the encounter (30 min units)

CPT S0265

genetic counseling performed under physician supervision (15 minute units)

Explanation of Benefits (EOB)

provides summary of the insurance company’s coverage and the patient’s financial responsibility after the claim has been processed

letter of medical necessity

written by a healthcare provider to justify the need for a particular treatment or service, often used to support prior authorization request

claim form

form submitted by healthcare provider to insurance company to request payment for services provided

COBRA

law that provides health insurance coverage after leaving a job (up to to 18 months)

Medicare

• health insurance for retirees (>65y)

• individuals with disabilities (SSDI)

• people with ALS

• people with end stage renal disease

Medicaid

• health insurance to aid those in need

• low income individuals

• disabled

• pregnant

• teens living alone

• patients can’t be balance billed

Tricare

health insurance for the troops (military)

Medicaid policies

state specific, may vary widely in coverage and scope dependent on the state

Coinsurance

health insurance and member split in-network healthcare costs

(20% = member pays 20%)

deductible

set amount at which the patient is 100% responsible for healthcare costs

max out-of-pocket

a maximum rate after which health insurance pays 100% of in-network healthcare costs

Medicare Part B

• covers outpatient services

• 20% coinsurance after deductible

• no maximum out-of-pocket

upcoding

billing for more than the actual services provided - medical fraud

unbundling

using individual CPT codes for a panel billing (ex. CPT codes for each gene on the panel)

insurance churning

person undergoes multiple changes in insurance coverage in a short period of time

Postmortem Decisionmaking - No will

next-of-kin is authorized to make decisions regarding the deceased’s health information

Postmorten Decisionmaking - Will

executor of the will is authorized to make decisions regarding the deceased’s health information in accordance with last will and testament

Children’s Health Insurance Plan (CHIP)

• provides health coverage to uninsured children and families

• for incomes too high to qualify for Medicaid, but too low for commercial insurances

Supplemental Nutrition Assistance Program (SNAP)

• “food stamps”

• provides benefits to eligible low-income individuals and families

Women, Infants, and Children (WIC)

• federal grants for food, healthcare referrals, and nutrition education

• supports low-income pregnant, breastfeeding, and postpartum women, infants and children up to age 5

early intervention

• provides access to services like PT, OT, speech

• for children ages 0-3 with developmental delays

504 Plan

• for individuals with physical disability with TYPICAL cognition

• no changes to curriculum, just increased access

• PT/OT is supportive - not teaching something their peers are not

IEP Plan

• for students with disabilities that need specially designed instruction and education - must be taught something their peers are not

• changes in curriculum accompanied with measurable goals