Insurance & Billing ABGC

Balance billing

The practice of billing patients for any balance left after deductibles, coinsurance, and insurance payments have been made.

Balanced billing is most common when...

Using an out of network provider

**Medicaid does not allow for balanced billing

Cost sharing insurance plan

(costs of health care are "shared" between patient and insurance company - incentive for patients to be cautious with healthcare utilization)

Risk adjustment

predict a person's likely use and costs of health care services. Used in Medicare Advantage to adjust the capitated payments to

cover expected medical costs of enrollees. This helps to ensure a plan's contracted providers don't avoid sicker and more costly patients.

Institutional billing for genetic testing

the hospital or healthcare facility acts as the billing provider. Testing may be performed in house or sent to a 3rd party laboratory (eg GeneDx, Invitae).

- usually hospital and lab will have contract with preferred pricing

Non-institutional billing (laboratory billing)

the laboratory acts as the billing provider (will bill the patient's insurance). Insurance may have in-network laboratories where testing can be performed.

ICD-10 codes

Diagnosis codes

Used in public health surveillance (e.g. prevalence of certain diseases)

CPT codes are for...

Charging PatienTs

- Can be outpatient or inpatient

- E&M codes are CPT codes ranging from 99202 to 99499

- AKA HCPCS Level I

96040 CPT code

is the code for genetic counselling clinic visit

would need to put in the code + "units"

each unit = 30mins

so 1 hr = 2 units

LOINC codes

mainly for Laboratory tests (more detailed than CPT codes). Not used for billing.

HCPCS Level II

billing codes for ambulance services and durable medical equipment, prosthetics, orthotics, and supplies. "II" looks like 2 legs. Mainly for Medicare.

Relative Value Unit (RVU)

Measures of value used in determining Medicare reimbursement formulas, including the difficulty level of the work involved, office overhead expenses, and malpractice risk for the given service or procedure.

3 main components of the RVU medicare fee schedule

Work RVU

Practice expenses

malpractice insurance

Geographic Practice Cost Indexes (GPCIs)

Is not a component of the RVU but it is used in the calculation to make adjustments based on geographical location of provider

Medicare

A federal program of health insurance for persons 65 years of age and older

individuals with disabilities (SSDI)

people with ALS and end stage renal failure

Medicare and genetic counselling billing

Does not recognize GCs as billing providers and RVU must be bundled with another service to bill

Medicare part A

The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.

Medicare part B

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

*part B is main one for Genetics

Medicare part C

Medicare advantage plan

Medicare advantage plan

Private health insurance company contracts with Medicare to provide all part A and Part B benefits including prescription drugs.

Medicare part D

Prescription drug coverage

Medicaid is for...

Low-income individuals and families, based on income level and family size (on SSI).

What is covered Varies by state. - fed and state run

Tricare coverage

Active duty military, retirees, and their families

T=troops

If unable to work because of physical and/or mental reasons, may be eligible for...

Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) disability payments.

To be considered disabled for SSDI or SSI

you must be unable to perform any substantial work due to a physical and/or mental condition, which has lasted or can be expected to last for at least 12 months or can be expected to result in death (e.g. ALS).

People on SSDI or SSI are eligible for medicare after how long

24 months

SSDI is based on

previous contributions to Social Security

SSI eligibility

is based on income

COBRA Insurance

A federal program that allows a person terminated from their employer to retain health insurance they had with that employer for up to 18 months, or 36 months if the former employee is disabled.

Medicare will cover cancer genetic testing for who?

Only people WITH a cancer dx

Plus meeting NCCN criteria

Medicare will cover genetic testing for Lynch syndrome for...

Person with a lynch cancer and at least 1 relative with a lynch cancer

Health Maintenance Organization (HMO)

Alternative means of health care in which people or their employers are charged a set amount and the HMO provides health care and covers hospital costs.

- lower premiums & deductibles

- only covers in network

- need a referral for specialists

- no need to file claims

- best for lower cost

Preferred Provider Organization (PPO)

- higher deductibles and premiums

- can go out of network

- no need or referrals for specialists

- may been to file claims

- offers more control and flexibility

Medicare part B covers what %

80%

other 20% co-insurance would need to be paid my the patient or a second insurance plan

**No out of pocket max with medicare

Circumstances where Medicare may Cover Genetic Counseling?

when the procedure is undertaken as the result of a medical necessity in a skilled nursing facility or when counseling has been ordered by a Medicare-approved physician

may also be covered as part of a temporary stay at hospital under medicare part A

Explanation of Benefits

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

Prior Authorization

the healthcare provider obtains approval from the insurance company before performing a service to ensure it will be covered. It does not provide a breakdown of charges or the patient's financial responsibility after services have been rendered.

Letter of medical necessity

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

It does not include billing information or insurance coverage details.

Upcoding

billing for a service at a higher level than was actually provided

medical fraud

Insurance churning

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

leads to discontinuity of care (some providers may not be in-network in a new plan), gaps in coverage.

Can be due to changes in income and employment.

Common for individuals with low income.

Unbundling codes

Separating the parts of a procedure to increase reimbursement rates

ex. labs used to unbundle each gene on a panel and have like 60 CPT codes vs 1 code for just a panel

Women, Infants, and Children (WIC)

federal grants to states for foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and postpartum women, and to infants and children up to age 5.

early intervention programs

for children ages 0-3

with developmental delays; provides access to services like speech, occupational, and physical therapy.

Children's Health Insurance Plan (CHIP)

Joint federal and state program that provides health coverage to uninsured children in families with incomes too high to qualify for Medicaid, but too low to afford private coverage. Similar to Medicaid.

**cannot be on both medicaid and CHIP

Supplemental Nutrition

Assistance Program (SNAP)

A food and nutrition service that works with state agencies nutrition educators, and neighborhood and faith-based organizations to offer nutrition assistance to millions of eligible, low-income individuals and families and provides economics benefits to communities.

IEP plan

- must have 1 of 13 specific dx outlined by the IDEA

- must be created by a IEP team, which includes the parents and school staff

- includes special education services i.e speech therapy + accommodations and gives the child specific goals

- must reviewed yearly

- 504 accommodations can be included within an IEP

- children with an IEP can be in a regular classroom

504 Plan

accommodation plan for students with disabilities that impacts their functioning

- includes modifications like extended test time but does not specify goals that are different from the general education curriculum

13 disabilities that qualify you for an IEP (ages 3-22)

Autism Spectrum Disorder

Deaf-Blindness

Deafness

Emotional Disturbance

Hearing Impairment (deafness not hearing loss)

Intellectual Disability

Multiple Disabilities

Orthopedic Impairment

Other Health Impairment

Specific Learning Disability

Speech or Language Impairment

Traumatic Brain Injury

Visual Impairment, including Blindness

Vocational rehabilitation program

designed to assist individuals with disabilities in achieving their employment goals.