Module 9- Ch 24 Health Insurance

What is third-party reimbursement?

Payment of services rendered by someone other than the patient

What is third-party liability (TPL)?

The legal obligation of third parties to pay part or all of the expenditures for medical assistance furnished under a state plan

What are the three steps to verify insurance coverage?

1. Ask patient for current insurance card 2. Copy both front and back of card 3. Verify patient's insurance at each visit by accessing insurance company website

Why should you verify insurance at each visit?

To ensure correct insurer is billed and the provider receives timely reimbursement

What is a managed care delivery system?

A system of health care that integrates the delivery and payment of health care for covered persons by contracting with select providers for comprehensive health care at a reduced cost

What is a main goal of managed care?

To provide health care with an emphasis on prevention

Who is a subscriber?

The person who has been insured, or policyholder

What is commercial health insurance?

Insurance owned and run by private companies that control the price of premiums and specify benefits

Give examples of commercial health insurance

Blue Cross and Blue Shield

What is a deductible?

A predetermined amount the insured must pay each year before the insurance company will pay for accident or illness

What is coinsurance?

The percentage owed by the patient for services rendered after a deductible has been met and a co-payment has been paid

What is indemnity-type insurance?

Insurance with the least amount of structural guidelines; patients can see provider of their choice and specialists without referrals

What are characteristics of indemnity insurance?

Higher premiums, patients choose providers, can see specialists without referrals, annual deductible must be satisfied

What does HMO provide?

Comprehensive health care with a focus on wellness and preventative care (annual physicals, PAP tests, well-child care)

What is a PCP (primary care provider)?

Also called gatekeeper; oversees medical care and refers to specialists if needed; members must choose one in HMO

What is a staff-model HMO?

Providers are employed by the HMO; all services (except emergencies) provided by the practice; preauthorization required when traveling

What is a group-model HMO?

Multispecialty practices contracted with HMO; may be reimbursed on a capitated basis

What is a PPO (Preferred Provider Organization)?

Members must select a PCP; network of providers that provide services to members at a discounted rate (in-network); members pay more for out-of-network providers

What is an EPO (Exclusive Provider Organization)?

Patient must use the EPO's provider network exclusively; does not require PCP; referral not necessary to see specialist

What is a POS (Point-of-Service) plan?

Members do not select a PCP and can self-refer to a specialist

What is an IPA (Independent Practice Association)?

Providers who practice in their own offices with their own staff

What is an HSA (Health Savings Account)?

Must be paired with a qualified health plan; part of consumer-driven health plans

What is an HRA (Health Reimbursement Arrangement)?

Employers contribute to HRA (not employees); part of consumer-driven health plans

What is an FSA (Flexible Spending Arrangement)?

Referred to as a cafeteria plan; usually funded by employee with pretax dollars; "use it or lose it" type of plan

What are the five government health plans?

Medicare, Medicaid, Workers' Compensation, TRICARE, CHAMPVA

Who is covered by Medicare?

People 65 years and older or disabled, receive Social Security benefits, or are in end-stage renal disease

When was Medicare created?

Created by the Social Security Act in 1965

Who administers Medicare?

Centers for Medicare & Medicaid Services (CMS)

What is Medicare Part A?

Hospital coverage

What is Medicare Part B?

Other medical expenses including office visits, X-ray and lab services, initial preventive physical

What is Medicare Part C?

Medicare Advantage; enables beneficiaries to select a managed care plan as their primary coverage

What is Medicare Part D?

Coverage for generic and brand-name drugs

What form must be used for Medicare claims?

CMS-1500 form

How must Medicare claims be submitted?

Electronically

How much does Medicare pay after deductible is satisfied?

Medicare pays 80% of allowed amount; 20% is paid by patient or supplemental insurance

What is an ABN (Advance Beneficiary Notice)?

Form completed if provider performs a service not covered by Medicare; must be signed by patient prior to procedure

When does Medicare only reimburse services?

Only reimburses services or supplies deemed reasonable and necessary for the diagnosis

What is Medicaid?

Health care coverage for individuals of limited or low-income; funded by state and federal governments

What is California's version of Medicaid?

Medi-Cal

What is CHIP?

Children's Health Insurance Program

What is SHIP?

State Health Insurance Assistance Program

What does Workers' Compensation cover?

State laws covering employees who are injured while working or become ill as a result of work

What benefits does Workers' Compensation provide?

Medical, income (weekly or monthly), death, and burial benefits

Who does TRICARE cover?

Active service personnel and their dependents, retired active service personnel and their dependents, dependents of service personnel who died in active duty

What was TRICARE formerly called?

CHAMPUS

Who does CHAMPVA cover?

Spouses and dependent children of veterans who have total, permanent, service-connected disabilities; spouses and children of veterans who died as a result of service-connected disabilities

What is coordination of benefits?

When patients have more than one insurance plan; charges are filed first with primary carrier, then secondary

What is the birthday rule?

Rule used to determine primary insurance for dependent children based on parents' birthdays

What is Medigap insurance?

Supplemental insurance that many Medicare patients have; covers the deductible and 20% coinsurance

When is Medicare secondary insurance?

When a person qualifies for Medicare but is still employed

What are self-pay patients?

Patients with no insurance; classified as self-pay and expected to pay out-of-pocket, usually at time services are rendered

What is accepting assignment?

When providers accept the allowed amount as the rate for services

What happens to disallowed amounts?

Written off as adjustments

What is a fee schedule?

Agreed upon (discounted) rate for services that providers enrolled in an insurance carrier's network agree to charge subscribers