Notes on Health Insurance and Reimbursement - chapters 13

Introduction to Health Insurance

  • Health insurance is a policy that promises to pay some or all of a customer’s medical bills.
  • Important for medical assistants to understand how to obtain insurance information to file claims.
  • Need to keep updated on changes in insurance plans and policies.

Health Benefits Plans

Group Health Benefits
  • Affordable Care Act (ACA) has specific requirements for health benefits.
  • Available to employees or group members.
  • Types:
    • Insured Benefits: Premiums paid by employer/employee to an insurance company, covering eligible benefits.
      • Subject to state regulations.
    • Self-Funded Benefits: Premiums paid to process claims, funds invested to pay claims.
  • Eligibility
    • Determined by criteria such as premium payment and coverage start dates.
    • Dependents included (spouse, children, etc.).
  • Claims administrator manages third-party reimbursement for medical practices.
Individual Health Benefits
  • Purchased by individuals from insurance companies.
  • Need to know primary and secondary carriers if multiple policies exist.
  • Coordination of Benefits: Designates order of coverage to prevent payment duplication.
Government-Sponsored Health Benefits
  • Funded by state or federal government.
  • Examples: Medicare, Medicaid, TRICARE, Workers’ Comp.

Medicare Benefits

  • Part A: No charge, covers hospital expenses.
  • Part B: Optional with a monthly fee, covers outpatient services.
  • Coverage includes diagnostic tests and certain immunizations.
  • Eligibility:
    • Automatic enrollment at age 65, for those disabled over 24 months, end-stage renal disease patients.
  • Both parts incur annual deductibles and copayments.
Medicaid
  • Federally funded, eligibility varies widely across states.
  • Covers inpatient hospital care, outpatient treatment, etc.
  • Not all practices accept Medicaid.

TRICARE/CHAMPVA

  • Administered by the U.S. Department of Defense for military personnel and families.
  • Patients must typically use in-network services for full benefits.

Managed Care

Overview
  • Developed to control costs by requiring adherence to specific rules by physicians.
  • Key Elements:
    • Precertification: Hospital admissions must be pre-approved.
    • Networks: Limited to in-network providers for full benefits.
  • Assignment of Benefits: Patients transfer their benefits to the provider.
Health Maintenance Organizations (HMOs)
  • Patients pay copayments instead of deductibles, often lower cost.
  • Requires use of network providers and may involve gatekeeping for referrals.
Preferred Provider Organizations (PPOs)
  • Contracts with providers offer flexibility in choosing care, with better benefits for in-network services.
  • Higher premiums usually accompany PPO plans in exchange for lesser restrictions.

Filing Claims

Claim Process
  • Use National Provider Identifier (NPI) for claims.
  • Can submit claims on the patient's behalf if patient authorizes it.
  • CMS-1500 form is standardized for filing insurance claims.
  • Common Reasons for Claim Denials:
    • Patient identification issues, incomplete data, services not covered.
Electronic Claims Submission
  • Most practices now submit claims electronically, enhancing efficiency.
  • Required to meet HIPAA guidelines for confidentiality and security of patient data.

Reimbursement

Diagnosis Related Groups (DRGs)
  • Used to determine reimbursement for Medicare inpatient services.
  • Code uses ICD-10-CM for specific conditions to establish billing.
Resource-Based Relative Value Scale (RBRVS)
  • Determines fees based on service intensity, time, skills, and overhead costs.
  • Adjusted for geographical cost differences using the Geographic Practice Cost Index (GPCI).

Practice Policies

  • Ensure patient signatures for assignment of benefits.
  • Understand balance billing implications; may be restricted under managed care contracts.
  • Knowledge of patient eligibility and coverage changes is essential for effective claims management.