Unit 2 Lesson 3: Other Third-Party Payers

Overview of Health Insurance Payers

  • Medical insurance availability: Available through employers, commercial/private organizations, and government programs.

  • Health Insurance Payers:

    • Commercial Insurance Plans:

      • Examples: HMO (Health Maintenance Organization), PPO (Preferred Provider Organization).

      • Specific companies: Kaiser, Blue Cross Shield, Aetna, Cigna, Health Net.

    • Government Insurance Plans:

      • Examples: Medicare, Medicaid, Medigap, CHIP (Children's Health Insurance Program), TRICARE, CHAMPVA.

  • Other Insurance Payers:

    • Workers' Compensation

    • Automobile Insurance

    • Homeowner Insurance

  • Uninsured/Self-Pay: The patient is fully financially responsible for their medical care.

TRICARE

  • Definition: A healthcare program for military members, retirees, and their families.

  • Coverage: Provides medical coverage through a combination of military hospitals/clinics and civilian providers.

  • Oversight: Overseen by the U.S. Department of Defense.

  • Eligibility: Available to active-duty service members (ADSMs), National Guard and Reserve members, retirees, and eligible family members.

    • Must be registered in the DEERS (Defense Enrollment Eligibility Reporting System) system.

  • Plans: Offers different plans based on the patient's status and location (e.g., TRICARE Prime, TRICARE Select).

  • Covered Services: Includes doctor visits, hospital care, prescriptions, and preventive care.

  • Key TRICARE Plans:

    1. TRICARE Prime:

      • Managed care option, similar to an HMO.

      • Requires enrollment and referrals for specialty care.

      • Usually has the lowest out-of-pocket costs.

      • Available to ADSMs and their families, plus some retirees.

    2. TRICARE Select:

      • Self-managed, preferred provider option, similar to a PPO.

      • Offers greater flexibility in choosing doctors, but typically has higher costs than Prime.

      • No referral is needed for specialists.

      • Available to active-duty family members, retirees, and reservists (but not ADSMs).

    3. TRICARE For Life (TFL):

      • Medicare-wraparound coverage for retirees who have Medicare Part A & Part B.

      • TRICARE acts as the secondary payer after Medicare.

  • Self-Assessment Question: Which statement correctly matches a TRICARE plan with its description?

    • Correct Answer: A) TRICARE Prime – A managed care option requiring referrals, usually with the lowest out-of-pocket costs.

Covered vs. Noncovered Services

  • Covered Services (e.g., Preventive Care):

    • Preventive services: Medical services designed to help detect or prevent illnesses, diseases, or other health problems before they become serious.

    • Typically fully paid for (100\%) even if the patient hasn't reached their annual deductible.

  • Noncovered Procedures:

    • Procedures such as cosmetic surgery must be paid out-of-pocket by the patient.

Primary Insurance for Accidents or Injuries

  • The following are considered primary insurance when an accident or injury has occurred:

    • Workers' Compensation

    • Car Insurance

    • Homeowners Insurance

  • Note: Each type of insurance requires different claim forms, codes, and documentation for payment.

Workers' Compensation

  • Definition: An insurance program that provides wage replacement and medical benefits to employees who are injured or become ill due to their job.

  • Exclusivity: In exchange for these benefits, employees usually give up the right to sue their employer for negligence.

  • Oversight: Overseen by the U.S. Department of Labor.

  • Employee's Responsibility:

    • Report injuries to the employer as soon as possible (within 30 days of the incident).

    • Complete compensation forms.

    • Seek medical care from approved providers.

    • Follow treatment and recovery guidelines.

  • Billing Specialist Responsibility:

    • Confirm: Contact the employer to confirm the Workers' Compensation (WC) injury.

    • Obtain: Case number, date of injury, case worker contact information, and claim mailing address.

    • Create: Create a new Electronic Medical Record (EMR) and identify the account as WC on the insurance screen.

Automobile Insurance

  • Definition: A contract between a driver and an insurance company that provides financial protection against losses from accidents, theft, or other damage involving a vehicle.

  • Mechanism: The driver pays a regular premium in exchange for this protection.

  • Oversight: Overseen by the National Association of Insurance Commissioners (NAIC).

  • Availability: Insurance is available for both personal and commercial vehicles.

    • Commercial policies typically have higher premiums.

  • Key Types of Coverage:

    1. Liability Coverage:

      • Often required by law.

      • Covers bodily injury and property damage you cause to others in an accident.

      • Example: If you hit another car, liability insurance pays for the other driver’s medical bills and car repairs.

    2. Personal Injury Protection (PIP) or Medical Payments (MedPay):

      • Covers medical expenses, hospital, surgery, testing, and ambulance services for you and your passengers, regardless of who caused the accident.

      • In some states, it also covers lost wages and rehabilitation costs.

      • If an auto policy includes MedPay, this policy would be the primary insurance for all related charges until its limit is used.

    3. Uninsured/Underinsured Motorist Coverage (UMI):

      • Protects you if you’re hit by a driver who has no insurance or insufficient coverage.

  • Self-Assessment Question: Which type of car insurance provides coverage for lost wages if you’re injured in an accident?

    • Correct Answer: C) Personal Injury Protection (PIP).

Homeowners Insurance

  • Definition: A type of property insurance that protects you financially if your home or belongings are damaged, destroyed, or stolen, and provides liability coverage if someone is injured on your property.

  • Requirement: Most mortgage lenders require homeowners insurance.

  • Billing Specialist Responsibility:

    • Contact: Homeowners insurance provider.

    • Provide: Details of the incident, date of injury, and how the injury occurred.

    • Obtain: Claim number, contact person, and mailing address.

    • Create: A new account number and electronic medical record (EMR), and identify the homeowner insurance carrier on the insurance screen.

Other Payment Methods

  • Direct Payments:

    • Cash

    • Check

    • Credit Card

  • Medical Credit Cards:

    • Example: CareCredit.

  • Health Savings Accounts (HSAs):

    • Often offered as an employee benefit during open enrollment.

    • Employers deduct a set amount from each paycheck and place funds on a medical card that can be used for medical expenses.

    • Funds are tax-exempt.

Scenario: Primary Payer for Work-Related Injury

  • Scenario: A construction worker falls from scaffolding and fractures his arm.

  • Question: Who is typically the primary payer for this medical claim?

  • Correct Answer: C) Workers’ compensation insurance.