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Health Insurance 


Centers for Medicare and Medicaid Services  is CMS 

health insurance is a contract requiring the health insurer to pay some or all of the patients healthcare costs in exchange for a premium 

Premium: is a monthly fee paid by the policyholder  (patient or their employee) for health coverage / to maintain insurance policy 

 

Health insurance can cover preventative care at  no extra costs. 

For example:

  • Vaccines 

  • Diabetic screenings

  • Cholesterol screenings

  • Screenings for breast cancer 

Health insurance plans reimburse providers (nurse practitioners, PA’s, physicians) for the care and services that are provided to patients. Basically paying them fully for the service while providing reduced costs to patients.



Questions


Before verifying the patient’s insurance plan ask yourself:


  1. Do I need to collect a copayment?

  2. Is a referral required?

  3. Is the insurance policy active?

  4. What kind of the insurance plan is it?


Terms

Plan: A benefit the employer, union or other group sponsor, provides to the patient to pay for their healthcare services

Co-payment (copay): A fixed dollar amount the patient pays for a covered service; amount can vary based on service 

Co-insurance: The patients’s share of costs of a covered service, calccalted as a percent of the allowed amount for the service; the patient pays co-insurance in addtional to deductibles owed 

  Example: 

Deductible: A specified annual dollar amount the patient will pay for healthcare services before the plan begins to pay; a deductible may not apply to all services 

Refferal: a written order from a provider to get care from a specialist or healthcare facility 



Types of Insurance Payers:

  1. Private

  2. Government 

  3. Supplemental



Private Health Insurance 

           Health Maintenance Organization (HMO)

                 -  A limited network of providers and premiums to reduce cost of health insurance 

                    Out-of-network coverage: no, except for emergencies

                     PCP required: yes 

                     Referrals needed: yes 

                 Co-pays, co-insurance, and deductibles may apply 

            Preffered Provider Organization (PPO)

                    - Offers more flexibility to see doctors that work best for he patient

                       Out-if-network coverage: yes, at a higher cost

                       PCP required: no

                       Refferal needed: no

                  Co-pays, co-insurance, and deductibles may apply 

Exclusive Provider Organization (EPO)

  •   Locally managed care plan

  Out-of-network coverage: no,except for emergencies

  PCP required: often, not always

  Refferal needed: no

                   Copays, co-insurance, and deductibles may apply

Indemnity

  • Allows the patient to direct their own care

 Out-of-network coverage: yes

 PCP required: no 

 Refferal needed: no

                Copays, co-insurance, and deductibles may apply; providers can balance bill the        patient above what the insurance company pays

Open Access

                -  Allows the patient to direct their own care

 Out-of-network coverage: yes

 PCP required: no 

 Refferal needed: no

     Copays, co-insurance, and deductibles may apply; providers can balance bill the patient above what the insurance company pays

Government Health Insurance 


Medicare 

  • Offered to elible people aged 65 and up, younger people with disabilities, and for patients with end-stage renal disease

   Medicare covers different services

            Part A:  hospital insurance; covers host=ptical stays,nursing facilities, hospice carem b       and home health care

              Part B: medical care; covers some doctors’ services, outpatient care, medical supplies, and preventative services

              Part C: medicare advantage: us a supplemental plan used to cover left-ovwe costs from parts A, B, and D. 

              Part D: prescription drug coverage; coers the cost of prescribed medication (also includes shots and vaccines)


  • Some plans require a PCP, copay,co-insurance, dedcutoble, and a referral 


If services are not covered by Medicare an Advanced Beneficary Notice or ABN is given

An ABN lists

  • The items/ services not covered

  • Esitmae of service cost

  • Reasoning why medicare wont pay

Signing an ABN is required for any uncovered costs 



Medicaid 

  • Healthcare coverage to low income adults, children, edlerly people, pregant women, and the disabled


  • Funded by the federal government 

  • Plans may require specific providersm and a referral for specialists and other medical care

  • States have different rules an regulations

  • States can impose copays, co insurance and deductibles


Workers Compensation

  • Government-madated program

  • Provides money/ healthcare benefits to those who are hurt on the job

  • Program requirements vary by state






Supplemental Health Insurance 

  • The US department of health and Human services or HHS says that a supplemental insurance is a policy that supplements the primary health insurance coverage 

Disability 

  • Supports people who are seen as medically unable to do certain things bc of a disability

Two types of supplemental disability 

  1. Short term 

  • Covers someone immediately following a serious illness or injury 

  1. Long term

  • Maintains income replacement if the illness/ injury keeps the person from working past the end of the short term disability benefit period (TT)

Dental

  • Covers dental care

  • Copays, coinsurance, and deductibles may need to be paid before receiving treatment and there is a cap to limit how much insurance plan will cover 

Accident

  • Pays the policy holder (the person who is paying for insurance) directly in the case of an accident causing injury

  


Insurance Claims

  • A request for the insurance company to pay for a service

Claim can be submitted:

  • Mailing a form

  • Electronically:

  • Insurance website

  • EHR ( electronic health record)

HIPAA requires every patient to sign an insurance claim consent form 

  • This allows the practice ti bill and exchange their info with the insurance comany

Claim rejections identify why the insurance company will not pay for a sefrivce or procedure 

  • You will then need to file and appeal or a peer review ( this require follow ups based on office policy. These follow-ups may include medical record requests or notifcation of missing codes or info)


Explanation Of Benefits  (EOB)

  • A statement generated by the health insurance company when the provider submits a claim for services rendered 

  • It is NOT A BILL

Includes the following 

  • Cost of services 

  • Amount paid 

  • Amount not covered 

  • Outstanding payment 



Insurance Coding 

  • Instructs the insurance company how to reimburse providers or patients for services rendered 

  • Involves assigning a CPT or HCPCS procedure code to provide a good reason why the procedure was preformed

-  can only be performed by a licensed medical provider or certified  medical coder



Coding Systems 

  • ICD-10-Cm 

- International Classifcation of Diesases, Tenth Revision, Clinical Modication (ICD-10-CM)

- classify diagnosis codes and use 3-7 alphanumeric characters 

-ICD-10-CPT: inpatient procedure codes 

-ICD-10-CPT: outpatient procedure codes 


  • CPT

- Current Procdural Terminology

- Describes tests, surgeries, evaluations, and other medical procedures 

- Has five characters but can be modified with a two-character modifier


  • HCPCS 

-  Healthcare Common Procedure Coding System 

- Represents procedures, supplies, products,, and services

- May be provided to Medicare beneficiaries and those with private health insurance


  • NDC 

- National Drug Code

- A directory containing finished drug products, unfinished drugs, and compounded products 

  • Inclusion does not indicate the FDA has verified information or that products are FDA-approved 

  • Does not contain all listed drugs 

  • Assignment of an NDC number does not denote FDA approval of the product 





Insurance Finance Application 

  • Before filing insurance finance application, a contract is needed 

  • The agreement has the negotiated rate that the insurance comany will pay for a service/ procedure

  • The practice usually receives a check once rhe claim is processed

  • Then the payment must be added to patients account saying the type of service and the date 


Sometime the provider (doctor) “write off” the payment so this gets ride of the fees for a service. They do this when:

  • A service keeps getting denied

  • They choose not to bill/ charge the patient or insurance 


As an MA you must keep track of the denial letters, write offs and other reports. Keep track of them in the EHR (electronic health record)




Financial Bookkeeping 

  • The process of noting and retaining financial documents 

  • Financial transactions

  • Payments

  • Debts

  • Taxes

  • Other documents


It is important that practices are on top of patient billing and balances 

Financial docs should be kept in a secure file/database for recordkeeping


Patient Billing 

  • Entering charges for services provided 

  • An encounter form is used to record information about patient office visits 

  • EHR automatically assigns charges and generates the bill; can be entered manually

  • Physicians fee schedule has a list of fees used my Medicare to pay providers/ doctors

Collecting and Posting Payment 

  • This determines what the patient owes 

  • Payments can be for a current visit, a previous visit, or an outstanding balance


  • It doesn’t matter what payment the patient is making, the MA must verify the patient’s responsibility by noting the copay, coinsurance, deductible, or outstanding balance to be able to collect the appropriate payment at the time of service. Using the EHR or manually noting the payment and providing a receipt 


Patient Ledger 

  • This is an electronic or handwritten record of the transactions completed by a medical practice 

  • A patient ledger card shows the charges, adjustments, and balances paid

To manage a patient ledger:

  • Enter financial data by manually using a ledger book or electronically using an accounting database

  • Verify account queries.

  • Reconcile payments

  • Prepare financial documents for a manager when sending to an offsite accounting firm 


Truth in Lending Act

  • Protects individuals against inaccurate and unfair billing 

  • Requires that borrowers receive written disclosures about important terms that they are legally bound 

  • These statements are reserved for managers or those who had specific training 

Itemized Statements 

A document requesting payment for all the applicable medical services rendered 

  • Breaks down the total amount owed and has a detailed  description of every item 

  • Billing cycles happen every 30 days but can vary based on policy

Make sure to verify the patients:

-Mailing address

-Other demographics


Aging and Revenue Reports

-shows outstanding insurance claims and patient balances 



Revenue reports show revenue earned during a specific range of time


Accounts received in:

  • 35 fewer days= good financial health 

  • 35-50 days= average 

  • 50 or more = poor 

An account that is 30 days past due is generally considered delinquent. This means that if an office policy states that all payments must be received within 30 days of service any account received 31 days and after is considered late 



Fair Debt Collection Practices Act (FDCPA)

  • Governs debt collection to practices