Y khoa - Dược - Chapter 17: Insurance and billing

17.1 Define the basic terms used by the insurance industry. 17.2 Compare fee-for- service plans, HMOs, and PPOs. 17.3 Outline the key requirements for coverage by the Medicare, Medicaid, TRICARE and CHAMPVA programs. 17.4 Describe allowed charge, contracted fee, capitation and formula for RBRVS.

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17Insurance and BillingLearning Outcomes (cont.)17.1 Define the basic terms used by the insurance industry.17.2 Compare fee-for- service plans, HMOs, and PPOs.17.3 Outline the key requirements for coverage by the Medicare, Medicaid, TRICARE and CHAMPVA programs.17.4 Describe allowed charge, contracted fee, capitation and formula for RBRVS.Learning Outcomes (cont.)17.5 Outline the tasks performed to obtain the information required to produce an insurance claim.17.6 Produce a clean CMS-1500 health insurance claim form.17.7 Explain the methods used to submit an insurance claim electronically. 17.8 Recall the information found on every payer’s remittance advice.Introduction Health care claims Reimbursement for servicesAccuracy = maximum appropriate paymentMedical assistantPrepare claimsReview insurance coverageExplain feesEstimate chargesUnderstand payment explanationCalculate the patient’s financial responsibilityBasic Insurance TerminologyMedical insurance Policy holderPremiumBenefitsDependentsLifetime maximum benefitsBasic Insurance Terminology (cont.)Three participants in an insurance contract:First party ~ patientSecond party ~ healthcare providerThird-party payer ~ health planBasic Insurance Terminology (cont.)Deductible ~ met annuallyCoinsurance ~ fixed percentageCopaymentManaged care plansPreferred providerExclusions Formulary Basic Insurance Terminology (cont.)Elective procedurePreauthorization ~ medically necessaryPredetermination Apply Your KnowledgeWhat is the difference between first party, second party, and third-party payer?ANSWER: The first party is the patient or owner of the policy; the second party is the physician or facility that provides services, and the third-party payer is the insurance company that agrees to carry the risk of paying for approved services.Private Health PlansInsurance companies ~ rules about benefits and proceduresSources of health plansGroup policies Individual plans Government plansNational Provider Identifier (NPI)Private Health Plans (cont.)Healthcare Legislation - 2010 Extend insurance coverage to all AmericansBan onLifetime limitsDenial of coverage for pre-existing conditionsPolicy cancellations for illnessChildren on family policy until 26 years oldFee-for-Service and Managed Care PlansFee-for-servicePolicy lists covered medical servicesAmount charged for services is controlled by the physicianAmount paid for services is controlled by the insurance carrierFee-for-Service and Managed Care Plans (cont.)Managed Care Plans (MCOs)Controls both the financing and delivery of healthcareEnrolls Policy holders Participating physiciansMCOs pay physicians in two waysCapitationContracted feesManaged Care Plans (cont.)Preferred Provider Organization (PPO)A network of providers to perform services to plan membersPhysicians in the plan agree to charge discounted feesHealth Maintenance Organization (HMO)Physicians are often paid a capitated ratePatients pay premiums and a copayment for each office visitCommercial PayersBlue Cross Blue Shield Private Commercial CarriersRules and regulations varyCovered services and fees varyLiability insuranceDisability insuranceApply Your KnowledgeMatching:ANSWER:Fee-for-ServiceParticipating physicianPPOHMOBCBSLiability insuranceDisability insurance nationwide federation of organizations enroll with managed care plans repay policyholders for healthcare costs does not cover medical expenses network of providers who care for subscribers covers injuries caused by the insured subscribers pay premiums and a copayment but no other fees for covered servicesABCDEFGGovernment PlansHealth care RetireesLow-income and disadvantagedActive or retired military personnel and their familiesMedicareThe largest federal programManaged by the Centers for Medicare and Medicaid Services (CMS)Medicare Part AHospital insuranceFinanced by Federal Insurance Contributions Act (FICA) taxCovers anyone with Social Security benefitsMedicare (cont.)Medicare Part BCovers outpatient servicesVoluntary programParticipants pay a premiumMedicare health insurance cardMedicare numberIndicates eligibilityMedicare (cont.)Part C – 1997Provides choices in types of plansMedicare Advantage plansPart D – prescription drug planMedicare (cont.)Medicare plan optionsFee-for-Service: The Original Medicare PlanAn annual deductible After deductible, the patient pays 20 percentMedigap plan – secondary insurance Medicare Administrative Contractor (MAC) Jurisdictions Medicare (cont.)Medicare Managed Care Plans Medicare Preferred Provider Organization Plans (PPOs)Medicare Private Fee-for-Service PlansMedicare Plans (cont.)Recovery Audit Contractor (RAC) ProgramDesigned to guard the Medicare Trust FundIdentify improper payments UnderpaymentOverpaymentMedicaidHealth cost assistance program not an insurance programFederal funds for mandated servicesStates – additional optional servicesAccepting assignmentDual coverageMedicaid (cont.)State guidelinesVerify Medicaid eligibilityEnsure that the physician signs all claimsPreauthorization required except in an emergencyVerify deadlines for claim submissionsTreat Medicaid patients with professionalism and courtesyTRICARE and CHAMPVATRICAREHealthcare benefitEligibility – enrollment in the Defense Enrollment Eligibility Reporting System (DEERS)CHAMPVACivilian Health and Medical Program of the Veterans AdministrationEligibility determined by the VAState Children’s Health Plan (SCHIP)Enacted in 1997 and reauthorized in 2009State-provided health coverage for uninsured children in families that do not qualify for MedicaidWorkers’ CompensationCovers employment-related accidents or illnesses Laws vary by stateVerify with employer before treating and obtain a case numberRecords managementApply Your KnowledgeA 72-year-old disabled patient is being treated at an office that accepts Medicare. The total office visit is $165, but Medicare Part B will only reimburse a set fee of $90. In this situation, what is the most likely solution?Bill the patient for the balance due.Expect the balance to be paid at the time of service.This patient probably has a secondary employer health insurance plan.This patient may qualify for the Medi/Medi coverage.ANSWER:Fee Schedules and ChargesResource-based relative value scale (RBRVS)Formula uses:Nationally uniform relative value unit (RVU)Geographic adjustment factor (GAF)Nationally uniform conversion factor (CF)CMS updates annuallyPayment MethodsAllowed chargesThe maximum amount the payer will pay a providerEquivalent termsBalance billingAdjustment Payment Methods (cont.)Contracted fee schedule – fixed fee schedules Capitation – fixed prepayment Calculating patient charges – may includeDeductiblesCopayments Coinsurance Excluded and over-limit servicesBalance billing Communication with Patients About ChargesRemind patients of financial obligationNotify office financial policyPostInformation packetNotify of uncovered servicesApply Your KnowledgeWhat do you need to consider when calculating patient charges?ANSWER: You need to consider whether the patient has met the deductible, if the patient has to pay a copayment or coinsurance, if the service is excluded, or if the patient is over his/her limit for services.The Claims Process: An OverviewPhysician’s officeObtains patient informationDelivers services and determines diagnosis and fees Records payments; prepares and submits healthcare claimsReviews the processing of a claimThe Claims Process: An Overview (cont.)Electronic billing programsStreamlines processCreating claimsFollow-upBills sent to patientElectronic data exchange (EDI)Obtaining Patient Information Basic Contact informationDOBSSNEmergency contactInsurance Employer informationInsurance carrier informationRelease signaturesTo insurance carrierAssignment of benefitsObtaining Patient Information (cont.)Eligibility for servicesScan or copy cardSigned releaseCheck effective date of coveragePreauthorizationPhone or onlineAuthorization numberObtaining Patient Information (cont.)Coordination of benefitsPrevents duplication of paymentPrimary insurance plan pays firstSecondary plan pays the deductible and copaymentThe insurance plan of the person born first becomes the primary payer. Birthday RuleDelivering Services to the PatientPhysician’s servicesDocuments visit in medical recordCompletes superbill or charge slipMedical coding Compare superbill to medical recordTranslate procedures on charge slipDelivering Services to the Patient (cont.)Referrals and AuthorizationsObtain authorization numberEnter into billing programPatient checkoutPrior to submitting an insurance claim, what do you need to do?Apply Your KnowledgeANSWER: You should have verified eligibility and obtained the patients signature on appropriate releases. You need to be sure you have the correct patient and insurance information to correctly complete the claim form. You should compare the superbill to the medical record. If a charge slip is used, you will need to determine the correct codesPreparing and Transmitting the Healthcare ClaimFiling LimitsVary from company to companyStart with date of serviceElectronic Claims transmission – X12 837 Health Care Claim Electronic Claim TransmissionPreparing electronic claimsInformation entered – data elementsData must be entered in CAPS in valid fieldsNo prefixes or special characters allowedUse only valid dataElectronic Claim Transmission (cont.)Data elements – major sectionsProvider – taxonomy codeSubscriber (policyholder) Patient (subscriber or another person) and payer Claim detailsServices Other standard transactions includeClaim status Payment statusPaper Claim CompletionCMS-1500 (CMS-1505) paper formMay be mailed or faxed to the third-party payerNot widely usedCMS-1505 requires 33 form locators Paper Claim Completion (cont.)Block 1 – 13: patient and insurance informationBlock 1Block 1aBlock 14 – 22: provider informationBlock 14Block 15xIN0001112304 15 20XXApply Your KnowledgeWhat are the major data element sections required by the X12 837 transaction?ANSWER: They are ProviderSubscriberPatient and payer Claim detailsServices Good Answer!Transmitting Electronic Claims Three methodsTransmitting claims directlyUsing a clearinghouseUsing direct data entry Offices and payers exchange information directly by electronic data interchange (EDI)Translates nonstandard data into standard format. Clearinghouse cannot create or modify dataInternet-based service that loads data elements directly into the health plan’s computerGenerating Clean ClaimsCarefully check claim before submissionMissing or incomplete informationInvalid informationRejected claimsProvide missing informationSubmit new claimClaims SecurityThe HIPAA rules Common security measuresAccess control, passwords, and log files Backup copiesSecurity policiesApply Your KnowledgeWhat are the three methods for electronic transmission of insurance claims?ANSWER: Direct transmission to insurance carrier using EDIUsing a clearinghouse that translated information into standard formats and “scrub” claims prior to submissionDirect data entry into the insurance carrier’s systemInsurer’s Processing and PaymentClaims Register Created by billing program or clearinghouseTrack submitted claimsReview for medical necessityReview for allowable benefitsPayment and Remittance AdviceWith payment of a claim – Remittance advice (RA) Amount billedAmount allowedAmount of patient liabilityAmount paidServices not coveredReviewing the Insurer’s RA and PaymentReview line by lineIf correct, make appropriate entry in claims log If unpaid or different than records TracePlace a queryIf rejected ~ review claim for accuracyWhen reviewing the RA, you note that several claims were rejected and one was not paid. What should you do?Apply Your KnowledgeANSWER: You need to review the rejected claims to be sure all information was correct. Either resubmit with corrected information or submit a new claim, depending on the carrier’s policy. You would have to call the insurance company to trace the claim that was not paid.In Summary17.1 There are a variety of terms used by insurance companies, knowledgeable medical assistants, medical billers, and coders.17.2 Fee-for-service plans are traditional plans where the insurance plan pays for a percentage of the charges. HMOs are prepaid plans that pay the providers either by capitation or by contracted fee-for-service A PPO is a managed care plan that establishes a network of providers to perform services for plan members..In Summary (cont.)17.3 Medicare provides health insurance for citizens aged 65 and older as well as certain categories of others. Medicaid is a health benefit plan for low-income and certain others with disabilities. TRICARE is a healthcare benefit for families of uniformed personnel and retirees . CHAMPVA covers the expenses of the families of veterans with total, permanent, service-connected disabilities as well as expenses for survivors of veterans who died in the line of duty or from service- connected disabilitiesIn Summary (cont.)17.4 An allowed charge is the maximum dollar amount an insurance carrier will base its reimbursement on. A contracted fee is negotiated between the MCO and the provider. Capitation is a fixed prepayment paid to the PCP. RBRVS stands for resource-based relative value scale. Its formula is RVU X GAF X CF.17.5 The claims process includes: obtaining patient information; delivering services to the patient and determining the diagnosis and fee; recording charges and codes; documenting payment from the patient; and preparing the healthcare claims.In Summary (cont.)17.6 The student should be able to produce a legible, clean, and acceptable CMS-1505 claim form.17.7 The three methods used to submit claims electronically are: a directly to the payer’s website; the use of a clearinghouse; and the use of direct data entry or DDE.17.8 Although the format may vary from payer to payer, all RAs (EOBs) contain similar information.I am always doing that which I can not do, in order that I may learn how to do it.~ Pablo PicassoEnd of Chapter 17
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