Post on 19-Jan-2016
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Chapter 14
Health Insurance
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Evolution of Health Insurance
• Historically, health insurance provided coverage for catastrophic illness and injury
• It has evolved into coverage for preventative care and services
• The traditional type of insurance is fee-for-service care
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Managed Care Delivery Systems
• This system integrates the delivery and payment of health care by contracting with select providers for a reduced cost
• The goal is to provide health care with an emphasis on prevention
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Types of Insurance Plans
• Commercial health insurance plans• Indemnity-type insurance• Health maintenance organizations (HMOs)• Consumer-driven health plans (CDHPs)• Government health plans
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HMOs
• Provide comprehensive health care with a focus on preventative care– Annual physicals and PAP tests, well-child care
• Members choose a Primary Care Provider (PCP) to oversee medical care– PCP refers to a specialist, if needed
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HMOs
• Types of HMOs– Staff-model HMO
• Providers are employed by the HMO; all services (except emergencies) are provided by the practice
• Preauthorization is required when traveling
– Group-model HMO• Multispeciality practices contracted with HMO• May be reimbursed on a capitated basis
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HMOs
• Types of HMOs– Preferred provider organization (PPO)
• Members must select a PCP• Network of providers that provide services to members
at a discounted rate (in-network)• Members pay more out of pocket for out-of-network
providers
– Point-of-service (POS) plans– Independent practice associations (IPAs)
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HMOs
• Types of HMOs– Point-of-service (POS) plans
• Members do not select a PCP and can self-refer to specialist
– Independent practice associations (IPAs)• Providers who practice in their own offices with their
own staff
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CDHPs
• Health savings account (HSA)– Must be paired with a qualified health plan
• Health reimbursement account (HRA)– Employers contribute to HRA (not employees)
• Flexible spending account (FSA)– Employees contribute to FSA– Can pay for health insurance premiums, qualified
medical expenses, dependent expenses
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CDHPs
• Flexible spending account (FSA)– Components
• Health insurance premiums• Qualified medical expenses• Dependent care expenses
– Funded by the employee’s pretax dollars– “Use it or lose it” plan
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Government Health Plans
• Medicare• Medicaid• Workers’ Compensation• TRICARE• CHAMPVA
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Medicare
• Created by the Social Security Act in 1965– Administered by the Centers for Medicare and
Medicaid Services (CMS)
• Who is covered?– People over age 65 meeting eligibility
requirements and have filed for Medicare– People who are disabled, receive Social Security
benefits, or are in end-stage renal disease
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Medicare
• Part A– Hospital coverage
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Medicare
• Part B– Other medical expenses, including office visits
• X-ray and laboratory services• Initial Preventive Physical Exam
• Part C– Enables beneficiaries to select a managed care
plan as their primary coverage• Part D
– Coverage for generic and brand-name drugs
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Medicare and Claims Processing
• Always keep up-to-date with Medicare requirements– Must use CMS-1500 form– Must submit Medicare claims electronically
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Medicare and Claims Processing
• Reimbursement to providers– Medicare pays 80% of allowed amount after the
deductible is satisfied– 20% is paid by patient, or supplemental insurance
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Medical Necessity
• Medicare only reimburses services or supplies deemed reasonable and necessary for the diagnosis
• Advance Beneficiary Notices (ABN)– If a provider performs a service not covered by
Medicare, an ABN is completed– Must be signed by patient prior to procedure
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Medicaid
• Health insurance for limited or low-income individuals– Must use participating provider
• Funded by both state and federal governments– Eligibility requirements and benefits vary by state– Medicaid cards are issued each month– Always verify current coverage prior to visit
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Workers’ Compensation
• State laws which cover employees who are injured while working or as a result of work
• Benefits– Medical treatment in or out of a hospital– Temporary disability: may receive weekly cash benefits
in addition to medical care– Permanent disability: weekly or monthly benefits, or a
lump sum settlement– Payments to dependents for fatal injuries
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TRICARE
• Beneficiaries– Active service personnel and their dependents– Retired active service personnel and their
dependents– Dependents of service personnel who died in
active duty
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CHAMPVA
• Beneficiaries– Spouses and children of permanently disabled
veterans– Spouses and children of veterans who died as a
result of service
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Patients with No Insurance
• Classified as self-pay patients• These patients are expected to pay at the time
of service
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Primary and Secondary Insurance
• Patients may have more than one insurance plan
• Charges are filed first with the primary carrier, and then secondary– Coordination of benefits
• Dependent children and the Birthday rule
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Primary and Secondary Insurance
• Medicare and supplemental insurance– Many Medicare patients have supplemental or
Medigap insurance – This covers the deductible and 20% coinsurance
• Medicare as secondary insurance– When a person qualifies for Medicare but is still
employed
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Verifying Insurance Coverage
• Always ask patients for current insurance card• Make a copy of the card, or scan into the EMR• Verify coverage online or over the phone
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Utilization Review
• Preauthorization • Precertification• Predetermination• Concurrent review• Discharge planning
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Fee Schedules
• Providers enrolled in an insurance carrier’s network agrees to treat subscribers for an agreed upon (discounted) rate for services
• Accepting assignment: when providers accept the allowed amount as the rate for services– Disallowed amounts are written off as
adjustments
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Fee Schedules
• Usual, customary, and reasonable (UCR)• Resource-based relative value scale (RBRVS)• Diagnostic-related groups (DRGs)