Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 14 Health Insurance.

Copyright ©2012 Delmar, Cengage Learning. All rights reserved.

Chapter 14

Health Insurance


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


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


Types of Insurance Plans

• Commercial health insurance plans• Indemnity-type insurance• Health maintenance organizations (HMOs)• Consumer-driven health plans (CDHPs)• Government health plans


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


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


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)


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


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


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


Government Health Plans

• Medicare• Medicaid• Workers’ Compensation• TRICARE• CHAMPVA


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


Medicare

• Part A– Hospital coverage


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


Medicare and Claims Processing

• Always keep up-to-date with Medicare requirements– Must use CMS-1500 form– Must submit Medicare claims electronically


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


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


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


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


TRICARE

• Beneficiaries– Active service personnel and their dependents– Retired active service personnel and their

dependents– Dependents of service personnel who died in

active duty


CHAMPVA

• Beneficiaries– Spouses and children of permanently disabled

veterans– Spouses and children of veterans who died as a

result of service


Patients with No Insurance

• Classified as self-pay patients• These patients are expected to pay at the time

of service


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


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


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


Utilization Review

• Preauthorization • Precertification• Predetermination• Concurrent review• Discharge planning


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


Fee Schedules

• Usual, customary, and reasonable (UCR)• Resource-based relative value scale (RBRVS)• Diagnostic-related groups (DRGs)

Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 14 Health Insurance.

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Transcript of Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 14 Health Insurance.