Chapter 23 Health insurance basics
Rendering provider's federal tax ID number
(EIN or SSN)
Health Maintenance Organization (HMO) Models
-IPA (Independent Practice Association) -staff -group
In 2010 the Patient Protection and Affordable Care Act, also known as the Affordable Care Act (also Obamacare), was enacted:
-It eliminates preexisting conditions and gender discrimination, so patients cannot be charged more based on their health status or gender. -Young adults can remain on their parent's or guardian's insurance policy until age 26.
The EOB breaks down each line item charge from:
Block 24 on the CMS-1500 into the charged amount, the amount allowable, and the amount paid.
The NPI is an identifier assigned by the :
CMS (centers of medicaid and medicare services) that classifies the healthcare provider by license and medical specialty.
IPA (Independent Practice Association)
General or family practice provider or provider group that practices independently and may contract with several HMOs. Can see patients outside of the HMO.
(MCOs)
Managed care organizations
An ambulatory care facility has the right to limit the number of:
Medicaid patients it accepts into the practice. The medical office cannot pick and choose which Medicaid patients they are willing to see. There can be no discrimination based on age, gender, race, religious preference, or national origin.
A provider who accepts Medicaid patients automatically agrees to accept:
Medicaid's allowed amount as payment in full for covered services.
The RBRVS is one of the outcomes of the :
Medicare Physician Payment Reform that was enacted in the Omnibus Budget Reconciliation Act of 1989 (OBRA '89).
Part C is an option for:
Medicare-qualified patients to turn their Part A and Part B benefits into a private plan that can offer some additional benefits.
Supplemental health insurance plans are known as:
Medigap policies, These policies can also pay for services not covered by Medicare.
Group
Multispecialty group with or without a primary care provider (PCP; i.e., gatekeeper); may contract with several HMOs.
Exclusive provider organization (EPO)
Must see network providers. No PCP required. No referral needed. Usually no deductible or co-insurance. Copayments required for office visits and prescriptions.
Health maintenance organization (HMO) (3)
Must see only HMO providers and choose a primary care provider (PCP). Referral required for specialized care. Usually no deductible or coinsurance. Copayments required for office visits and prescriptions.
Staff
One or more providers hired by an HMO. Providers see only HMO patients.
Preferred provider organization (PPO) No PCP required: (3)
There is a network of providers, but out-of-network providers can be seen. No referral required. Preauthorization needed for expensive services. Lower deductible and co-insurance if an in-network provider is used. Copayments required for office visits and prescriptions.
Many businesses offer a group policy:
a private health insurance plan purchased by an employer for a group of employees. These plans can cover the employee, their spouse (i.e., domestic partner), and their children.
A claims clearinghouse is an organization that acts as a go-between for the healthcare facility and the insurance company. The clearinghouse:
accept the claim from the provider and send it out • accepts electronically submitted claims information from healthcare agencies. • audits the claims for completeness. • reformats claims to meet the insurance companies' specifications.
Medicare is a federal health insurance program that provides healthcare coverage for individuals who are:
age 65 or older; people who are disabled patients who have been diagnosed with end-stage renal disease (ESRD).
Part B covers
ambulatory care, including primary care and specialists.
In the health insurance contract between the third-party payer and the patient, the patient receives the payment when a claim is submitted. For the healthcare facility to receive the reimbursement directly from the insurance company, the patient must sign an:
assignment of benefits.
TRICARE is the:
comprehensive healthcare program for uniformed service members and retirees and their families.
Verification of eligibility is the process of:
confirming health insurance coverage for the patient. When scheduling an appointment, health insurance information should be collected (unless it is an emergency situation).
Most EOBs will also indicate how much was applied to the:
deductible, what the patient's co-insurance amount is, and if any services were denied.
The medical assistant should also verify the:
effective date, or date the insurance coverage began, and confirm that the patient will be covered on the date the medical services are provided.
Direct billing is the process by which an insurance company allows a provider to:
electronically submit claims directly to the company.
CHAMPVA, a health benefits program similar to TRICARE, provides coverage for the:
families of veterans who were permanently disabled or killed in the line of duty.
Originally, Medicare Part B had paid providers using a:
fee-for-service system based on usual, customary, and reasonable (UCR) charges.
Government health insurance plans provide coverage with reduced or no monthly premiums for the:
indigent, the elderly, the military, and government employees.
Medicaid is the government program that provides medical care for the:
indigent.
Part A covers:
inpatient hospital charges.
When a patient makes a first appointment, it is routine to ask the patient for:
insurance billing information.
To become a participating provider in an insurance network, the provider must agree to accept the:
insurance plan's fee schedule as payment in full for services rendered. This means that if the provider's fee is higher than the plan's allowed amount, the difference should be adjusted.
Fraud is defined as
knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program or to obtain by means of false or fraudulent pretenses, representations, or promises any of the money or property owned by any healthcare benefit program.
The Medicaid fee schedule is the:
lowest of all insurance companies, and it may not be in the medical office's financial interest to accept a large number of Medicaid patients.
The medical assistant should make it a practice to review each insurer's:
online insurance web portal, which can verify insurance eligibility, benefits, and exclusions, prior to the patient's appointment. If the online insurance web portal is not available, the medical assistant should contact the provider services desk; the phone number should be listed on the patient's health insurance ID card.
Part D is a:
prescription drug program
Many MCOs require the patient to choose a
primary care provider (PCP), who coordinates the patient's care.
Managed care plans can also require:
referrals for their patients to be treated by a specialist, thus limiting patient access to more expensive care. The preauthorization process can further control patient care costs. Medical care, testing, or medication therapy is provided only when it is justified to the health insurance plan.
Basic medical coverage for Medicare Part B is 80% of the allowed amount after the deductible. This means that patients are:
responsible for the remaining 20%.
The two main reasons for denial of payment are:
technical errors and insurance policy coverage issues.
Abuse is similar to fraud, except that it is unclear if the:
unethical practice was committed on purpose
Abuse is an
unintended action that directly or indirectly results in an overpayment to the healthcare provider.
The Affordable Care Act (ACA) requires all health plans to cover essential health benefits. There are 10 categories of essential health benefits:
• Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services • Rehabilitative and habilitative services and devices • Prescription drugs • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care
All health insurance companies accept:
• CMS-1500 as the standard claim form • ICD-10-CM for diagnostic codes • CPT and HCPCS procedural codes However, each health insurance company has its own policies and procedures for the submission of claims.
There are two types of health insurance plans in the United States:
• Government health insurance plans • Private health insurance plans
In order to receive federal funds for Medicaid, each state Medicaid plan must cover the following services:
• Inpatient hospital services • Laboratory and x-ray services • Outpatient hospital services • Family planning services • Nursing facility services • Nurse midwife services • Early and periodic screening, diagnostic, and treatment (EPSDT) services • Certified pediatric and family nurse practitioner services • Home health services • Freestanding birth center services • Physician services • Transportation to medical care • Rural health clinic service • Federally qualified health center services • Tobacco cessation counseling for pregnant women
Most major insurance companies, including Medicare and Medicaid, provide software packages that are used to enter the following:
• Patient's information • Insured's information • Charges • Provider details
implementation of the RBRVS in 1992 changed this system to a fee scale consisting of three parts:
• Provider work • Charge-based professional liability expenses • Charge-based overhead
The two main reasons for denial of payment are technical errors and insurance policy coverage issues.
• The patient was not covered by the insurance plan on the date of service. • A listed procedure was not an insurance benefit. • Preauthorization for the service was not obtained. • Medical necessity
Precertification must be done before the procedure or service is performed. To obtain precertification, the medical assistant:
• calls the provider services phone number on the back of the patient's health insurance ID card. • provides the insurance company with procedures and/or services requested and the diagnoses. • documents the outcome of the call in the patient's health record, including the precertification number.
