Chapter 24 and 25 Health Insurance

Who is Medicare for?

those over the age of 65 and meet the eligibility requirements amd have filed coverage. also people who are disabled, receiving Social Security benefits, or in end-stage renal disease, regardless of age, are also eligible.

Health Savings Account (HSA)

a tax-sheltered savings account, with contributions from the employer and employee, which can be used to pay for medical expenses.

Counseling

communicating with someone about non-job-related issues that may be affecting or interfering with the person's performance

the four principal types of state benefits

(1) Medical Benefits: the patient may have medical treatment in or out of a hospital; (2) Income Benefits: if a temporary disability is present, the patient may receive weekly cash benefits in addition to medical care, and when a percentage of permanent disability is found, the patient is given weekly or monthly benefits, and in some cases a lump-sum settlement; or (3) Death and (4) Burial Benefits: payments are made to dependents of employees who are fatally injured.

carrier

A person whose genotype includes a gene that is not expressed in the phenotype.

Affordable Care Act

An expansion of medicaid, most of employers must provide health insurance, have insurance or face surtax, prevents rejection based on pre-existing condition. Also referred to as "Obamacare", signed into law in 2010.

E/M codes

CPT code relating to the evaluation and management of the patient; related to medical services as opposed to surgical services.

CHAMPVA

Civilian Health and Medical Program of the Department of Veterans Affairs -established in 1973 for the spouses and dependent children of veterans who have total, permanent, service-connected disabilities. This service is also available for the surviving spouses and dependent children of veterans who have died as a result of service-connected disabilities. The local VA hospital determines eligibility and then issues identification cards. The insured members can then choose their own private providers. There are deductibles and cost-sharing requirements your office needs to be aware of.

Exclusive Provider Organization (EPO)

EPOs are like HMOs in that patients must use their EPO's provider network when receiving care. There is no partial coverage for out-of-network care.

HEDIS measures

Effectiveness of Care Access/Availability of Care Utilization Risk Adjusted Utilization Measures Collected Using Electronic Clinical Data Systems According to HEDIS, their future focuses will be on these core ideas: Allowable Adjustments: New flexibility lets users modify measures without changing their clinical intent. Licensing and Certification: Updated requirements ensure accuracy of measure results. Digital Measures: HEDIS specifications that download directly into users' data systems bring new ease. Electronic Clinical Data Systems (ECDS): This new reporting method helps clinical data create insight for managing the health of individuals and groups. Schedule Change: A new schedule gives users more time by giving them complete measure specs sooner—11 months earlier than the traditional timeline. Telehealth: The access to care that telehealth has brought Americans during the COVID-19 pandemic is vital to quality now and after the pandemic (HEDIS, n.d.).

Group-model hmos

Group models are multispecialty practices contracted to provide health care services to members. The providers may be reimbursed on a capitated basis. Capitation means that providers are paid a set fee per patient on their patient listing each month, whether the patient is seen one or more times or not at all.

What does the eligibility application allow you to do?

In an EHR enables you to view a history of eligibility checks. It also allows you to electronically check eligibility with the primary insurance as well as the secondary insurance saved in patient demographics. EHRs differ in components and applications.

what medicare wont cover

Medicare usually does not pay for this service. Medicare usually does not pay for this injection. Medicare does not pay for this service because it is considered experimental.

point of service plan

Point-of-service (POS) plans allow members greater freedom in their choice of care. They do not have to select a PCP and can self-refer to specialists. If they choose to use a nonpanel provider, the benefit is more like an indemnity plan with a deductible and coinsurance. If they choose a panel provider, they receive the HMO benefit of only paying a co-payment with no deductible or coinsurance responsibility.

TRICARE for Life

Program for beneficiaries who are both Medicare and TRICARE eligible.

staff-model HMOs

Staff-model HMOs are plans in which the providers are employed by the HMO, and all services (physical therapy, radiology, and so on) are provided by the practice. The PCP is responsible for routine care and referrals. True emergency (life-threatening) care does not require preauthorization. If the patient is traveling outside the HMO geographic service area, they must call and obtain preauthorization of any nonemergency care. Failure to do so may result in the HMO's refusing payment of the services.

What does the eligibility check help with?

The eligibility check helps to identify potential payer sources, reducing the number of denied claims, bad debt write-offs, and staff hours required for performing manual eligibility checks while increasing revenue through improved collection rates

What does the birthday rule state?

The plan of the parent whose birthday occurs first in the calendar year is primary, and the other parent's plan is secondary. If both parents have the same birth date, the plan in effect the longest is primary. If the parents divorce and retain their plans, the parent with custody is primary. If a court order exists that dictates which parent is responsible for medical expenses, the court order supersedes the birthday rule.

commercial health insurance

These plans are typically provided by employers to employees as part of a benefit package.

TRICARE

U.S. government health insurance plan for all military personnel

Verifying Insurance Coverage

When greeting the patient upon arrival in the office for an appointment, ask the patient for a current insurance card (or for all current ones) (see Figure 24-1). Scan or make a copy of both sides of the card; the copy is needed to complete forms or to request information regarding that patient and their coverage. It is a good idea to write the date at the bottom of each card copy when the copy is made. The date alerts the medical assistant of the last time a copy of the card was obtained. If the document is scanned into an electronic health record (EHR), the date it is scanned indicates the most current card. Also, in conjunction with an EHR, the patient's demographics that should be updated with the current insurance information.

concurrent review and discharge planning

While a patient is hospitalized, treatments, tests, and procedures are reviewed before they are provided to assure their medical necessity. Once a patient is ready to leave the hospital, discharge planning is used to assure that the patient is being discharged to the most appropriate setting and with the services or supplies that they require.

add-on codes

a code that is always assigned in addition to the primary procedure or service; codes are designated with the + symbol and are found in Appendix D of the CPT code book; they are never reported as a stand-alone code.

comordity

a condition that exists along with the primary diagnosis of a patient.

medicare

a federal program for providing health care coverage for individuals over the age of 65 or those who are disabled.

medicaid

a joint funding program by federal and state governments (excluding Arizona) for the medical care of low-income patients on public assistance.

conventions

a list of abbreviations, punctuations, symbols, typefaces, and instructional notes; provide guidelines for using the code set.

fee schedule

a list of predetermined payment amounts for professional services provided to patients.

birthday rule

a means to identify primary responsibility in insurance coverage; identifies the primary insurance carrier when children have coverage through more than one parent. The insurance of the parent with the birthday earliest in the year, month and day only, is identified as the primary insurer. If both parents have the same birth date, the policy that has been in effect the longest is the primary carrier.

prospective payment system

a method of reimbursement in which the Medicare payment for patient services is made based on a predetermined, fixed amount. The amount of payment for a particular service is derived based on the diagnosis-related group's (DRGs) classification system of that service (e.g., DRGs for inpatient hospital services). There are separate PPSs for reimbursement to various facilities, including acute inpatient hospitals, home health agencies, hospice, hospital outpatient, and more.

Current Procedural Terminology (CPT)

a numerical listing of procedures performed in medical practice; a standardized identification of procedures. Published by the American Medical Association.

coinsurance

a percentage that a patient is responsible for paying for each service after the deductible has been met.

third-party reimbursement

a phrase coined to indicate payment of services rendered by someone other than the patient. With this came the need for some form of paperwork as the means of reporting the health care provided to the source of payment, and the claim form was developed. Today, the most common third-party payers are federal and state agencies, insurance companies, and workers' compensation.

downcoding

a practice of third-party payers in which the benefits code has been changed to a less complex or lower-cost procedure than was reported; another payer practice in which a reported evaluation and management service is reduced to a lower level based strictly on the diagnosis code reported.

explanation of benefits

a printed description of the benefits provided by the insurer to the beneficiary; provides information to the patient about how an insurance claim from a health provider (such as a physician or hospital) was paid on their behalf.

combination code

a single code used to classify (a) two diagnoses; (b) a diagnosis with an associated secondary process (manifestation); (c) a diagnosis with an associated complication.

co-payment

a specified amount the insured must pay toward the charge for professional services rendered at the time of service.

indemnity type insurance

a type of insurance plan that has the least amount of structural guidelines for patients to follow. Patients are able to see the provider of their choice without having to deal with listings of participating providers and other managed care guidelines.

health maintenance organizations

a type of managed care operation that is typically set up as a for-profit corporation with salaried employees; group insurance that entitles members to services provided by participating hospitals, clinics, and providers.

contributory factors

additional components that can be considered when selecting an evaluation and management code: time, nature of presenting problem, counseling, and coordination of care.

deductible

an amount to be paid before insurance will pay.

independent practice associations (IPA)

an association of independent physicians, or other organization that contracts with independent physicians, and provides services to managed care organizations on a negotiated per capita rate, flat retainer fee, or negotiated fee-for-service basis; also known as individual practice associations, they consist of providers who practice in their own individual offices and retain their own office staff and operations; a type of HMO in which contracted services are provided by providers who maintain their own offices.

National Commission on Quality Assurance (NCQA)

an independent organization that sponsors the Health Plan Employer Data and Information Set (HEDIS®), which consists of performance measures to evaluate managed care plans. Report cards for each plan are developed using this data so that employers can then make informed decisions about the plans they offer to their employees. Quality reviews by NCQA are not required but provide further evidence of a plan's commitment to providing quality care and accountability if it is willing to subject itself to this type of scrutiny.

Preferred Provider Organization (PPO)

an organization of physicians who network together to offer discounts to purchasers of health care insurance.

bundled code

any code that includes more than one procedure in its description.

what are examples of third parties?

certain individuals, entities, insurers, or programs

HCPCS Level II codes

codes that identify products, supplies, and services not included in CPT.

medicare part D

created to provide coverage for both generic and brand-name drugs. Coverage is provided through either a specific Medicare Part D plan or a Medicare Advantage plan. Beneficiaries are responsible for paying a monthly premium in addition to standard cost-sharing of a co-payment and/or coinsurance.

coordination of care

defined as the time a licensed provider spends coordinating patient care with other health care agencies, for example, home care or nursing home care.

Advance Beneficiary Notice (ABN)

document used to notify a Medicare beneficiary that it is either unlikely that Medicare will pay or certain that Medicare will not pay for the service they are going to be provided. Beneficiaries are required to sign this document if they wish to have the service with the understanding that they will be responsible for payment.

geographic practice cost index (GPCI)

each of the RSRVS components is then adjusted for geographical cost differences by multiplying each by a geographic practice cost index. This results in different payment amounts, depending on the location of the provider's practice, and amounts can vary from state to state and even within the same state, depending on whether the location is considered urban or suburban.

examples of third parties which may be liable to pay for services;

group health plans; court-ordered health coverage self-insured plans; settlements from a liability insurer managed care organiztions; workers comp pharmacy benefit managers; long-term care insurance medicare; other state and federal programs (unless excluded by federal statute).

medigap (longggg definition)

health insurance offered by private companies to persons eligible for Medicare benefits and is specifically designed to supplement Medicare benefits. Medicare generally forwards the claim information directly to the Medigap carrier (known as crossover), thus saving the office staff time. It is important to ask the patient about any supplemental insurance at the time of service. If the patient does not have a commercial supplemental insurance and is unable to pay the deductible or coinsurance, the patient might be eligible for Medicaid. In this case, Medicare would be the primary insurance, and Medicaid would be secondary and the coverage billed for the balance, deductible, and coinsurance. It is important to know that Medigap policies generally do not cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

Utilization management

includes preauthorization, precertification, predetermination, concurrent review, and discharge planning.

quality assurance

inclusive policies, procedures, and practices as standards for reliable laboratory results that includes documentation, calibration, and maintenance of all equipment, quality control, proficiency testing, and training.

80/20 plan

insurance pays 80%, you pay 20%

managed care

is a system of health care that integrates the delivery and payment of health care for covered persons (patients, or subscribers) by contracting with selected providers for comprehensive health care services at a reduced cost

medicare part A

is for hospital coverage, and any person who is receiving monthly Social Security benefits is automatically enrolled. Along with health care costs in general, the annual deductible increases each year.

medicare part B

is for payment of other medical expenses, including office visits, X-ray and laboratory services, and the services of a provider in or out of the hospital. The premiums are automatically deducted for those who wish the coverage and are on Social Security, railroad retirement, or civil service annuity. Other eligible individuals pay premiums directly to the Social Security Administration. With the passage of the Affordable Care Act in 2010, all Medicare beneficiaries became eligible for annual wellness visits with no cost sharing. Patients insured with Medicare Part B have an annual deductible to satisfy (pay) before any portion of their medical expenses is paid by Medicare. In 2020 the deductible was $198. Medicare pays 80 percent of the approved amount after the deductible is satisfied. The remaining 20 percent is paid by either the patient's supplemental insurance, after that deductible is satisfied, or by the patient. For example, a patient is seen in the provider's office for follow-up of medical conditions and the provider bills Medicare for an office visit. According to the provider's Medicare fee schedule, if the allowed amount for the visit is $100, Medicare will reimburse the provider $80 and the patient or the supplemental plan will be responsible for payment of the additional $20. The Medicare fee schedule is a list of approved professional services Medicare will pay for with the maximum fee it pays for each service.

Resource-Based Relative Value Scale (RBRVS)

is the methodology Medicare uses to create the Medicare provider fee schedule (MPFS). The MPFS is developed by using relative value units (RVUs) assigned to each service. The payment components consist of: Physician work, which accounts for the level of skill and amount of time required by the provider to perform the service or procedure (judgment, skill, effort). Practice expense, which reflects the overall cost to the provider for performing the service or procedure (rent, utilities, equipment expense, salaries). Professional liability insurance, which accounts for the cost of liability insurance.

when are automated batch eligibilty checks done?

they are performed for a patient once every 30 days regardless of the number of appointments scheduled for the patient during that month

consumer-driven health plan (CDHP)

medical insurance that combines a high-deductible health plan with a medical savings plan

Diagnosis-related groups (DRGs)

method of determining reimbursement from medical insurance according to diagnosis on a prospective basis.

primary

occurring first in time, development, or sequence; earliest.

secondary

one step removed from the first; not primary.

gatekeeper

one who regulates access to someone or something; in insurance, a primary care physician who coordinates the patient's referral to specialists and hospital admissions.

accept assignment

participating physician's agreement to accept allowed charge as full payment

established patient

patient who has received professional services from a provider of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

fee-for-service

payment for each service that is provided; individuals who choose to pay high premiums so that they have the flexibility to seek medical care from health care professionals of their choice.

Health Reimbursement Arrangement (HRA)

pays for medical expenses. It can be paired with a standard or high-deductible health plan. An employer can contribute to an HRA, but an employee cannot.

dependent

person covered under a subscriber's insurance policy; refers to spouses and dependent children.

beneficiary

person entitled to benefits of an insurance policy. This term is most widely used by Medicare.

flexible spending arrangement (FSA)

pretax funds set aside for use in payment of medical services and supplies not covered by insurance; referred to as a cafeteria plan. Qualified medical expenses are those specified in the plan that would generally qualify for the medical and dental expenses deduction, which is explained in IRS Publication 502. The plan is usually funded by the employee with pretax dollars. In some instances, an employer might contribute small amounts. This is a "use it or lose it" type plan.

PCP

primary care physician -responsible for referring the patient to a specialist and approving additional services if needed

preauthorization

prior approval of insurance coverage and necessity of procedure; refers to obtaining plan approval for services prior to the patient receiving them; relates not only to whether the services are covered but also whether the proposed treatment is medically necessary (see Figure 24-12). See Procedure 24-2 for steps in obtaining preauthorization for a procedure.

medigap

private insurance to supplement Medicare benefits for payment of the deductible, co-payment, and coinsurance.

CMS-1500

the standard claim form designed by the Centers for Medicare and Medicaid Services to submit physician services for third-party (insurance companies) payment; the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed.

cross-reference

referencing from one part of the code book to another part containing related information (e.g., cross-referencing from the index to the Tabular List).

Precertification

refers to obtaining plan approval for services prior to the patient receiving them; refers to seeking approval for a treatment (surgery, hospitalization, diagnostic test) under the patient's insurance contract. See Procedure 24-2 for steps in obtaining a managed care referral for treatment.

predetermination

refers to the discovery of the maximum amount of money the carrier will pay for primary surgery, consultation service, postoperative care, and so on.

Third Party Liability (TPL)

refers to the legal obligation of third parties (e.g., certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished under a state plan. Table 24-1 provides examples of third parties that may be liable to pay for services.

medicare advantage

the Part C segment of Medicare that enables beneficiaries to select a managed care plan as their primary coverage.

assignment of benefits

the authorization, by signature of the patient, for payment to be made directly by the patient's insurance to the provider for services.

etiology

the cause, set of causes, or manner of causation of a disease or condition.

conversion factor

the dollar amount that converts the RVUs into a fee.

category

the first three characters of an ICD-10-CM code designate the category of the diagnosis.

capitation

the health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization regardless of whether services were provided.

alphabetic index

the index arranged in alphabetic order by disease (specific illness, injury, eponym abbreviation, or other descriptive diagnostic term); includes diagnostic terms for other reasons for the encounter.

chief complaint

the main reason for the patient's visit

allowed amount

the maximum amount an insurer will pay for any given service.

global period

the period of time that is covered for follow-up care.

subscriber

the person who has been insured; an insurance policyholder.

diagnosis

the reason the patient is receiving care; the identification of the illness or problem by the provider upon examination of the patient.

medicare part C

the segment of Medicare that enables beneficiaries to select a managed care plan as their primary coverage. This type of coverage is provided by private insurance companies approved by Medicare to provide this type of coverage. Medicare Advantage plans are in operation in many states. The plans usually offer the patient additional services outside of what traditional Medicare covers. If a patient chooses, they may also carry supplemental insurance. Benefits vary from plan to plan.

bundle

to "bundle" is the arbitrary practice of some insurance carriers to group codes together, by which they either ignore additional codes reported on a claim and reimburse one of the lesser codes, or they ignore modifiers through edits built into their claims processing system.

waivers

to give up; forgo; waiving of a right or claim; a document outlining services that will not be covered by a patient's insurance carrier and the cost associated with those services. Patient signature indicates they understand that these services will not be covered and that they agree to pay for the service out of pocket.

consultation

when a patient visits with another provider at the request of the health care provider.

coordination of benefits

when both spouses have health care insurance, the policy provision that limits benefits to 100 percent of the cost; also known as dual coverage; procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy. One insurer becomes the primary payer, and no more than 100 percent of the costs are covered.

critical care

when constant bedside attention is required to a patient who is critically ill or unstable.

concurrent care

when similar care is being provided to a patient by more than one provider.