COMPREHENSIVE HEALTH INSURANCE Flashcards
Prepaid health plans (also called prepaid medical plans) are
contracts that cover specific medical expenses for individuals or groups
Medical insurance covers specific medical expenses. However, in the healthcare industry, the term health insurance now covers all aspects of medical insurance as well.
To the insurance industry, health insurance now includes medical insurance and means protection against the following:
Income losses for illness or injury (accident insurance)
Disability income
Accidental death or dismemberment (loss of limbs)
Sickness insurance
Medical expense insurance
Commercial health insurance is often separated into two categories:
private insurance and employer-based insurance.
Private, or individual, insurance
provides healthcare coverage for the policyholder and the policyholder’s family.
Employer-based, or group, insurance
provides coverage to a group of people (such as employees).
Group insurance policies
generally cost less than private plans and provide a wider range of benefits because the cost is spread across more people and therefore can be offered at a lower rate.
Private health insurance (also called non-group insurance)
often used by self-employed people and others who aren’t eligible for group plans.
Private insurance holders pay premiums, or regular, pre-established amounts. The insurance company uses the money collected to pay claims submitted by those who have purchased insurance.
FEP
Federal Employee Program
Underwriting
is the process whereby an insurer reviews applications submitted for insurance coverage and decides whether to accept or reject all or part of the coverage requested.
Blue Cross and Blue Shield (BC/BS) covering over ______ Americans.
100 million
An insurer’s responsibilities include the following (Underwriting)
Reviewing applications submitted for insurance coverage
Deciding whether to accept or reject all or part of the coverage requested
Fixing the terms of coverage
The FEP offers two plans:
the preferred provider organization (PPO) plan and the point-of-service (POS) plan
PPOs (preferred provider organizations) provide
discounted healthcare services to members in the plan
POS (point-of-service)
members must select providers within their network to receive the discount
COB
Coordination of Benefits
HDHP
high-deductible health plan
UCR
Usual, Customary, and Reasonable
X12
reason codes
You can view the codes for remittance advice and codes for claim adjustments. They’ll be listed on the remittance after each patient’s claim
EHR
Electronic Health Record
RAC
Recovery Audit Contractor
Recovery Audit Contractor explained
If the Centers of Medicare and Medicaid (CMS) suspect fraud, waste, abuse, or error in claims that are being billed, they’ll ask for an audit of the claims through a Recovery Audit Contractor (RAC).
These claims are reviewed to make sure they both meet coding standards and documentation standards. They’re also reviewed to make sure the services that are billed are actually being provided. If not, the RAC will ask for the money that was originally paid to be returned to CMS.
UPICs
Unified Program Integrity Contractors
Unified Program Integrity Contractors explained
Medicare uses UPICs.
These contractors use data analysis to identify billing trends that are outside of the norm.
If a provider bills consistently at a higher level of service than what’s typically provided for their specialty or routinely adds services that don’t go together, then their practice may be flagged.
The UPIC may request medical records or may even visit the provider’s practice in person.
The OIG
The Office of the Inspector General
OIG Provider Self-Disclosure Protocol
providers can reduce the number of penalties they’ll need to pay. The OIG will investigate instances of fraud and abuse and pursue legal action against providers, if appropriate. They often take the results of the UPIC and RAC organizations and study their findings. They’ll investigate if the broad, sweeping increases are due to some legislative change in billing patterns, or if there’s another cause.
Some indicators of fraud and abuse that the OIG, UPIC, and RAC may look for:
An overuse of modifiers that override NCCI edits
Billing services more frequently than other providers of the same specialty
Billing E/M codes with every surgical procedure may raise red flags with an audit.
Even if your practice bills exactly the same as others of the same kind, you still may get RAC audits, everyone does. It’s your chance to prove that you have the documentation to support the patient’s visit and that you’re in compliance with all laws.
Medicare was formerly known as?
Title XVIII of the Social Security Act
Title XVIII of the Social Security Act signed into law by who and when?
President Johnson
1965
Medicare eligibility criteria:
- At least 65 years or older
- U.S. citizenship or permanent residence
- At least 10 years of Medicare-covered employment for individual or spouse
- Under 65 End-stage renal disease (or permanent kidney failure that requires dialysis or transplantation)
- Under 65 Received disability benefits under Social Security or Railroad Retirement (that is, benefits for railroad workers and their families for 24 months
BBA
The Balanced Budget Act of 1997
The Balanced Budget Act (BBA) explained
amended Medicare and made the most legislative changes to the program since it was established. The BBA established a Part C (in addition to Parts A and B) of the Medicare program to create new managed care and other health plan choices for beneficiaries.
This act includes the following:
New payment system for Medicare services to improve accuracy and reduce healthcare spending.
Expanded preventive-care benefits
Establishment of a new State Children’s Health Insurance Program (SCHIP)
New eligibility options for Medicaid
Expanded assistance for low-income Medicare beneficiaries
New quality standards for Medicaid managed-care programs
In 2006, a Part D was added to cover prescription drugs.
Medicare Part A is
Hospital insurance
Medicare Part A explained
People who meet the eligibility requirements can automatically receive Medicare Part A without paying a premium because they or their spouse paid Medicare taxes while they were working. Medicare is financed almost entirely by a nearly universal tax on employee pay.
Some people who don’t automatically receive coverage because they didn’t pay Medicare taxes while they were employed voluntarily pay for Medicare Part A coverage. In this case, they can purchase Medicare Part A coverage just like any other insurance coverage.
Because Medicare Part A is hospital insurance, it covers specific healthcare services normally related to hospital care.
Inpatient hospital care
covers patients who are expected to remain in the hospital for at least 24 hours or more to receive treatment from a physician.
Long-term care
covers persons with chronic disease or disabilities (diseases that persist for a long period or for the rest of the person’s life).
This coverage includes a wide range of health and social services provided under the supervision of medical professionals.
Medicare Part A covers inpatient hospital care and long-term care when these services are
medically necessary; that is, when lack of such service or treatment could adversely affect the patient’s condition.
Skilled nursing facility (SNF) care
includes rehabilitation, 24-hour nursing coverage, and physical, occupational and speech therapy.
HHA
home health agency
home health agency (HHA)
is a certified facility approved by a health plan to provide services under contract.
Hospice care
is primarily designed to provide pain relief, symptom management, and supportive services for the terminally ill and their families.
Medicare Part B is called supplemental insurance because
people don’t automatically receive Part B coverage. Instead, a premium must be paid for this coverage.
Medicare Part B is a voluntary program that’s financed through a combination of payments from general federal revenues and premiums paid by beneficiaries who elect to participate. The premium payments are generally deducted from the person’s?
Social Security, Railroad Retirement, or Civil Service Retirement check. If the person doesn’t receive any of those payments, then a bill for the Part B premium is sent every three months.
Medicare Part C is also known as the
Medicare Advantage Program
Medicare Part C provides
Medicare members with alternative insurance providers instead of the government.
Out-of-pocket expenses
are those expenses that aren’t covered by Medicare. These are the expenses that patients must pay themselves.
Medigap insurance
is a health insurance plan that fills the “gaps” in Medicare plan coverage. This means that Medigap covers the services that aren’t covered by the Medicare options.
Each state offers standard Medigap plans, with different benefits for each plan.
If a person has a Medicare managed care plan, a private fee-for-service plan, or is covered by Medicaid, then Medigap insurance isn’t necessary.
managed care plan
is a plan that involves financing, managing, and delivery of healthcare services. Typically, it involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, quality healthcare service.
fee-for-service-plan
physicians and other providers receive payment based on their billed charge for each service provided.
Medicaid programs provide healthcare coverage for
low-income families who meet specific eligibility requirements.
Medicaid eligibility is limited to individuals who fall into specified categories. To be eligible for federal funding assistance, the state Medicaid programs must provide Medicaid coverage for specific groups of individuals as defined by the federal government. The federal statute identifies more than 25 different eligibility categories for which federal funds are available. These categories can be classified into five coverage groups:
Children
Pregnant women
Adults in families with dependent children
Individuals with disabilities
Individuals 65 years and older
There are two eligibility groups:
categorically needy and medically needy.
Categorically needy eligibility means
that the person and/or dependents fall into one of the categories outlined by the program and are therefore eligible to receive Medicaid coverage.
Medically needy means
means that persons would be eligible for Medicaid because they have high medical expenses, except that their income and/or resources are above the eligibility level set by their state. In these cases, specific medical needs make them eligible for Medicaid. Not all states offer medically needy Medicaid programs.
SCHIP
State Children’s Health Insurance Program
State Children’s Health Insurance Program explained
Initiated by the Balanced Budget Act in 1997.
Is also known as Title XXI of the Social Security Act. SCHIP provides federal funds to states to expand Medicaid eligibility to include a greater number of uninsured children.
You’ll sometimes see SCHIP referred to as simply Children’s Health Insurance Program, or CHIP. Both of these terms refer to the same program .
NCD
National Coverage Determinations
where the medically necessary diagnosis code for each procedure can be found and indications when a procedure should be performed.
You’ll find how to submit a claim, the rules around time limits, and when to charge a patient. As part of your local _____?
Medicare Administrative Contractor (MAC)’s website
you can find information on how those payers prefer their claims to be submitted, along with special instructions they have on coding or other billing guidance. You’ll find their list of medically necessary diagnoses for specific procedures under their LCD (Local Coverage Determinations).
Managed care
is a type of healthcare system that manages utilization, quality, and cost of services. Resources and services are closely monitored to ensure that the costs of services are within the amount that the insurance company will reimburse.
HMO
health maintenance organization
Examples of managed care plans with which you may be familiar are
HMOs and PPOs
Generally speaking, a managed care health plan is a collection of interdependent systems that integrate the delivery of healthcare services to a specific population. Managed care health plans used the following processes:
Arrangements with selected providers to furnish a comprehensive set of healthcare services to members
Credentialing standards for the selection of healthcare providers
Quality assurance and utilization review programs
Financial incentives for member to use providers and procedures associated with the health plan (the network)
IDS
Integrated delivery systems
ren’t necessarily nonprofit
CCN
community care networks
tends to be community-based and nonprofit
MCO
Managed care organization
UCR explained
Providers set their Usual, Customary, and Reasonable (UCR) free for each procedure code, for those providers who bill based on fee-for-service.
This is the set amount that’s billed to all insurance companies. The insurance company pays on the contracted rate for each procedure code. The amount the insurance company has contracted with the provider to pay is called the allowed amount. The difference between the allowed amount and the UCR is written off as a contractual discount. If the provider bills $300 and the insurance allowed amount is $100, the provider will receive $100 for that service and the rest will be written off. The patient is never responsible for the contractual discount.
