Test 1 Flashcards
HMO
health maintenance organization plans
PPO
preferred provider health organization
HSAs
health savings accounts
HRA
health reimbursement arrangements
POS
points of service
Electronic claims processing
90% of insurance claims are filed electronically
subscriber
the insured
assignment of benefits
authorization for insurance carrier to pay the physician or practice directly
carrier
insurance carrier
premium
basic annual cost
deductible
fixed dollar amount that must be paid or met once a year before the insurer begins to cover expenses
copayment
small fee paid at the time of service
coinsurance
fixed percentage of covered charges ofter deductible is met
exclusions
uncovered expenses such as eye exams or dental care
health insurance provider
insurance company
provider of medical services
the doctor
claims process
obtain patient information
delivery of service to a patient and determination of diagnosis and fee
recording payment form the patient and preparing insurance claim forms
reviewing insurer’s processing of the claim, explanation of benefits, and payment
Patient registration form
name current address current telephone number date of birth social security contact in case of emergency current employer employer address and number insurance carrier and effective date of coverage group plan number name of insured patient signature
CPT
Current procedural terminology
published by the AMA
What is CPT?
contains diagnoses and treatment codes, it is the responsibility of the person doing the insurance billing to translate the medical terminology on the charge slip into precise descriptions of the medical services, procedures and codes corresponding to that patient.
Health insurance history
First offered in the US in 1847 (accident insurance was offered three years later)
Coverage was only for income loss because of disability from an illness
Did not cover basic medical expenses
In 1929, the first group coverage started
Claim forms
filled out either manually of electronically
physician must sign the forms (not medicare)
There are time limits to file claims
Insurer’s processing and payment
review for medical necessity
review for allowable benefits
payment and explanation of benefits
review for medical necessity
determination of whether the diagnosis and treatment are compatible and whether treatment was medically necessary
review for allowable benefits
comparing fees the doctor charges with the benefits provided by the patien’s health insurance policy; determination of deductible or co-payment patient owes
payment and explanation of benefits
after review, insure pays benefit either to subscriber or to the practice; with the payment an EOB is sent
EOB
explanation of benefits
What is an EOB?
gives the following information name of subscriber identification number name of beneficiary claim number date place type of service amount billed amount allowed amount of subscriber liability amount paid notation of any services not covered and why
UCR
Usual, Customary and Reasonable fees system The UCR for federally funded insurance is applied by Congress. This included Medicare, Medicaid, Champus/Tricare and Champva. By law, providers must accept the UCR fee as payment in full. They cannot bill the patient for the difference.
Customary fee
This is either the average fee charged for the procedure by similar doctors in the same region or the 90% of the fees charged for the procedure by similar doctors in the same area. The insurance company calculates the 90th percentile rate. The Physician Fee Guide published by Practice Management Information Corporation in Los Angeles lists fees for all current procedural terminology (CPT) codes.
UNIVERSAL HEALTH INSURANCE CLAIM FORM- CMS-1500:
- Health Care Financing Administration (HCFA)
- Designed by congress
- Originally used for Medicare and Medicaid claims
- Now used also by many insurance carriers
- The CMS-1500 form must be completed properly
- CMS-1500 forms should not be duplicated; originals must always be used for each claim.
Rules to follow file CMS 1500 claim forms
- keep information inside field
- align paper
- do not enter data by hand
- use all uppercase (capitals)
- don’t use colored ink
- don’t use N/A for a field if not applicable; instead, leave blanks
Fee-for-Service (or Indemnity) Plans
With this traditional plan, you can make an appointment with almost any medical provider. After your visit, you or your provider sends your claim to the insurance company. If you have met your deductible for the year, then the Fee-for-Service plan will pay a percentage of the bill - usually 80%. You pay for the other 20%, known as coinsurance. Few purchase this traditional type of plan. Why? Because it’s expensive.
Managed Care
This term refers to types of health insurance plans that provide health care services at a lower cost. The key to these lower costs? Members of managed care plans must adhere to certain rules designed to lower the cost of medical care
Types of managed care
HMOs: health maintenance organizations
PPOs: preferred provider organization
POSs: point of service
What is Health Maintenance organization HMO?
- Provide specific services to individuals and their dependents who are enrolled in them
- Payment to providers is mostly done by capitation
- Physicians enrolled in these plans are called participating providers
- The patients must go to participating providers only
- Described as managed care organizations because they manage, negotiate, and contract for health care
- Main goal is to keep health-care costs down (this is the primary purpose of HMOs)
- Focus is on wellness and preventive care
- Encourage patients to have annual check-ups
- Copayments are usually $10 or $20 per visit (goes up higher every year)
- Many Medicare and Medicaid patients receive their benefits through an HMO
- Became popular in the 1980’s
Types of HMOs
Staff moder HMO
Individual practice associations IPAs HMO
Group model HOM
Open ended HMO
Staff Model HMO
A form of HMO in which doctors are employees of the HMO and you see them at a central medical facility.
- All services (physical therapy, x-rays, etc) are provided at the same location or a central medical facility
- PCP is responsible for routine care and referrals
- True emergencies do not require preauthorization
- Patient must however be preauthorized if they are outside their service area
Individual Practice Associations HMO (IPAs)?
Here, an HMO contracts with outside physician groups or individual doctors who have private practices. This means the HMO network will include doctors in various locations rather than only at a central facility.
- HMO contracts with outside physician groups or individual doctors who have private practices.
- HMO network will include doctors in various locations rather than only at a central facility such as the Staff model
What is Preferred Provider Organization (PPO)?
This isn’t an HMO, but it is another type of managed care. In this system, you may seek treatment from an approved network of providers, or may see other providers outside the network. Usually, you will pay small copay and satisfy a deductible before benefits are paid. Then you’ll pay a set coinsurance amount. It’s less expensive to visit one of the providers in the plan’s list. You can go outside the plan’s list, but your share of the bill will be higher.
What is Point of Service (POS)?
A hybrid of the HMO and PPO is known as a POS plan. Like a standard HMO, your primary care doctors make referrals to other providers within the plan. But if you want to go to a physician outside the network without consulting your primary care doctor, the POS plan will pay a predetermined amount of the bill and your share of the bill will be higher than it would if you stay in-network. These plans usually cost more in monthly premiums than straight HMOs, but they give you the flexibility to call any doctor - within the plan or not
- A network of physicians and hospitals that contract to provide an insurance company or an employer with services for their members or employees at a discount rate (this is like a hybrid of the HMO and PPO)
- Primary care doctor makes referrals to other providers within the plan, but if the patient wants to go to a physician outside the network without consulting the primary care doctor, the POS plan will pay a predetermined amount of the bill and the share of the bill will be higher than it would if the patient had stayed in-network.
- This benefits the insurance company by reducing the cost of care, which in turn should reduce the cost of the insurance for the employer
- The physicians benefit by gaining a group of patients from whom they can receive payments.
Copay
A fixed dollar amount you pay at the time services are rendered. Typical copays are for office visits, prescriptions, or hospitalizations.
