C H A P T E R 9 9 Health Care Coverage. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 2 Fundamentals

C H A P T E RC H A P T E R

99 Health Care Coverage

Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.

9 - 2

Fundamentals of Managed Care11

U N I TU N I T


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Changes in Health Care Coverage

Variety of health care plans Health maintenance organizations (HMOs) Preferred provider organizations (PPOs) Health savings accounts (HSAs) Traditional health plans

Variety offers choice and a way to cut costs


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The Purpose of HMOs

HMOs offer affordable health care plans designed to promote good health and encourage preventive medicine

Provided through employers at a reasonable cost


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The Concept of Managed Care

Create an organized system of medical team members

Team members would provide quality and cost-effective care

Would cover both the delivery of the care and payment for these services

Help to contain rising health care costs


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Two Classes of Health Insurance

1. Individual Bought by one person generally for a higher

premium

2. Group Bought by employers or unions generally at

discounted premiums Costs paid completely by the employer or

shared with the patient


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Types of Health Insurance

Government sponsored Medicare, Medicaid, and TRICARE

Private insurance HMO PPO Workers compensation


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The Birthday Rule

If a dependent child is covered under the insurance policies of both parents, the birthday rule applies:

The parent whose birthday falls first in the calendar year is primary.

If parents have the same birthday, the insurance policy that has been in effect the longest is primary.


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Divorce and the Birthday Rule

If parents are divorced, the court order that dictates which parent is responsible for health care is primary.

A court order supersedes the birthday rule.


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Unit Summary

What is the purpose of managed care? When would the birthday rule apply in

the medical office?


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Health Care Plans22U N I TU N I T


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Indemnity-Type Insurance Plans

Commercial plans in which the insurance company reimburses the physician for services


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The Health Care Philosophy of an HMO

To provide a wide range of health care services at a fixed fee schedule and to promote wellness and good health


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How a PPO Differs from an HMO

PPOs allow the physician to sign up to provide services at a discounted rate

HMOs allow employers to arrange for group health care at discounted premiums


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Federal Health Care Plans

Workers compensation Covers those injured on the job

Medicaid Covers individuals of limited or low income

Medicare Covers individuals over 65, those who

receive Social Security benefits, and those who meet eligibility requirements

(continued)


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Federal Health Care Plans

TRICARE Covers dependents of active military

personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty

Easter Seals/Crippled Children’s Services

Covers disabled children under age 21


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Centers Established by 2001 Changes

The Center for Medicaid & Medicare Service (CMS)

The Center for Beneficiary Choices The Center for Medicaid and State

Operations


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Unit Summary

What is the difference between an HMO and a PPO?

What are the five federal health care plans identified in this unit?


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Preparing Claims33U N I TU N I T


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The Development of Claim Forms

As health care evolved from a system where the patient paid for all services, to a benefit that is offered by employers, health care companies grew and claim forms were designed to create the beginnings of the billing process we use today.


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Primary and Secondary Coverage

Primary coverage The insurance policy that lists the patient as

the insured Secondary coverage

Any supplemental insurance coverage, such as dual coverage under another insurance policy, or Medigap


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Insurance Codes

Coding by diagnosis ICD-9-CM or International Classification of

Diseases, 9th Revision, Clinical Modification Coding by procedures and services

CPT or Current Procedural Terminology code book


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HCPCS Codes

Healthcare Common Procedure Coding System

Identifies products and supplies that are not identified in the CPT book


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The Reason Rule and Sequencing

The reason rule states that the reason for the visit is always coded first.

Sequencing means that the codes must be listed in an order that makes it possible to understand the chronology of events.


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General Coding Rules

Code all diagnoses, procedures, and services correctly and completely.

Code the diagnosis that fully identifies the reason for the visit and the patient’s need for x-rays, treatment, procedures, or medications.

(continued)


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General Coding Rules

Code each problem to the highest level of specificity.

Sequence the code to make it possible to understand the chronology of events.


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Two Things to be Done Before Completing Insurance Forms

1. Make sure you have a copy of both sides of the patient’s insurance card.

2. Verify that the patient has signed the “release of information” and the “assignment of benefits” sections of the claim form.


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Common Errors Made WhenFiling Claims

The certificate number listed is the patient’s, not the insured’s, number

“Coordination of benefits” section is incomplete

Use of incorrect ICD-9-CM code(s)


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Common Claim Errors

Incorrect CPT or place of service codes, PINs, spelling of the patient’s name, birthdates

Attaching illegible superbills to the claim Incomplete request for clarification of

insurance Lack of operative report when billing for

unusual or complicated fees or procedures Inconsistent use of the patient’s name Placing middle name as the first name


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Items to Enter in an Insurance Log

Date claim was filed Insurance company information Patient’s name Amount of claim Date billed Amount paid Date patient was billed Follow-up date


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Preparing to Follow UpDelinquent Claims

Make sure you have the following information:

Patient’s name Insured’s name (if other than the patient) Identification number Group name and/or number

(continued)


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Preparing to Follow Up Delinquent Claims

Make sure you also have a copy of the claim, and be prepared to give:

The date of service The total amount of the claim The date the claim was submitted

Make complete notes in the log on the insurance company’s responses.


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Accepting Assignment

An assignment is accepted when a physician agrees to treat persons enrolled in an insurance program for a specified rate.

The physician may not bill the patient for any balance between the amount charged and the payment once the deductible is met.


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Noncovered Procedures Guidelines

Identify all noncovered procedures. Explain the procedure and the charges to

the patient. Arrange for payment with the patient. The office may also have the patient sign

a statement that verifies that he or she understands the charges and payments due.


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Items Necessary for Adequate Documentation

Complaints and symptoms Duration and course of illness Details of the illness Examination and findings Lab and x-ray findings Diagnosis Treatment


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Staying Current with Medicare and Insurance Company Regulations

Visit the CMS web site. Sign up for their listing services so that

each time there are news releases the announcement is sent to you via e-mail.

Click on the link to view the release.

http://www.cms.hhs.gov/


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Unit Summary

What is the reason rule? When would you use the ICD-9 and CPT

codes? What is a HCPCS code?


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Keys to Career Success

The successful medical assistant understands the relationship between proper billing and coding and increased office revenue.

When insurance forms are properly completed the first time, payment arrives promptly.


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Hot Links to Career Success

www.ama-assn.org/cpt American Medical Association

www.cms.hhs.gov Centers for Medicare & Medicaid Services

http://www.ama-assn.org/cpt

http://www.cms.hhs.gov/

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C H A P T E R 9 9 Health Care Coverage. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 2 Fundamentals