Embed Size (px)
Citation preview
FROM PATIENT TO PAYMENT
Chapter 1
Chapter 1 2
FROM PATIENT TO PAYMENT Learning Objectives
Explain the main differences between indemnity plans and managed care plans.
Define the various types of insurance coverage. Identify five steps in the payment process of a
patient’s insurance claim form. Discuss four primary responsibilities of a medical
insurance specialist. List effects of insurance claim errors on medical
office routines.
Chapter 1 3
Key Terms Assignment of benefits Benefits Coinsurance Copayment Cost-containment
practices Deductible Dependent Diagnosis (dx)
Direct payment Electronic claims Electronic remittance
advice (ERA) Encounter form Explanation of benefits
(EOB) Fee-for-service Indemnity plans Indirect payment
Chapter 1 4
Key Terms (cont’d)
Insurance carrier Insurance claim form Insurance log Managed care Managed care
organization Medical insurance Medical insurance
specialist
Patient information form Policyholder Preauthorization Premium Provider Release of information Schedule of benefits
Chapter 1 5
Introduction to Medical InsuranceMedical Insurance
Medical Insurance – is an agreement between a person, who is called the Policyholder, and a Health Plan.
Health Plan– is also know as “Insurance Carriers or Payers”“Insurance Carriers or Payers” are organization that offer financial protection in case of
illness or injury People buying medical insurance pay a PremiumPremium to the health
plan. In Exchange for the Premium,Premium, the health plan agrees to pay
amounts, called Benefits,Benefits, for Medical ServicesMedical Services. Medical ServicesMedical Services – include the care supplied by a Provider,
Hospitals, Physicians & other medical staff and facilities.
Chapter 1 6
Introduction to Medical InsuranceMedical Insurance
Insurance Policy – may contain a “schedule of benefits,“schedule of benefits, which is a list of covered medical services. May include:
Payment for medical necessary medical treatments received by policyholders & dependents
Surgery, primary care, emergency care, hospital-based services, etc.
Preexisting Conditions–may not be a covered service. It is an illness or disorder that existed before the effective date of the
insurance coverage. Preexisting Conditions - are excluded from coverage under some
policies, or a specified length of time must elapse before the condition is covered.
Chapter 1 7
Indemnity PlanIndemnity Plan Indemnity Plan – An insurance company’s
agreement to reimburse a policyholder a predetermined amount for covered losses.
Also known as fee-for-servicefee-for-service plans Providers charge a specific Fee for each service rendered. Fee paid by Patient and/or Patient Insurance. Allows insured individuals to choose any physician or
hospital when seeking medical services.
Chapter 1 8
Indemnity PlansIndemnity Plans
Benefits paid when treatment is received Schedule of Benefits (list the services that are paid & the amounts
that are paid) Patient pay a coinsurance, deductibles, and a premium
Coinsurance – percentage of the Fee(s) that the policyholder pays.
Deductibles – A certain amount of money that the patient must pay each year toward his/her medical expenses before health insurance benefits begin.
Premium – Periodic amount of money the insured pays to a health plan for a health care policy
Chapter 1 9
Indemnity Plans - Indemnity Plans - FormulaFormula
Charge – Charge – DeductibleDeductible – – Patient CoinsurancePatient Coinsurance==Health Plan Health Plan PaymentPayment
Case StudyAn indemnity policy states that the deductible is the first $200 in
covered annual medical fees and that the coinsurance rate is 80-20. A patient whose first medical charge of the year was $2,000 would owe $560.Charge $2,000
Patient owes the deductible
$ 200
Balance $1,800
Patient also owes coinsurance (20% of the balance)
$ 360
Total balance due from patient
$ 200+$360=$560
Chapter 1 10
Indemnity Plans - Indemnity Plans - FormulaFormula
Charge – Charge – DeductibleDeductible – – Patient CoinsurancePatient Coinsurance==Health Plan Health Plan PaymentPayment
Case StudyIn this case, the patient must pay an out-of-pocket expense of $560
this year before benefits begin. The health plan will pay $1,440, or 80% of the balance.
Charge $2000
Patient payment $ -560
Health Plan Payment $1,440
Chapter 1 11
Indemnity Plans - Indemnity Plans - FormulaFormula
Charge – Deductible – Patient Coinsurance=Charge – Deductible – Patient Coinsurance=Health Plan Health Plan PaymentPayment
Case StudyIf the patient has already met the annual deductible, the patient's
benefits apply to the charge.
Charge $2000
Patient Coinsurance (20%) $ 400
Health Plan Payment (80%) $1,600
Chapter 1 12
Managed Care PlansManaged Care Plans
Manage Care Plan – is a plan composed of a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, but quality service.
Manage Care – offers a more restricted choice of providers and treatments in exchange for lower premiums, deductibles, and other charges than traditional indemnity insurance.
Chapter 1 13
Managed Care OrganizationManaged Care Organization
Managed Care Organizations (MCO) Responsible for both the delivery and ffinancing of health
care services Establish links among provider, patient and payer. Both Patient and Provider have agreements with the
MCO. The Patient agrees to the payments for the services The Provider agrees to accept the fees the MCO offers
for services
Chapter 1 14
Managed Care OrganizationManaged Care Organization
Managed Care is the leading type of health plan. Patients maybe required to pay fixed premiums at
regular time periods, such as monthly. A Patient may also pay a copayment.
Copayments – A fixed fee, such as $10 that a health plan requires a policyholder to pay at the time of service for each health care encounter.
Chapter 1 15
Cost ContainmentCost Containment
Cost-Containment Practices - is a method to help control cost. Patients may be required to choose from a specific group of
physicians and hospitals. Visits to specialist often must be made by a Referral from
the patient’s primary care physician. A second physician’s opinion may be required before
surgery can be reimbursed. Many services that involved overnight hospital stays are now
covered only if done during day-time hospital visits, with patients recuperating at home.
Chapter 1 16
Cost Containment - Cost Containment - PreauthorizationPreauthorization
Preauthorization – a cost-containment practice to help control cost. If preauthorization is required, the health plan must
approve a procedure before it is done in order for the procedure to be covered.
Referrals my be required from patients’ primary care physician before visits to a specialist.
Nonemergency services must be approved before a patient is admitted to the hospital.
Shorter hospital stays are encouraged, and weekend hospital admissions for Monday service may not be permitted.
Chapter 1 17
Managed Care PlansManaged Care Plans
Basic Type of Manage Care Plans Are : Health Maintenance Organization (HMO) Point-of-Service Plan (POS) Preferred Provider Organization (PPO) Consumer-Driven Health Plans (CDHP)
Chapter 1 18
Managed Care Plans Managed Care Plans HMO DefinedHMO Defined
Health Maintenance Organization (HMO) Combine coverage of medical costs and delivery of health
care for a prepaid premium. HMO creates a network of physicians, hospital, and other
providers by employing or negotiating contracts with them.
HMO then enrolls members in a health plan under which they use the services of those network providers.
Chapter 1 19
Managed Care Plans Managed Care Plans POS DefinedPOS Defined
Point-of-Service Plan (POS) POS is also known as “Open HMO “ Reduces restriction by allowing members to choose out-of-
network providers. Members must pay additional set fees when they use out-of-
network services. The HMO pays out-of-network providers on a fee-for-
service basis.
Chapter 1 20
Managed Care Plans Managed Care Plans PPO DefinedPPO Defined
Preferred Provider Organization (PPO) PPO is another health care delivery system that manages care. PPO are the most poplar type of insurance plan. They create a network of physicians, hospitals, and other providers
with whom they have negotiated discounts from the usual fee. Premiums & copayments are required, and maybe higher than HMO
and POS plans PPO do not require a primary care physician to oversee patients’
care. Referrals to specialists are also not required. Members can use out-of-network Providers at a higher copayment &
deductibles.
Chapter 1 21
Managed Care Plans Managed Care Plans CDHP DefinedCDHP Defined
Consumer-Driven Health Plans (CDHP) CDHP combine two elements:
The first element is a health plan, usually a PPO, that has a high deductible (such as $1,000) and low premiums.
The second element is a special “Saving Account” that is used to pay medical bills before the deductible has been met.
The Saving Account, similar to an individual retirement account (IRA), it lets people put aside untaxed wages that they may use to cover their out-of-pocket medical expenses.
Some employers contribute to employees’ account as a benefit.
Chapter 1 22
Private Medical Insurance Private Insurance
Private Insurance are health plans. Most are Group contracts/policies that covers
people who work for the same employer or belong to the same organization.
They include private companies such as professional association, labor unions and schools.
Other plans are offered as individual contracts, which are policies purchased by people who do not qualify as members of a group
Chapter 1 23
Private Medical Insurance Auto or liability insurance
May also provide coverage for treatment Coverage may varies by State
Self-Funded Health Plans Approximately 50 million employees have health
insurance through employers that have established themselves as self-funded (self-insured) health plans.
Chapter 1 24
Private Medical Insurance Self-Funded Health Plans – Cont. Examples of Self-funded health plans /companies are
General Motors and, UPS (United Parcel Service) Rather than paying premiums to an insurance carrier, the
organization “insures itself.” It assumes the risk of paying directly for medical services
and sets up a fund from which it pays for claims. The organization establishes the benefit levels and the plan
types it will offer. Self-Funded Health Plans may set up their own provider
networks or, buy the use of existing networks from managed care organizations.
Chapter 1 25
Government Programs Military-Related
Tricare (formerly CHAMPUS) CHAMPVA
Medicare Medicaid Workers’ compensation
Chapter 1 26
Government ProgramsMilitary-Related
TRICARE (formerly CHAMPUS) - is a government health program that serves:
• dependents of active-duty service members,
• military retirees and their families,
• some former spouses, and
• survivors of deceased military members.
Chapter 1 27
Government ProgramsMilitary-Related
•CHAMPVA • The Civilian Health and Medical Program
of the Veterans Administration, which shares health care costs for families of veterans with 1—percent service-related disabilities and;
• for the surviving spouses and children of veterans who died from service-related disabilities.
Chapter 1 28
Government ProgramsMilitary-Related
Medicare – A federal health plan that covers persons aged 65 and over, peoples with disabilities, and dependent widows.
Medicaid – A federal and state assistance program that pays for health care services for people with incomes below the national poverty level.
Chapter 1 29
Government ProgramsMilitary-Related
Workers’ Compensation - A State or Federal Plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment.
Chapter 1 30
A person covered by a health plan receives insurance benefits by filing a Health Care Claims. The Claim Identifies
The Policyholder (and the patient). Tells health plans which medical services were
performed and why.
The Health Care Claim Billing & Payment Cycle
Chapter 1 31
The Health Care Claim Billing & Payment Cycle
Five Steps in the Payment Process of Health Care Claim:
Step 1 Patient information formStep 2 Doctor determines the dxStep 3 Medical insurance specialist collects data from patient records and completes claim formStep 4 Insurer reviews claimStep 5 Medical insurance specialist checks ERA/EOB for accuracy
Chapter 1 32
Patient Information Form –includes a patient’s personal, employment, and insurance company information needed to complete a health care claim.
The patient information form is also known as the “registration form”.
Step 1 - Patient Information Form
Chapter 1 33
The Patient Information Form has space for the patient’s & guardian’s signature, signature for release of medical information or the phrase, “signature on file” (SOF).
Assignment of Benefits Allows payment to be made directly to provider
Release of Information Used to assist in patient treatment or processing of claims
The patient completes (or updates) the patient information form.
Step 1 - Patient Information Form
Chapter 1 34
Completed by physician Diagnosis(es) determined Treatment documented
Encounter form Also called superbill Compiles data for each office visit Details dx and procedure codes and charges
Step 2 - Diagnosis and Encounter Form
Chapter 1 35
Completed by medical insurance specialist Collects data from patient information form,
patient medical record, and encounter form Completes and submits claim form
Paper or electronic
Insurance log Used to track status of claims
Step 3 - Data Collection
Chapter 1 36
Completed by insurance company Compares dx and procedures
Fee-for-service Compares fees to schedule of benefits Determines amount of benefit and
coinsurance/deductible Claim is paid or denied
ERA/EOB sent to provider
Step 4 - Claim Review
Chapter 1 37
Completed by medical insurance specialist Checks ERA/EOB for accuracy Payment/denial recorded in insurance log
Patient account Payment recorded in patient ledger
Patient Ledger – is a record of all charges and payments made on the patient’s account.
Remainder billed to patient, if balance due
Step 5 - Follow-up
Chapter 1 38
Responsibilities of Responsibilities of Medical Insurance SpecialistsMedical Insurance Specialists
Gathering patient information
Obtaining signatures Release of Information Assignment of Benefits
Submitting insurance claim forms
Paper or electronic
Reviewing insurance payments/denials
Resubmitting corrected claims
Help patients understand insurance procedures
Chapter 1 39
Effects of Errors Lower payments and
denied claims
Delayed payments
Disruption of other work
Patient questions and complaints
Chapter 1 40
Quiz
fee-for-service
managed care organization
physician
medical insurance specialist
The ___________ determines the dx code.
Indemnity plans are also known as _________________ plans.
The ___________ ___________ ________ completes the claims process.
1. The _______________________________ determines the payment for managed care insurance claims.
Chapter 1 41
Critical Thinking What are some benefits of keeping an
insurance log?
• The status of all claims is available at any time.
• Delays in payment can be investigated.
• Analysis of the efficiency of the practice’s and insurer’s claims process can be made.
