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InsuranceInsurance
Lori HowardLori Howard
TermsTerms
ClaimClaim PremiumPremium DeductibleDeductible BenefitsBenefits Primary CoveragePrimary Coverage Secondary CoverageSecondary Coverage RiderRider ExclusionsExclusions
ProviderProvider Co-payCo-pay EOBEOB UCRUCR HCFA 1500HCFA 1500 Itemized BillItemized Bill UB 92UB 92 CPT codeCPT code
TYPES OF INSURANCETYPES OF INSURANCE
HealthHealth
»HMOHMO
»PPOPPO
»POSPOS
»IndemnityIndemnity
TYPES OF INSURANCETYPES OF INSURANCE
HospitalizationHospitalizationAccidentAccidentAthletic InsuranceAthletic Insurance
AccidentalAccidentalSelf Self
InsuranceInsurance
TYPES OF INSURANCETYPES OF INSURANCE
Catastrophic InsuranceCatastrophic Insurance
–NCAANCAA
»Benefits start after $50,000 and Benefits start after $50,000 and pay for lifetimepay for lifetime
»www.ncaa.orgwww.ncaa.org
NFSHSANFSHSAMembership benefitsMembership benefitsBenefits start after $25,000 Benefits start after $25,000 www.nfhs.orgwww.nfhs.org
COORDINATE INSURANCECOORDINATE INSURANCE
(Ed Setting)(Ed Setting)
–philosophy of administrationphilosophy of administration
–philosophy of physicianphilosophy of physician
–be familiar with your policy be familiar with your policy (exclusions)(exclusions)
–know NCAA rulesknow NCAA rules
–get to know insurance get to know insurance coordinators at your provider’s coordinators at your provider’s officesoffices
–Consider buying a CPT code Consider buying a CPT code bookbook
COORDINATE INSURANCECOORDINATE INSURANCE
–Be organized, have a systemBe organized, have a system
–Utilize time managementUtilize time management
–Get to know CSR at your Get to know CSR at your insurance companyinsurance company
CLAIM PROCESSING (Ed)CLAIM PROCESSING (Ed)
get insurance info prior to athletic get insurance info prior to athletic participationparticipation
keep insurance files separate from keep insurance files separate from medical filesmedical files
Managed Care: find out how many Managed Care: find out how many athletes have itathletes have itcontact each one, speak to a contact each one, speak to a manager, find out if athlete can see manager, find out if athlete can see team MD, if he accepts UCRteam MD, if he accepts UCRCoverage under Athletics Dept. Coverage under Athletics Dept. policypolicy
CLAIM PROCESSING (Ed)CLAIM PROCESSING (Ed)
–Try to have local PC physician Try to have local PC physician assignedassigned
–Mark the files of athletes with Mark the files of athletes with managed caremanaged care
–Have a follow up system for Have a follow up system for checking the status of claimschecking the status of claims
DO NOTSDO NOTS
wait until claim to get primary wait until claim to get primary insurance informationinsurance information
say the institution will pay the claimsay the institution will pay the claim take responsibility for filing the take responsibility for filing the
primary claimsprimary claims pre-pay from the athletic budgetpre-pay from the athletic budget wait to file the claimwait to file the claim
DO NOTSDO NOTS
assume CPT codes are correct assume CPT codes are correct fail to check claims carefullyfail to check claims carefully
IF A CLAIM IS DENIEDIF A CLAIM IS DENIED
find out whyfind out why get statement from M.D. saying get statement from M.D. saying
treatment was necessarytreatment was necessary provide evidence from clinical studiesprovide evidence from clinical studies convince M.D. to waive fees above UCRconvince M.D. to waive fees above UCR contact the state insurance commission contact the state insurance commission
and challenge denialand challenge denial
INS. BILLING (Clinic)INS. BILLING (Clinic)
services are dictated by a physician services are dictated by a physician (must have a script)(must have a script)
paid directly from insurance companiespaid directly from insurance companies wait until have authorization from wait until have authorization from
insurance company before initiating insurance company before initiating treatmenttreatment
CLAIM PROCESSING (Clinic)CLAIM PROCESSING (Clinic)
fill out charge slip (super bill)fill out charge slip (super bill) find out CPT codesfind out CPT codes list charges & procedures dailylist charges & procedures daily file claim on HCFA 1500 formfile claim on HCFA 1500 form Have PT sign claim (not nec. In GA)Have PT sign claim (not nec. In GA) keep copy of pt claim in chartkeep copy of pt claim in chart enter claim into registry in patient chartenter claim into registry in patient chart
CLAIM PROCESSING (Clinic)CLAIM PROCESSING (Clinic)
mail claim to insurance companymail claim to insurance company make a note of date submittedmake a note of date submitted have a follow up system for checking have a follow up system for checking
the statusthe status usually takes 4-6 weeks to receive usually takes 4-6 weeks to receive
paymentpayment New year = new deductibleNew year = new deductible
PURCHASING INSURANCE PURCHASING INSURANCE
contact agentscontact agents get bidsget bids
TO SELECT & PURCHASETO SELECT & PURCHASE
monetary limitsmonetary limits exclusions/ridersexclusions/riders primary/secondary/HMO’sprimary/secondary/HMO’s deductibledeductible co-paymentsco-payments who is coveredwho is covered out of season injuryout of season injury
TO SELECT & PURCHASETO SELECT & PURCHASE
annual premiumannual premium how to file claimshow to file claims