Medical Insurance Medisoft

  1. First Party
    Patient, insurance holder
  2. Second party
  3. Third party
    Health plan, medical insurance
  4. HMO
    Health maintenance organization; HMO creates network of Physicians, hospitals, and other providers by negotiating contracts with them. Members use the contracted physicians, providers, and hospitals. Combines coverage of medical costs and delivery of health care for prepaid premium.
  5. HMO cost containment methods
    • 1. Restricts patients choice of providers, only emergency care or urgent care are covered services outside the policy when away from geographical area.
    • 2. Requires preauthorization for services.
    • 3. Controlling use of service; HMOs have a medical necessity guideline for the use of medical services. Can be denied questionable service requests made by patient and/or provider.
    • 4. Controlling drug costs. Providers may only prescribe drugs for patients from the HMOs list of selected pharmaceuticals and approved dosages. Drugs not listed require preauthorization.
    • 5. Cost sharing. Patient/member must pay a copayment. Lower copayments are usual for seeing a primary care physician, and higher copayments are given for seeing specialists or use of emergency services.
  6. Schedule of benefits
    Summarizes the payments that may be made for medically necessary medical services which policy holders receive.
  7. Covered services
    Are listed in the schedule of benefits.
  8. Non-covered services
    • Medical insurance policy also describes excluded services. Some of the following are excluded on most plans.
    • ~ most do not cover dental, eye exams or eye glasses, employment related industries, cosmetic procedures, experimental procedures.
    • ~ Policies may exclude specific items such as vocational rehab or surgical treatment for obesity.
    • ~Many policies do not have prescription drug benefits
    • ~Pre-existing condition treatments are often not covered for new policy holders.
  9. Disability and workers' compensation
    • Disability insurance provides reimbursement for income lost because of an inability to work.
    • Workers' compensation is purchased by employers to pay benefits and provide medical care for employees who are injured in a job-related accidents and pay benefits to employees dependents in the event of a work-related death.
  10. Indemnity
    Is protection against loss. Indemnity plans the payer indemnifies the policyholder against costs of medical services and procedures as listed on the benefits schedule. Patients choose a provider the want to see.
  11. Condition for payments (Indemnity)
    • Four conditions:
    • 1. Medical charge must be for medically necessary services and covered by the insured's health plan.
    • 2. Patient's premium- the periodic payments the patient in required to make to keep the policy in effect, must be up-to-date.
    • 3. If part of the policy, deductible-the amount the insured pays on covered services before benefits begin- must have been paid.
    • 4. Any coinsurance- the percentage of each claim that the insured pays- must be taken into account. The coinsurance rate states the health plan's percentage of the charge. Followed by the insured's percentage. 80-20 means the insurance plan pays 80% and the insured pays 20% after the premiums and deductibles are paid.
  12. Indemnity formula
    • Charge-Deductible-Patient Coinsurance= Health plan payment.
    • Charge: $2,000
    • Deductible: $200 (patient owes)
    • Balance: $1,800
    • Coinsurance $360 (20% of the balance) (patient owes)
    • Total due from patients: $200+$360=$560
    • Insurance pays: $1,440

    • If patient already met the annual deductible, patient's benefits apply:
    • Charge: $2,000
    • Coinsurance: $400 (20%, patient owes)
    • Health plan payment: $1,600
  13. Fees-For-Service payment approach
    Indemnity plans usually reimburse medical costs on a fee-for-service basis. The FFS payment method is retroactive: the fee is paid after the patient receives services from the physician.
  14. Managed care
    offers a more restricted choice of and access to providers and treatments in exchange for lower premiums, deductibles, and other charges than the traditional indemnity insurance.
  15. MCOs- Managed Care Organizations
    • establish links between the provider, patient, and payer. The patient AND the provider have agreements with the MCO which gives the MCO more control over what services the provider performs and the fees for the services.
    • Basic types of plans available:
    • ~Health maintenance organizations
    • ~point-of-service plans
    • ~preferred provider organizations
    • ~consumer-directed health plans
  16. Capitation in HMOs
    is a fixed prepayment to a medical provider for all necessary contracted services provided to each patient who is a plan member. It covers a specific time period. The health plan makes the payment whether the patient receives many or no medical services during that specified period.

    Fee-for-service, the more patients a provider see, the more charges the health plan reimburses, whereas in capitation, the payment remains the same.
  17. POS- Point of Service Plans
    Is also called an open HMO, reduce restrictions and allows members to choose providers who are not in the HMOs network. Members must pay additional fees set by the plan when the use out of network providers.
  18. PPO- Preferred Provider organization
    is another health care delivery system. They create a network of physicians, hospitals, and other providers with whom they have negotiated discounts from the usual fees. Requires a premium and often a copayment at the time of service and the PPO pays the full balance of the visit charge.
  19. PPO cost containment system
    • ~ Directing patients' choices of providers
    • ~ Controlling use of services
    • ~ Requiring pre-authorization for services
    • ~ Requiring cost-sharing
  20. Consumer Driven Health Plans- CDHP
    has two elements; the first is a health plan, usually a PPO, that has a high deductible and low premiums. The second element is a special "savings account" that is used to pay medical bills before the deductible has been met.
  21. Government-Sponsored Health Care Programs
    • ~ Medicare is 100% federally funded that covers people who are 65+ yrs old, are disabled, or have permanent kidney failure (end stage renal disease, ESRD)
    • ~ Medicaid jointly funded by federal and state governments, covers low income people who can't afford medical care.
    • ~TRICARE, Department of Defense program, covers medical expenses for active-duty members of the uniformed services and their spouses, children, and other dependents; retired military personnel and their dependents; and family members of deceased active-duty personnel. Replaced (CHAMPUS{Civilian Health and Medical Program} in 1998)
    • ~CHAMPVA, the civilian health and medical program of the department of veterans affairs, covers veterans with permanent service-related disabilities and their dependents. Also covers surviving spouses and dependent children of veterans who died from service related disabilities.
  22. Duties of the Medical Insurance Specialist:
    The medical billing process
    • Main job functions:
    • ~ To understand patients' responsibilities for paying for medical services.
    • ~ To analyze charges and insurance coverage to prepare accurate, timely claims
    • ~ To collect payment for medical services from health plans and from patients

    • These functions include:
    • ~ Verifying patient insurance information and eligibility before medical services are provided.
    • ~ Collecting payments that are due, such as co-payments, at the time of service
    • ~ Maintaining up-to-date information about health plans' billing guidelines
    • ~ Following federal, state, and local regulations on maintaining the confidentiality of information about patients
    • ~ Abstracting information from patients' records for accurate billing
    • ~ Billing health plans and patients, maintaining effective communication to avoid problems or delayed payments
    • ~ Assisting patients with insurance information and require documents
    • ~ Processing payments and requests for further information about claims and bills
    • ~ Maintaining financial records
    • ~ Updating the forms and computer systems the practice uses for patient information and health care claims processing
  23. Medical billing process steps:
    • 1. Pre-register Patients
    • 2. Establish financial Responsibility for the Visit
    • 3. Check in patients
    • 4. Check out patients
    • 5. review coding compliance
    • 6. Check billing compliance
    • 7. Prepare and transmit Claims
    • 8. Monitor Payer Adjudication
    • 9. Generate patient Statements
    • 10. Follow up patient payments and handle collections

    • Each step has 3 parts:
    • ~ Following procedures
    • ~ Communicating effectively
    • ~ Using information technology
  24. EHR
    Electronic Health Records
  25. What information technology cannot do
    Do not expect the computer programs to fix your errors, if you make an incorrect entry, it will incorrect in the program too.
  26. The Physician's Advisory, a health care journal:

    "... good, experienced billing/coding specialist are in short supply; to retain good workers in these very important positions, going up in salary is a bargain compared to risking their going to another employer... the work of insurance specialists is an increasingly complex job."
  27. Required skills for being successful medical coder
    • ~ Knowledge of medical terminology, anatomy, physiology, and medical coding
    • ~ Communication skills
    • ~ Attention to detail
    • ~ Flexibility
    • ~ Information technology skills
    • ~ Honesty and integrity
    • ~ Ability to work as a team member
  28. Medical Ethics and Etiquette
    • Ethics~ Standards of behavior requiring truthfulness, honesty, and integrity. Guides the behavior of physicians, who have the training, the primary responsibility, and the legal right to diagnose and treat human illness and injury. In general this code states that information about patients and other employees and confidential business matters should not be discussed with anyone not directly concerned with them.
    • Etiquette~ Important for medical insurance specialists. Correct behavior in a medical practice in generally covered in the practice's employee policy and procedure manual.
  29. AHIMA code of ethics 2004
    • 1. Advocate, uphold, and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information.
    • 2. Put service and the health and welfare of persons before self-interest and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and to the health management profession.
    • 3. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard the contents of the records and other information of a confidential nature, taking into account the applicable statues and regulations.
    • 4. Refuse to participate in or conceal unethical practices or procedures
    • 5. Advance health information management knowledge and practice through continuing education, research, publications, and presentations.
    • 6. Recruit and mentor students, peers, and colleagues to develop and strengthen professional work force.
    • 7. Represent the profession accurately to the public
    • 8. Perform honorably health information management association responsibilities, either appointed or elected, and preserve the confidentiality of any privileged information made known in any official capacity
    • 9. State truthfully and accurately their credentials, professional education, and experiences
    • 10. facilitate interdisciplinary collaboration in situations supporting health information practice
    • 11. Respect the inherent dignity and worth of every person.
Card Set
Medical Insurance Medisoft
Notes for Ch. 1