Y khoa, dược - Health insurance billing procedures

15Health Insurance Billing Procedures15-2Learning Outcomes15.1 Define Medicare and Medicaid.15.2 Discuss TRICARE and CHAMPVA health-care benefits programs.15.3 Distinguish between HMOs and PPOs.15.4 Explain how to manage a workers’ compensation case. 15-3Learning Outcomes (cont.)15.5 List the basic steps of the health insurance claim process.15.6 Describe your role in insurance claims processing.15.7 Apply rules related to the coordination of benefits.15.8 Describe the health-care claim preparation process. 15-4 Learning Outcomes (cont.)15.9 Explain how payers set fees.15.10 Complete a Centers for Medicare and Medicaid Service (CMS-1500) claim form.15.11 Identify three ways to transmit electronic claims.15-5Introduction Health care claims = reimbursementAccuracy = maximum appropriate paymentMedical assistantPrepare claimsReview insurance coverageExplain feesEstimate charges for payersPrepare claims15-6Basic Insurance TerminologyMedical insurance – written contract between a policy holder and a health planFirst Party – the patient or policy holder Premium – the amount of money paid by the policy holder to the insurance carrier Lifetime maximum benefit – a total sum that the health plan will pay out over the patient’s life15-7Basic Insurance Terminology (cont.)Second Party – the physician who provides medical servicesBenefits – payment by the insurance carrier for medical services providedThird-party payer – the health plan that agrees to carry the risk of paying for services Deductible – a fixed dollar amount paid or met once a year before third-party payers begin to cover expenses15-8Basic Insurance Terminology (cont.)Coinsurance – a fixed percentage of coverage charges after the deductible is metCopayment – a small fee that is collected at the time of the visitExclusions – uncovered expensesFormulary – a list of approved drugsElective procedure – one not required to sustain life15-9Basic Insurance Terminology (cont.)Pre-authorization – approval in advance of the need for a specific procedurePre-certification – determination of whether the proposed procedure is a covered service under the patient’s insurance planLiability insurance – covers injuries caused by the insured or on their propertyDisability insurance – insurance that is activated when the insured is injured or disabled15-10Apply Your KnowledgeWhat is the difference between first party, second party, and third-party payer?ANSWER: The first party is the patient or owner of the policy; the second party is the physician or facility that provides services, and the third-party payer is the insurance company that agrees to carry the risk of paying for approved services.Good Job!15-11Types of Health PlansInsurance companiesRules about benefits and proceduresManuals, printed or onlineRepresentatives to assistSources of health plansGroup policies – through employerIndividual plans Government plans15-12Fee-for-Service PlansOldest and most expensive type of planCovers costs of select medical servicesAmount charged for services is determined by the physicianAmount paid for services is controlled by the insurance carrier15-13Managed Care PlansControls both the financing and delivery of health care to policy holdersBoth policy holders and physicians (participating physicians) are enrolled by the Managed Care Organizations (MCOs)MCOs pay physicians in two waysContracted feesCapitated fees – fixed amount per month to provide contracted services to patients enrolled in the plan15-14Managed Care Plans (cont.)Preferred Provider Organization (PPO)A network of providers to perform services to plan membersPhysicians in the plan agree to charge discounted feesHealth Maintenance Organization (HMO)Physicians who contract with HMOs are often paid a capitated ratePatients pay premiums and a small copayment for each office visit15-15Government PlansHealth care RetireesLow-income and disadvantagedActive or retired military personnel and their familiesMaintain features of managed care plans15-16MedicareThe largest federal program that provides health care to citizens aged 65 and olderManaged by the Centers for Medicare and Medicaid Services (CMS)Part AHospital insurance available to anyone receiving social security benefitsNo premium unless ineligible for social security benefits15-17Medicare (cont.)Part BCovers physician services, outpatient services, and many other servicesAvailable to United States citizens and permanent residents 65 and olderParticipants must pay a premium15-18Medicare (cont.)Part C – 1997Provides choices in types of plansMedicare Advantage plansPPOHMOPrivate Fee for Service (PFFS)Special Needs PlansMedicare Medical Savings plan (MSA)Part D –Passed in 2003Coverage began in 2006Prescription drug plan15-19Medicare PlansFee-for-Service: The Original Medicare PlanAllows the beneficiary to choose any licensed physician certified by MedicareAn annual deductible feeMedicare pays 80 percent and the patient pays 20 percentMedigap plan – secondary insurance 15-20Medicare Advantage Plans Medicare Managed Care PlansMedicare Preferred Provider Organization Plans (PPOs)Medicare Private Fee-for-Service Plans15-21Medicare Plans (cont.)Recovery Audit Contractor (RAC) ProgramDesigned to guard the Medicare Trust FundIdentify improper payments UnderpaymentOverpayment15-22MedicaidA health-benefit program designed for:Low-income Blind Disabled patientsTemporary assistance to needy familiesFoster children Children born with disabilitiesNot an insurance program15-23Medicaid (cont.)Funded by the federal and state governmentsProvides assistance such as:Physician services Emergency servicesLaboratory and x-rays Skilled nursing facility (SNF) care Vaccines Early diagnostic screening and treatment for minors15-24Medicaid (cont.)MedicaidAccepting AssignmentMedi/MediPhysicians agreeing to treat Medicaid patients also agree to the set amount for reimbursementsOlder or disabled patients unable to pay the difference between the bill and the Medicaid payment may qualify for both Medicaid and Medicare15-25Medicaid (cont.)Comply with state guidelinesVerify Medicaid eligibilityEnsure that the physician signs all claimsAuthorization must be received in advance for medical services except in an emergencyVerify deadlines for claim submissionsTreat Medicaid patients with the same professionalism and courtesy that you extend to other patients15-26Types of Health PlansDepartment of DefenseFamilies of uniformed personnel and retireesTRICARE for Life Medicare-eligible military retirees 65 and olderDependent spouses and children of veterans with disabilitiesSurviving spouses and dependent children of veterans who died in the line of duty or from service-connected disabilitiesTRICARECHAMPVA15-27Blue Cross and Blue ShieldA nationwide federation of nonprofit and for-profit service organizations that provide prepaid health-care services to subscribersSpecific plans for BCBS can vary greatly because each local organization operates under its own state laws15-28State Children’s Health Plan (SCHIP)Enacted in 1997 and reauthorized in 2009State-provided health coverage for uninsured children in families that do not qualify for Medicaid15-29Covers accidents or diseases incurred in the workplaceBy federal law, employers must purchase a minimum amount of workers’ compensation insuranceCoverage IncludesBasic medical treatment Weekly or monthly amount paid to patient while not employedRehabilitation costsTypes of Health Plans: Workers’ CompensationVerify coverage prior to procedures and treatments.15-30Apply Your KnowledgeA 72-year-old disabled patient is being treated at an office that accepts Medicaid. The total office visit is $165, but Medicaid will only reimburse a set fee of $125. In this situation, what is the most likely solution?Bill the patient for the balance due.Expect the balance to be paid at the time of service.This patient probably has a secondary employer health insurance plan.This patient may qualify for the Medi/Medi coverage.ANSWER:Correct!15-31The Claims Process: An OverviewObtains patient informationDetermines diagnosis and fees based on services providedRecords patient paymentsPrepares health-care claimsReviews the insurer’s processing of the claimServices Provided by the Physician’s Office15-32The Claims Process: An Overview (cont.)Gathering and reporting patient informationVerifying patient’s insurance coverageRecording procedures and services performedRecording applicable diagnosis and codes for each procedure performedFiling insurance claims and billing patientsReviewing and recording paymentsTasks Supported by Using a Billing Program15-33Obtaining Patient Information Insurance informationCurrent employerEmployer address and telephone numberInsurance carrier and date of coverageInsurance group planInsurance identification numberName of subscriber or insured Personal informationNameHome addressTelephone numberDate of birthSocial security numberEmergency contact person 15-34Obtaining Patient Information (cont.)Release signaturesForm to release insuranceinformation to insurance carrierForm for assignment of benefitsVerify eligibility Check effective date of coverage15-35Obtaining Patient Information (cont.)Coordination of benefitsLegal clauses to prevent duplication of paymentPrimary or main insurance plan pays firstSecondary or supplemental plan pays the deductible and co-paymentThe Birthday RuleIf a husband and wife both have a family insurance plan, the insurance plan of the person born first becomes the primary payer. 15-36Delivering ServicesPhysician’s servicesExamines patientDocuments symptoms, diagnosis, and treatment plan in medical recordMedical codingTranslates the medical terminology into codes for reimbursement15-37Delivering Services (cont.)Referrals to other servicesThe medical assistant Secures authorization from the insurance company for additional servicesArranges an appointment for referred services15-38Preparing the Health-Care ClaimFiling the insurance claimOnce prepared, the physician reviews the claimUsually transmitted to payer electronicallyTime limitsVary by company and stateMedicare and Medicaid 15-39Insurer’s Processing and PaymentInsurance claims are reviewed for:Medical necessityAllowable benefitsPayment and remittance advice15-40Insurer’s Processing and Payment (cont.)Remittance advice (RA)Sent with payment to patient and physicianAlso known as explanation of benefits (EOB)Information the RA FormInsured name and identification numberName of beneficiaryClaim numberDate, place, and type of serviceAmount billed and amount allowedAmount of copayment and payments madeNotation of any services not covered15-41Reviewing the Insurer’s RA and PaymentVerify all information on the remittance advice (RA) line by line If a claim is rejected, check the diagnosis codes for accuracyTrack all unpaid claims using either a follow-up log or computer automation15-42A patient had two appointments in the same week for different ailments. On Monday, the patient complains of back pain and receives a prescription for a muscle relaxant. On Wednesday, the patient complains of hair loss. When the medical assistant files the claims, she accidentally codes the first visit diagnosis (muscle spasm) with the prescribed treatment for the second visit (hair loss) which was an anti-fungal shampoo. The insurance claim is probably rejected for which of the following reasons:Medical necessityPaymentsApply Your KnowledgeAllowable benefitsANSWER: Very Good!15-43Fee Schedules and Charges: Medicare Payment Systems—RBRVS Resource-based relative value scale (RBRVS)Payment system used by MedicareThree Parts to an RBRVS Fee:A nationally uniform conversion factorThe nationally uniform relative valueA geographic adjustment factorThe current annual Medicare Fee Schedule (MFS) is published by CMS in the Federal Register15-44CapitationContractedFee ScheduleFee Schedules and Charges (cont.)Payment MethodsAllowed Charges15-45Fee Schedules and Charges (cont.)Allowed chargesThis represents the most the payer will pay any provider for that workOther equivalent termsMaximum allowable feeMaximum chargeAllowed amountMaximum chargeAllowed feeAllowable chargeBilling the patient for the difference between the higher usual fee and a lower allowed charge is called balance billing15-46Fee Schedules and Charges (cont.)Contracted fee scheduleFixed fee schedules for participating physiciansNon-covered services billed to patientCapitationThe fixed prepayment for each plan memberNon-covered services billed to patient15-47Fee Schedules and Charges (cont.)Calculating patient chargesDepending on plan, patients may be obligated to payPremiums and deductiblesCopayments and coinsuranceExcluded and over-limit servicesBalance billing15-48Communication with Patients About ChargesA practice may require patients toSign an assignment of benefits statement orPay in full for services at the time providedRemind patients of financial obligationAsk patients to agree in writing to cost of procedures not covered by planAdvance Beneficiary Notice of Noncoverage (ABN)15-49Communication with Patients About Charges (cont.)Financial policy Patient responsibility for payment for servicesCopayments must be paid before patients leave the officeManaged Care MembersThe patient is responsible for any amounts not covered by the insurance carrierAssigned ClaimsUnassigned ClaimsUnless other prior arrangements are made, payment is expected at the time service is delivered15-50Apply Your KnowledgeWhat do you need to consider when calculating patient charges?ANSWER: You need to consider whether the patient has met the deductible, if the patient has to pay a copayment, if the service is excluded, or if the patient is over his/her limit for services.Nice Job!15-51Preparing and Transmitting Health-Care ClaimsHIPAA claimsElectronicX12 837 Health Care Claim - official name Information entered is called data elementsData must be entered in CAPS in valid fieldsNo prefixes or special characters allowed15-52Preparing and Transmitting Health-Care ClaimsData elements – five major sectionsProvider section – Billing and rendering providerTaxonomy informationSubscriber (insured or policyholder) section Patient (may be the subscriber or another person) and payer sectionClaim detailsServices 15-53Preparing and Transmitting Health-Care Claims (cont.)Paper claimsA CMS-1500 paper form is usedMay be mailed or faxed to the third-party payerNot widely used as a result of HIPAA requirementsCMS-1500 requires 33 form indicators15-54Preparing and Transmitting Health-Care Claims (cont.)Transmission of Electronic Claims Three major methods of transmitting claims electronicallyDirect transmission to the payerUsing a clearinghouseDirect data entryOffices and payers exchange information directly by electronic data interchange (EDI)Translates nonstandard data into standard format. Clearinghouse cannot create or modify dataInternet-based service that loads data elements directly into the health plan’s computer15-55Preparing and Transmitting Health-Care Claims (cont.)Generate clean claims by avoiding common errorsor incomplete service facility name, address, and identification for services rendered outside the office or home Medicare assignment indicator or benefits assignment indicatorpart of the name or the identifier of the referring provideror invalid subscriber’s birth dateinformation about secondary insurance plans, such as spouse’s payerpayer name and/or payer identifierMissing...15-56Preparing and Transmitting Health-Care Claims (cont.)Claims securityThe HIPAA rules Standards for protecting individually identifiable health information when maintained or transmitted electronicallyCommon security measuresAccess control, passwords, and log files Backup copiesSecurity policies to handle violations15-57A medical assistant has two part-time positions, one for a pediatrician and the other for a surgeon. When completing the X12 837, which of the following would be a major difference?Provider informationTaxonomy informationHIPAA identifiersApply Your KnowledgeThe taxonomy information would be very different because the physician preparation and licensing are very different.ANSWER:Excellent!15-58In Summary 15.1 Medicare provides health care for citizens aged 65 and over, and certain patients under 65 may also qualify for Medicare. Medicaid is a health benefits program for low-income, blind or disabled patients, needy families, foster children, and children born with birth defects. 15.2 TRICARE is a health insurance plan for families of uniformed personnel and retirees from the uniformed services. CHAMPVA covers the expenses of families of veterans with total, permanent, service-connected disabilities, as well as the surviving spouses and children of veterans in this same category.15-59In Summary (cont.)15.3 HMOs generally seek services from a specific group of providers within their plan. PPOs establish a network of providers to perform services for their plan members.15.4 Keep medical and financial records of workers’ compensation cases separate from other employee records; verify coverage and maintain confidentiality.15.5 The claims process consists of obtaining patient information, determining diagnosis and fees, recording charges and codes, preparing the claim, reviewing the processing of the claim and remittance advice, and making sure the payment comes into the office.15-60In Summary (cont.)15.6 Medical assistants gather and record patient information; verify coverage, record procedures and services performed; file claims; bill patients; and review and record payments.15.7 The rules that determine the coordination of benefits are guidelines for payments from insurance companies. 15.8 Preparing the health-care claim consists of filing the claim, setting time limits for filing the claim, reviewing the claim for medical necessity, reviewing for allowable benefits, payment, and remittance advice.15-61In Summary (cont.)15. 9 Payers set fees based on the amounts that Medicare allows, geographic factors, a uniform conversion factor, practice costs, insurance, and the physician’s work.15.10 The CMS-1500 form contains numbered items that refer to the patient and the patient’s insurance coverage. 15.11 Three ways to transmit electronic claims are toTransmit claims directly to the clearinghouseUse a clearinghouse to prepare and send claimsUse direct data entry using an Internet-based service15-62I am always doing that which I can not do, in order that I may learn how to do it.~ Pablo PicassoEnd of Chapter 15