c h a p t e r 9 9 health care coverage. copyright © 2008 thomson delmar learning, a division of...
TRANSCRIPT
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 3
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 4
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 5
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 6
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 7
Types of Health Insurance
Government sponsored Medicare, Medicaid, and TRICARE
Private insurance HMO PPO Workers compensation
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 8
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 9
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 10
Unit Summary
What is the purpose of managed care? When would the birthday rule apply in
the medical office?
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 11
Health Care Plans22U N I TU N I T
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 12
Indemnity-Type Insurance Plans
Commercial plans in which the insurance company reimburses the physician for services
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 13
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 14
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 15
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)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 16
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 17
Centers Established by 2001 Changes
The Center for Medicaid & Medicare Service (CMS)
The Center for Beneficiary Choices The Center for Medicaid and State
Operations
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 18
Unit Summary
What is the difference between an HMO and a PPO?
What are the five federal health care plans identified in this unit?
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 19
Preparing Claims33U N I TU N I T
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 20
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 21
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 22
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 23
HCPCS Codes
Healthcare Common Procedure Coding System
Identifies products and supplies that are not identified in the CPT book
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 24
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 25
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)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 26
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 27
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 28
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)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 29
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 30
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 31
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)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 32
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 33
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 34
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 35
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
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 36
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 37
Unit Summary
What is the reason rule? When would you use the ICD-9 and CPT
codes? What is a HCPCS code?
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 38
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.
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
9 - 39
Hot Links to Career Success
www.ama-assn.org/cpt American Medical Association
www.cms.hhs.gov Centers for Medicare & Medicaid Services