Heath Insurance

Evolution of Health Insurance

•Historically, health insurance provided coverage for catastrophic illness and injury

•It has evolved into coverage for preventative care and services

•The traditional type of insurance is fee-for-service care

Managed Care Delivery Systems•This system integrates the delivery and

payment of health care by contracting with select providers for a reduced cost

•The goal is to provide health care with an emphasis on prevention

Types of Insurance Plans

•Commercial health insurance plans•Indemnity-type insurance•Health maintenance organizations

(HMOs)•Preferred Provider Organization (PPO)• •Consumer-driven health plans (CDHPs)•Government health plans

HMOs

•Provide comprehensive health care with a focus on preventative care▫Annual physicals and PAP tests, well-child

care•Members choose a Primary Care Provider

(PCP) to oversee medical care▫PCP refers to a specialist, if needed

PPO, POS, IPA▫Preferred provider organization (PPO)

Members must select a PCP Network of providers that provide services to

members at a discounted rate (in-network) Members pay more out of pocket for out-of-

network providers ▫Point-of-service (POS) plans

Members do not select a PCP and can self-refer to specialist

▫ Independent practice associations (IPAs) Providers who practice in their own offices with

their own staff

Consumer Driven Health Plans:DHPs

•Health savings account (HSA)▫Must be paired with a qualified health plan

•Health reimbursement account (HRA)▫Employers contribute to HRA (not

employees)•Flexible spending account (FSA)

▫Employees contribute to FSA▫Can pay for health insurance premiums,

qualified medical expenses, dependent expenses

CDHP’s

•Flexible spending account (FSA)▫Components

Health insurance premiums Qualified medical expenses Dependent care expenses

▫Funded by the employee’s pretax dollars▫“Use it or lose it” plan

Government Health Plans

•Medicare•Medicaid•Workers’ Compensation•TRICARE•CHAMPVA

Medicare

• Created by the Social Security Act in 1965–Administered by the Centers for Medicare

and Medicaid Services (CMS)

• Who is covered?–People over age 65 meeting eligibility

requirements and have filed for Medicare–People who are disabled, receive Social

Security benefits, or are in end-stage renal disease

Medicare

•Part A▫Hospital coverage

Medicare

• Part B–Other medical expenses, including office

visits• X-ray and laboratory services• Initial Preventive Physical Exam

• Part C–Enables beneficiaries to select a managed

care plan as their primary coverage• Part D–Coverage for generic and brand-name drugs

Medicare and Claims Processing•Always keep up-to-date with Medicare

requirements▫Must use CMS-1500 form▫Must submit Medicare claims electronically

•Reimbursement to providers▫Medicare pays 80% of allowed amount

after the deductible is satisfied▫20% is paid by patient, or supplemental

insurance

Medical Necessity

•Medicare only reimburses services or supplies deemed reasonable and necessary for the diagnosis

•Advance Beneficiary Notices (ABN)▫If a provider performs a service not

covered by Medicare, an ABN is completed▫Must be signed by patient prior to

procedure

Medicaid

• Health insurance for limited or low-income individuals–Must use participating provider

• Funded by both state and federal governments–Eligibility requirements and benefits vary by

state–Medicaid cards are issued each month–Always verify current coverage prior to visit

Workers’ Compensation

• State laws which cover employees who are injured while working or as a result of work

• Benefits–Medical treatment in or out of a hospital– Temporary disability: may receive weekly

cash benefits in addition to medical care–Permanent disability: weekly or monthly

benefits, or a lump sum settlement–Payments to dependents for fatal injuries

TriCare

•Beneficiaries▫Active service personnel and their

dependents▫Retired active service personnel and their

dependents▫Dependents of service personnel who died

in active duty

CHAMPVA:Civilian Health and Medical Program of the Veterans’ Administration

•Beneficiaries▫Spouses and children of permanently

disabled veterans▫Spouses and children of veterans who died

as a result of service

Patients with No Insurance

•Classified as self-pay patients•These patients are expected to pay at the

time of service

Primary and Secondary Insurance•Patients may have more than one

insurance plan•Charges are filed first with the primary

carrier, and then secondary▫Coordination of benefits

•Dependent children and the Birthday rule

Primary and Secondary Insurance•Medicare and supplemental insurance

▫Many Medicare patients have supplemental or Medigap insurance

▫This covers the deductible and 20% coinsurance

•Medicare as secondary insurance▫When a person qualifies for Medicare but is

still employed

Verifying Insurance Coverage

• Always ask patients for current insurance card

• Make a copy of the card, or scan into the EMR

• Verify coverage online or over the phone

Utilization Review

•Preauthorization •Precertification•Predetermination•Concurrent review•Discharge planning

Fee Schedules

•Providers enrolled in an insurance carrier’s network agrees to treat subscribers for an agreed upon (discounted) rate for services

•Accepting assignment: when providers accept the allowed amount as the rate for services▫Disallowed amounts are written off as

adjustments