Insurance Terms 101. Patient Access Specialists I

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1 Access Management Insurance Terms 101 University of Mississippi Medical Center Patient Access Specialists I

2 As a Patient Access Specialist Your job is to collect ACCURATE patient information during registration. Accurate patient information is DIRECTLY LINKED to the hospital s ability to COLLECT MONEY for services it provides. Your MAIN GOAL is to ensure that patient information is CORRECT for the final bill.

3 Access Management Statistics On average, 50% of PAYER DENIALS are caused by INCOMPLETE or INACCURATE information gathered by Patient Access Specialists. This means that half of the problems with billing occur before patients receive any treatment. DEMOGRAPHIC errors were the reason behind 40% of the denials. (Source: The 2003 American Health Insurance Plans -AHIP- Claims Payment Processes Survey.) You MUST be THOROUGH and DETAIL OREINTED in obtaining patient information.

4 What to Expect This module will introduce terms you MUST be familiar with in order to be successful. You will learn the basic insurance terminology you will encounter on the job every day. A quiz at the end will measure what you learned.

5 1. PAYER this is a broad term describing any organization that pays medical expenses on behalf of patients. For example: Blue Cross Blue Shield, Aetna, Medicaid, id Medicare, etc. 2. HEALTH PLAN an individual or group that provides or pays the cost of medical care as well as any plan or organized format for delivering healthcare services. Could be Commercial Insurance (BCBS, Aetna), Managed Care (HMO, PPO), or an option within either of those plans (POS).

6 3. COMMERCIAL INSURANCE a plan that is generally more expensive for patients but provides them more options for selecting doctors and treatment facilities. In most cases, the Commercial Insurer has negotiated a contract with the provider that results in the patient paying a percentage of what the payer deems reasonable for the service.

7 For Example: Insurance Terms If a claim is submitted to the payer for a $189 office visit, the payer s contract with the provider states that $100 is a reasonable or customary charge for such visit. In that case, the allowable charge is $100 and the payer will reimburse the doctor 80% or $80 and the patient s responsibility would be $20% or $20.

8 4. CONSUMER DIRECTED HEALTH PLAN tax deferred plan generally consisting of a Healthcare Savings Account(HSA) or a Healthcare Reimbursement Arrangement (HRA) along with a high-deductible insurance plan.

9 5. MANAGED CARE a concept under which an organization delivers health care to enrolled members and controls costs by closely supervising and reviewing the delivery of health care.

10 6. HMO (Health Maintenance Organization) an organization that contracts with Providers to render health care services to members at predetermined fees. Members must select a Primary Care Physician and receive all treatment from Providers within the network.

11 8. PPO (Preferred Provider Organization) this is another option available in a managed care system. It offers much more freedom than an HMO. With a PPO, patients usually pay a co- payment for services within the PPO Network. When they choose a doctor outside the network, they are responsible for a much larger portion of their medical expenses, usually a deductible d and co-insurance.

12 7. POS (Point of Service Plan) possible option in a managed care system with traits of an HMO and PPO where members choose a PCP. The plan pays maximum benefits when members choose Providers within the network. Members must pay higher out of pocket expenses and file their own claims for reimbursement when receiving ii treatment outside the network.

13 9. EXCLUSIVE PROVIDER ORGANIZATION - a plan where an employer bundles their group health plan, disability plan, and worker s compensation into a single health plan. Has traits of HMO or PPO. 10.NON-PAR ARRANGEMENT deal where patient pays doctor directly for medical services, files a claim with the payer, who then reimburses the patient.

14 11.PAR ARRANGEMENT deal where patient authorizes payer to reimburse hospital on their behalf. 12. FIRST PARTY individual receiving medical service. 13. SECOND PARTY doctor, hospital, or institution providing service. 14. THIRD PARTY organization paying for service on behalf of first party.

15 Example In a NON PAR ARRANGEMENT, the First Party (Patient) pays the Second Party (Doctor) at time of service, and is reimbursed by the Third Party (Payer). In a PAR ARRANGEMENT, the Third Party (Payer) bypasses the First Party (Patient) to pay the Second Party (Doctor) directly.

16 15. NETWORK A defined group of doctors, hospitals, and other healthcare providers linked through contractual arrangements, who supply a full range of healthcare services for an HMO. 16. COORDINATION OF BENEFITS Determines who pays first when a patient has more than one insurance. Primary, Secondary, Tertiary, etc. Reimbursement payment cannot exceed 100% of bill.

17 17. BIRTHDAY RULE - When a child is covered by both parents group insurance, the parent s insurance with the earliest birth month is primary. If both parents were born in same month, then day becomes the deciding factor. 18. THIRD PARTY ADMINISTRATOR A firm that an insurance company pays to take care of certain administrative duties such as certifying eligibility, preparing reports and processing claims. Fox Everett is an example. This is not a Health Plan.

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