Medical Assisting Review

Transcription

1 Fifth Edition Medical Assisting Review Passing the CMA, RMA, and CCMA Exams Chapter 14 Medical Insurance 14-2 Learning Outcomes 14.1 Define terminology used in association with medical insurance Identify the different types of health insurance Identify the different types of health plans Describe how benefits are determined Explain the process of submitting claims for reimbursement Medical Insurance Terminology Premium Insurance benefit Lifetime maximum benefit Rider UCR Usual fee Customary fee Reasonable fee 1

2 14-4 Medical Insurance Terminology Prevailing charges Payment Third-party payer Assignment of benefits Acceptance of assignment Allowed charge Coordination of benefits 14-5 Medical Insurance Terminology Medical provider Participating (PAR) provider Nonparticipating (nonpar) provider Subscriber Beneficiary Overpayment Schedule of benefits Explanation of benefits (EOB) 14-6 Medical Insurance Terminology Waiting period Copayment (copay) Coinsurance Exclusions Utilization review Peer review organizations 2

3 14-7 Types of Insurance Basic medical Major medical Hospital coverage Surgical coverage Disability protection Dental care Vision care Liability insurance Life insurance 14-8 Indemnity plans Group policies Individual policies Service benefit plans Government plans Medicare plans The Original Medicare Plan Diagnosis-related groups (DRGs) 14-9 Medical fee schedule (MFS) Resource-Based Relative Value Scale (RBRVS) Medicare supplements (Medigap policies) Medicare + Choice Plans Medicare Managed Care Plans Medicare Preferred Provider Organization Plans (PPOs) Medicare Private Fee-for-Service Plans 3

4 14-10 Medicaid Plans Medicaid Third-party liability TRICARE TRICARE Prime TRICARE Extra TRICARE Standard TRICARE for Life CHAMPVA Private plans Coverage with private insurance companies Blue Cross Blue Shield (BCBS) Association Local BCBS organizations Customary maximum Fixed-fee schedule Blue card Kaiser Foundation Health Plan

5 14-13 Managed care Managed care organizations Cost-containment practices Health maintenance organization (HMO) Group model HMO Staff model HMO Preferred provider organization (PPO) Point-of-service Physician-hospital organization (PHO) Fee-for-service Capitation Withhold Relative value scale (RVS) Precertification Preauthorization Utilization management Referrals Regular referral Urgent referral STAT referral Authorization Formulary Member services Provider relations 5

6 14-16 Determination of Benefits Indemnity schedules Service benefit plans Usual, Customary, and Reasonable Fee Resource-based relative value scale HIPAA claims X Health-Care Claim Paper claims CMS-1500 ( universal claim ) Proofread the form. Photocopy the form and place it in the patient s medical record Enter the date sent, the patient s name, and the name of the insurance carrier in the insurance log. Enter the date and the words Insurance filed in the patient ledger. Transmit the form. 6

7 14-19 File acknowledgment Format rejection HIPAA s privacy rule National Standard Format (NSF) Advantages of electronic claim submission Immediate transmission and feedback about errors Faster payment and electronic funds transfer Faster explanation of benefits and appeal resolution Easier tracking of claim status Steps in claims processing Verify insurance information. Complete the CMS-1500 claim form. Base the claim on the superbill. Use electronic claims submissions if possible. Track insurance claims. Tracing Rebilling 7

8 14-22 Reasons claims are denied or payments are delayed Claim is not for a covered contract benefit. Patient s preexisting condition is not covered. Patient s coverage has been canceled. Workers compensation is involved. No preauthorization was obtained. Physician provided services before patient s health insurance contract went into affect. Carrier asks for additional information Medicaid claims processing Physician is free to accept or refuse to treat a patient under Medicaid. Patient s eligibility should be verified before service. Preauthorization may be required. Claims should be filed on the CMS There is always a time limit for processing claims. 8

9 14-25 Medi/Medi (Medicare plus Medicaid) claims processing Physician must always accept assignment. Claim form is first processed through Medicare and then automatically forwarded to Medicaid Blue Cross Blue Shield claims processing Claims should be submitted ASAP. Like Medicare, Blue plans have arrangements with participating and nonparticipating providers. Blue plans have provider manuals TRICARE Plans claims processing Use the CMS-1500 claim form. If the physician accepts assignment, insurance claim is filed and patient can be billed for the entire deductible and coinsurance portion of the allowed charge. If physician does not accept assignment, patient must submit claim forms to the insurance company and is responsible for all charges. Claims must be filed no later than December 31 of the year service was provided. Providers are paid within 21 days of filing claim. 9

10 14-28 CHAMPVA claims processing Follow same guidelines as TRICARE claims Workers compensation claims processing Records of the WC case should be kept separate from the patient s regular records. Insurance carrier is entitled to receive copies of all records pertaining to the industrial injury. Insurance carrier may supply own billing forms. Payment is based on fee schedule. At the termination of treatment, final report and bill are sent to insurance carrier. Do not bill the patient Legal considerations Stay current on laws that affect medicine. It is the physician's responsibility to identify the procedures that have been performed; tell the physician to update the records before filing a claim. An incorrect code used to bill a service can be considered fraud. Obtain patient signatures to permit insurance billing. Obtain proper authorization from the insurance carrier whenever required. 10

11 14-31 Fraud Altering a patient s chart to increase the amount of reimbursement Upgrading or falsifying medical procedures Billing primary or secondary insurance carriers while at the same time collecting payment form the patient Under Medicare law, not attempting to collect a required payment from a Medicare patient 11