Insurance Terminology 102

Transcription

1 Access Management Insurance Terminology 102 University of Mississippi Medical Center Access Management Patient Access Specialists II

2 As a Patient Access Specialist II You will possess ADVANCED KNOWLEDGE of insurance terminology. You will CONSISTENTLY maintain a 97% registration accuracy rate. You will perform basic job functions INDEPENDENTLY, needing supervisor assistance rarely. You will COACH/ASSIST PAS I s in their understanding and application of this information.

3 What to Expect This module will help prepare you to be an INFORMED Patient Access Specialist II. You will learn in-depth knowledge of common insurance terms. A quiz at the end will measure what you learned.

4 This Module Explains Commercial Insurance Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) TriCare Auto Insurance Worker s Compensation Liability Insurance

5 Commercial Insurance Commercial Insurance is NOT Medicare, Medicaid, or any Federal or State Program. Blue Cross, Auto Insurance, PPO, HMO, Workman s Compensation, and Liability are considered d Commercial Insurance. Commercial Insurance is monitored by the State Insurance Commission.

6 Commercial Insurance Patients covered can typically go to any Healthcare Provider they want because Commercial Insurers do not usually require a specific contract to reimburse for services. C i l I i ll Commercial Insurance is generally more expensive, but it yields more options.

7 Health Maintenance Organization (HMO) HMOs are Commercial Insurance Plans that strive to control health care costs by requiring members to receive services at designated facilities. Therefore, all services except those in LIFE- THREATEINING situations must be provided d by or approved by a Participating Physician.

8 Health Maintenance Organization (HMO) HMOs are different because they typically require members to select a Primary Care Physician affiliated with the HMO to oversee their health care. The Primary Care Physician approves all nonemergency services for reimbursement.

9 Preferred Provider Organization (PPO) PPOs are contracts between employers and Providers. These Providers agree to perform services at a discount in return for the employer funneling a large volume of patients to their clinics. The patients are known as PPO Members and the Providers are called Participating Providers.

10 Preferred Provider Organization (PPO) Unlike HMOs, members do not have to select a Primary Care Physician, but they must use a Participating Provider within the network to receive full coverage. If a member chooses to go to a non- Participating Provider, their coverage decreases and they pay more out of their own pocket. PPOs often don t have PPO printed on their cards.

11 TRICARE TRICARE is a health care program overseen by the Department of Defense in cooperation with regional civilian contractors. Members include active and retired military personnel and their dependants. They provide four options to eligible beneficiaries. i i

12 TRICARE 1. TRICARE PRIME similar to a Health Maintenance Organization (HMO) 2. TRICARE EXTRA similar to a Preferred Provider Option (PPO) 3. TRICARE STANDARD a fee for service option the same as the former CHAMPUS (Civilian ili Health and Medical Program of the Uniformed Services). 4. TRICARE FOR LIFE provides expanded coverage for Medicare eligible beneficiaries.

13 Auto Insurance Auto Insurance is coverage for injuries resulting from an auto accident. Most patients in auto accidents are covered by auto insurance. Auto Insurance is usually primary for all auto accident victims. There may or may not be an Auto Insurance card depending upon the state.

14 Worker s Compensation Worker s Compensation is coverage related to a work related accident or injury. The medical bills are paid by either the patient s employer or the employer s workman s compensation insurance company. If you re unable to get authorization, YOU MUST CONTACT EMPLOYER to verify. There is no card for Worker s Compensation.

15 Liability Coverage Liability coverage is for injuries that are the result of negligence of another party. For example, a patient slips and is injured at Wal-Mart because there was not a Wet Floor sign. Wal-Mart could be held liable and therefore may be responsible for the medical bills. There is no insurance card for this type of coverage.