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74 Cards in this Set

  • Front
  • Back
Health Insurance
Protection Against Financial Loss of Unplanned Events
Types Of Health Insurance Programs
1. Commercial
2. Managed Care
3. Government Plans
Commercial Health Plans
Policies created and sold by private companies
a) Fee-for service
b) usually have a deductable
c) Commonly pay for percentage of allowed charges (commonly 80%)
d) patient can make appointment with any doctor in any specialty; insurance will pay designated amount for services.
Managed Care Plans
Movement to control healthcare costs while improving preventative care
a) each patient chooses one provider as primary care provider
b) Care may be restricted to providers, labs, and hospitals unless they accepy payment
c) Patient may not have access to providers or services outside of plan
d) Plan may require referrals from primary care provider (Gatekeeper) for consults, therapy, and testing.
e) plan usually requires pre-authorization for surgery or other procedures
Types of Manged Care Plans
1) Health Maintenance Organization (HMO)
2) Preferred Provider Organization
(PPO)
3) Exclusive Provider Organization
(EPO)
4) Point-of-service Plans
HMO
Health Maintenance Organization - Organization that provides a comprehensive range of services for a prepaid fee.

- Type of Managed Care Plan
PPO
Preferred Provider Organization - Agreement between employers and physician to provide services to employee subscribers at a discount

- Type of managed care plan
EPO
Exclusive Provider Organization - Members must receive services within the network only

- Type of managed care plan
Point-of-Service Plan
- In-network combined with out-of-network

- Type of managed care plan
Fee-for-service
Commercial Plan
Gatekeeper
Primary Care Provider (PCP) in a managed care plan. Each PCP is responsible and accountable for the coordination, supervision, delivery and documentation of medical services to assigned members.
Government Plans
A) Medicare
B) Medicaid
C) State Children's Health Insurance Plan
D) Workers' Compensation
E) Armed Services and Veteran Insurance Plans (TRICARE and CHAMPVA)
Medicare
1) Federal program administered by Health Care Financing Administration
(HCFA)
2) Established 1965 as Title 18 of the Social Security Act
What makes you eligible for Medicare?
1) Age 65 or older
2) Disabled under Medicare Rules
Medicare Part A
A) Covers inpatient care after applicable deductible is supplied
Is your Brain melting yet?
Correct Answers:

1) Yes - keep studying
2) Not Yet - keep studying
3) Ahhhhhhhhh!! - Open a beer and keep studying (or Rum and Coke)

(I chose choice 3 at noon today.)
Medicare Part B
1) Voluntary Program (means you have to pay????)

2) Covers CERTAIN outpatient procedures.
Medicare Part C
Medicare + Choice, Medicare Advantage; Expanded benefits for a fee through private health insurance programs
Medicare Part D

(Damn - I didn't even know it went up to D)
Drug and Prescription Benefits

* Think "D" for "drugs" *
Medigap
Commercial insurance policies available to cover the Medicare deductible, the co-insurance, and some specific treatments not covered by Medicare.
Medicaid
-Federal program administered by each state
-Established 1965 as Title 19 of the Social Security Act
Which insurance always gets billed last?
Medicaid
Medicaid Eligibility Requirements
- Determined by each state
- Available to persons with income levels below the federal poverty level
- Eligible patients receive an official identification card for their periods of eligibility
- Person may have both Medicaid and Medicare (Medi/Medi). Medicare is primary carrier and is always billed first.
State Children's Health Insurance Plan
- Federal government funding for states to further assist children whose parents cannot afford insurance for them.
- Administered by the state.
Workers' Compensation
-State-administered program to help pay the cost of medical care and lost wages associated with work-related injuries or illnesses.
- Patients are compensated in full for their related medical expenses and for a portion of their lost wages.
Workers' Compensation Eligibility
Patients must sustain an illness or injury while carrying out their job duties
Classification of Workers' Comp. cases
1) Claim with no disability : minor injuries or illnesses. Pt returns to work in a few days.
2) Temporary disability : injuries and illnesses requiring more than a few days of recuperation before returning to work
3) Permanent disability : injuries and illness resulting in diminished capacity of the pt; ranges from 10% to 100% disability
4) Vocational rehabilitation : filed for permanently or temporarily disabled persons who require training or education to return to work.
Workers' Comp case for minor injuries or illnesses. Pt returns to work in a few days.

What Workers' Comp classification is this?
Claim With No Disability
Which Workers' Comp classification is this?

Workers' Comp case for injuries and illnesses requiring more than a few days of recuperation before returning to work.
Temporary Disability
Permanent disability
Workers' Comp case for injuries and illness resulting in diminished capacity of the pt; ranges from 10% to 100% disability
Which workers' comp classification is this?

Workers' comp case filed for permanently or temporarily disabled persons who require training or education to return to work.
Vocational Rehabilitation
Armed Services and Veterans Insurance Plans
1) TRICARE - Active military and their dependents (formerly CHAMPUS)
2) CHAMPVA - dependents of injured or killed military veterans

I think the Vets themselves are under TRICARE. I can't figure it out.
TRICARE Standard
fee-for-service plan for military personnel and their dependents
TRICARE Extra
PPO plan for military personnel and their dependents.
TRICARE Prime
HMO plan with a point-of-service option for military personnel and their dependents.
CHAMPVA
Provides inpatient and outpatient benefits for dependent spouses and children of veterans who have suffered total, permanent service-connected disabilities.
Beneficiary
person receiving the benefits of insurance program
Birthday Rule
When individual is covered under 2 insurance policies, the insurance plan of the policy holder whose birthday falls first in the year (month and day) becomes the primary insurance.
Carrier
Insurance Company;
insurer
Co-insurance
Percentage of the allowed amount that is the patient's responsibility; Policyholder and insurance company share the cost of covered losses in a specified ratio
Copayment
Portion of the cost of service to be paid by the insured.

Set amount per visit. (example: $20)
Deductible
Annual amount to be paid by the insured toward the cost of service before insurance policy benefits are paid.
(example: $2000)
Exclusion
treatment or conditions not covered by the insurance policy
Explanation of Benefits
Document prepared by the carrier that identifies the services covered by the policy, the amount billed by the provider and the amount paid by the carrier.
EOB
Explanation of Benefits
fee-for-service
provider bills for each service rendered
Group Policy
policy purchased by an organization for the benefits of its members
Insured
Policy holder; subscriber
managed care
health care program that designates a primary care physician
Preauthorization
Process required by some insurance carriers where the provider obtains permission to perform certain procedures/ services or refer a pt to a specialist
Preexisting condition
Medical conditions present or being treated at the time a health insurance application is made
Premium
the fees paid for the health insurance coverage
Provider
health professional who provides services
Rider
Clauses to the health insurance policy designating coverage items in addition to those included within the standard contract
Basic plan benefits
diagnostic studies,
hospitalization,
surgical treatments,
obstetrical care,
intensive care,
chemotherapy
List major medical services not usually covered by a basic plan
outpatient visits,
minor surgery,
physical and occupational therapies,
cost of medical equipment,
mental health care,
dental care,
prescriptions
Companion plans
Policy that pays in addition to health insurance policies carried;
Pays the fees not covered by conventional plans.
Physician fee profile
usual, customary, and reasonable charges
Assignment of Benefits
A) gives carrier instructions to send insurance payments directly to the provider
B) most commercial carriers will reimburse the patient unless instructed not to do so
C) accomplished by the pt (insured) signing the appropriate box on insurance claim form or completing a separate assignment of benefits form
D) pt is responsible for paying the difference between the provider's charge and the insurance paid
E) if provider accepts the assignment,m the carrier then makes payment to the provider (in accordance with the policy language)
If provider claim is a government plan claim, the provider must then indicate on the claim form whether the assignment is accepted or rejected.
F) If the provider rejects the assignment of benefits, then the provider may bill the pt the difference between the fee charged and the fee reimbursed.
AOB
Assignment of Benefits

I think.
Medicaid and Workers' Comp payment
Provider must accept government reimbursement as payment in full if the provider agrees to treat Medicaid and/or Workers' Comp pts.
Deductibles and Copayment payment
pts are responsible to pay any deductible or copayment according to the terms of the insurance policy.
Coordination of Benefits
Term for the rules insurance companies use to coordinate payments so no provider is paid more than 100%
If pt has more than one insurance policy, claim is sent first to ________________.
Primary Insurance
Order of Insurances billed
1. Private insurance
2. Government Insurance
3. Medicaid is always last
if both members of a couple have insurance:
1. Pt's insurance is Primary and spouse's is secondary
2. If a child is the pt "birthday rule" applies
(Parent whose b-day comes first in the year is primary)
Pt has Private insurance and Medicare. Which insurance is primary?
Private Insurance is Primary.

*Always bill Private Insurance before Government Insurance.
CMS-1500 Form
Universal health claim form developed by HCFA that standardizes data required by most carriers so that claims can be processed
CMS-1500 Form rules
1. Before submitting make sure that pt information release forms are current
2. Use uppercase letters
3. no periods, hyphens, commas, dollar signs, or slashes
4. For whole dollar amount: Use "00" in cents column. (no blanks cents)
5. 8 digit dates: (mmddyyyy)
6. Fill necessary boxes in with "X"
7. Use correction fluid for corrections (white out)
8. Completed forms should be maintained in provider files for 6 years
How long should a provider hold onto completed CMS-1500?
6 years
Medicare Insurance Claims
1. Filing deadline is December 31 of the year following the service.
2. Requires the provider to report to the primary carrier on HCFA form
Medicaid Insurance Claims
1. file ASAP
2. Providers must acceppt assignment of benefits and accept Medicaid reimbursements as payment in full
3. Pts cannot be billed for qualified services, regardless of the amount reimbursed to the provider
4. Services not covered by Medicaid may be billed directly to the pt
5. Keep a copy of pt's Medicaid ID card within his/her chart
Workers' Comp Insurance Claims
1. 4 copies needed: state workers' compensation board, compensation carrier, employer, and pt's chart.
2. deadlines vary by state
3. progress reports should be narrative and should indicate any significant changes on the pt's current status.
4. an established pt seeks treatment for a work-related condition, create a separate chart and separate ledger card for the work-related condition
5. Provider must accept assignment and reimbursement as payment in full
Reasons for rejected Claims or delayed claims
coding errors,
typographical errors,
missing dates,
incorrect ID or policy numbers, diagnosis does not support treatment rendered,
patient names do not match the policy holder's names,
dates of treatment do not correspond with dates on document,
missing attachments,
defacement of bar code area of the claim form,
submission of claim to the wrong carrier,
pt ineligible for benefits,
fee total calculated incorrectly