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chapter 2

by: Kasi Greer
Kasi Greer

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About this Document

Intro to Insurance forms
Medical Insurance Forms
Ms. Stephanie Patterson
Class Notes
25 ?




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Popular in Applied Mathematics

This 14 page Class Notes was uploaded by Kasi Greer on Wednesday February 3, 2016. The Class Notes belongs to 22939 at Youngstown State University taught by Ms. Stephanie Patterson in Spring 2016. Since its upload, it has received 35 views. For similar materials see Medical Insurance Forms in Applied Mathematics at Youngstown State University.


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Date Created: 02/03/16
YOUNGSTOWN STATE UNIVERSITY DEPARTMENT OF HEALTH PROFESSIONS COLLEGE OF HEALTH AND HUMAN SERVICES COURSE: MEDICAL INSURANCE FORMS COURSE CODE: 22939 CATALOG: MATEC 2600 SPRING 2016 Instructor: Ms. Stephanie Patterson, BSAS,CMA (AAMA) Office: Cushwa Hall Room #1074 Office Hours: After class and by appointment at a mutually agreed date and time  Department Phone: (330) 941­1760 Class Site: Cushwa Hall Room#2230 Class Day/Time: Tuesday 11AM to 12:50PM E­Mail:  Chapter 2: Introduction to Health Insurance Health Insurance   Contract that protects insured from loss  Contract between policyholder and third­party payer or government program  Provides reimbursement for medically necessary treatment or preventive care Types of Insurance  Automobile   Disability  Health  Liability Medical Care vs. Health Care  Medical Care  Indetification of disease  Provision of care and treatment to sick and injured  Health Care  Includes medical care and preventive services  Preventative services­ help individuals avoid health and injury problems  Results in early detection of health problems Health Insurance Terminology  Policyholder  Person who signs contract with insurance company   Policyholder is the insured (or enrollee)  Policy might include coverage for dependents  Third­Party Payer  Health care insurance company that processes reimbursement  Examples include commercial insurance, BlueCross, BlueShield, Medicare,  Medicaid, Tricare and workers’ compensation Health Insurance Coverage Statistics  64% covered by private health insurance  55% covered by employment­based plans  32% covered by government plans  16.5% covered by Medicaid Health Care Documentation  Patient record (or medical record) ―documents health care services provided to a patient  Continuity of care―documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment Secondary Purposes of Record  Evaluating quality of patient care  Providing data for use in clinical research, epidemiology studies, education, public policy making, facilities planning, and health care statistics  Providing information to third­party payers for reimbursement  Serving medico­legal interests of patient, facility, and providers of care Teaching Physicians  Involve residents in patient care  Present during critical or key portions of procedures performed on patient  Available to furnish services during the entire service provided to patient Medical Necessity Documentation Requirements  Procedures are proper and needed for diagnosis/treatment of medical condition  Procedures are provided for diagnosis, direct care, and treatment of medical condition  Procedures are consistent with standards of good medical practice in local area  Procedures are not mainly for convenience of physician, patient, or health care facility Problem­Oriented Record  Systematic method of documentation  Consists of four components  Database  Problem list  Initial plan  Progress notes Problem­Oriented Database  Chief complaint  Present conditions and diagnoses  Social data  Past, personal, medical, and social history  Review of systems  Physical examination  Baseline laboratory data Problem­Oriented Problem List  Serves as table of contents for problem­oriented record (POR)   Filed at beginning of record  Contains numbered list of patient problems  Helps index documentation throughout record Problem­Oriented Initial Plan  Strategy for managing patient care  Actions taken to investigate condition and to treat/educate patient  Consists of three categories:  Diagnostic/management plans  Therapeutic plans  Patient education plans POR Progress Notes  Documented for each problem documented  SOAP format is used:   Subjective  Objective  Assessment  Plan Electronic Health Record (EHR)  Global concept  Collection of patient information documented by a number of providers at different  facilities about one patient  Facilitates record linkage  Allows patient information to be created at different locations  Unique patient identifier or identification number is assigned to patient Electronic Medical Record (EMR)  Narrow focus  Record created for a single medical practice  Allows providers to prescribe medications and order/view results of ancillary tests  Alerts provider about drug interactions, etc.  Allows access to evidence­based decision support tools Total Practice Management Software (TPMS)  Automates medical practice functions:  Registering patients  Scheduling appointments  Generating insurance claims and patient statements  Processing payments from patient and third­party payers  Producing administrative and clinical reports Meaningful EHR User  Physicians who demonstrate that certified EHR technology is used for electronic  prescribing, exchange of health information, and submission of information on clinical  quality measures  Hospitals that demonstrate that certified EHR technology provides for electronic  exchange of health information to improve quality of health care and submit information  on clinical quality measures Meaningful Use Measures  Engage patients/families in their health  Ensure adequate privacy and security of protected health information  Improve care corrdination  Improve population and public health  Improve quality, safety, efficiency   Reduce health diparities Stages of Meaningful Use Objectives and Measures  Stage 1 (2012)­ Data Capture and Sharing  Stage 2 (2014)­ Advanced Clinical Processes  Stage 3 (2016)­ Improved Outcomes Chapter 3: Managed Health Care Managed Health Care  Also called managed care  Provides reasonably priced health care for consumers and providers who agree to certain  conditions  Is currently being challenged by growing consumer­directed health plans, “a sort of  401(k) plan for health care” Managed Care  Provides health care services that are:  Affordable  Comprehensive  Prepaid   Enrollees are subscribers or policyholders and usually:  Employees and dependents who join a managed care plan  Beneficiaries in private insurance plans Managed Care Organizations  Responsible for the health of a group of enrollees and can be a:  Health plan  Health system  Hospital  Physician group Capitation Payment System  Financing method for managed care  Pre­established payments for health care services provided to enrollees  If services cost less than capitation amount, profit results  If services cost more than capitation amount, provider loses money Primary Care Provider (PCP)  Supervises and organizes health care services  Approves referrals to specialists  Approves inpatient hospital stays  Serves as a gatekeeper to control costs of health care services Quality Assurance (QA)  Activities that assess the quality of care in a health care setting   Types of QA programs  Government oversight  Patient satisfaction surveys  Data from grievance procedures  Reviews by independent organizations  NCQA  The Joint Commission Quality Assurance  QISMC  Ensures accountability of managed care plans  Requires evaluation of objective, measurable standards  PQRI  Provides financial incentive for eligible professionals who participate in a voluntary  quality reporting program (e.g.,  HEDIS)  HEDIS  Voluntary quality reporting program  Sponsored by NCQA, which develops data report cards Utilization Management (UM)  Also called utilization review (UR)  Method of controlling health care costs and quality of care via:  Prospective review (review of appropriateness and necessity of care provided to  patients prior to the administration of care)  Retrospective review (review after care has been provided to patients) Utilization Management Activities  Preadmission certification (PAC)  Medical necessity of inpatient care prior to admission  Preauthorization  Prior approval for reimbursement of health care service  Concurrent review  Medical necessity of tests and procedures ordered during hospitalization  Discharge planning  Arranging appropriate services for discharged patients Utilization Review Organization (URO)  Contracting agency that establishes UM program  Performs external utilization review services NOTE: Self­insurance companies also contract with a third­party administrator (TPA), which  provides health benefits claims administration and other outsourced services Case Management  Development of patient care plans:  Coordinate care  Provision of care  Manage complicated cases  Ensure most cost­effective services  Case manager authorizes treatment  Written confirmation  Submitted to provider and managed care plan Second Surgical Opinions (SSO)  Second physician asked to:  Evaluate necessity for surgery  Recommend most economical, appropriate facility  Outpatient clinic  Doctor’s office versus inpatient hospitalization  When SSO is required by payer:  Report modifier ­32 on CMS­1500 claim  Report E/M service code as new patient visit (not a consultation) Gag Clause  Prevents providers from discussing all treatment options with patient, even when  managed plan will pay for treatment  Is now prohibited from being included in managed care contracts  Ensures that all medical advice is shard with patient, whether treatment is covered or not Physician Incentives  Direct or indirect payments to providers  Encourage providers to reduce or limit services to save money  Physician incentive plan: federal law that requires managed care plans to disclose all  physician incentive plans before a Medicare or Medicaid contract will be renewed Managed Care Models  Exclusive provider organization (EPO)  Integrated delivery system (IDS)  Health maintenance organization (HMO)  Point­of­service plan (POS)  Preferred provider organization (PPO)  Triple option plan Exclusive Provider Organization (EPO)  Subscribers are required to receive services from network providers  Network provider―physician or health care facility under contract to managed care plan  Most restrictive type of managed care model Integrated Delivery System (IDS)  Organization of affiliated providers’ sites that offer joint health care services to  subscribers  IDS models include:  Physician­hospital organization (PHO)  Management service organization (MSO)  Group practice without walls (GPWW)  Integrated provider organization (IPO)  Medical foundation (nonprofit) Health Maintenance Organization (HMO)  Comprehensive health care services for members on prepaid basis  Preventive care services and more provided to promote “wellness”  Often require copayments  There are 5 HMO models HMO Models  Group model (closed panel)  Staff model ( closed panel)  Direct contract model ( open panel)  Individual practice association( open panel)  Network model( open panel) Point­of­Service Plan (POS)  Offers freedom to use managed care panel of providers or to self­refer to out­of­network  providers  In­network services incur standard out­of­pocket costs (e.g., copayment)  Out­of­network services require payment of deductible and/or coinsurance Preferred Provider Organization (PPO)  Also called participating provider organization  Physician/hospital network contracts with payers/employers to provide health care to  members at discounted rate  Use of non­PPO providers results in higher out­of­pocket costs Triple Option Plan  Offered by single insurance plan or as joint venture among multiple insurance payers  Provides subscribers with choice of HMO, PPO, or traditional health insurance plans  Also called cafeteria plan or flexible benefit plan  Different benefit plans and extra coverage options provided through the insurer or  TPA  Intended to prevent problem of covering members who are sicker than the general  population (called adverse selection)  Risk pool is created when a number of people are grouped for insurance purposes (e.g.,  employees of an organization)  Cost of health care coverage is determined by employees’ health status, age, sex, and  occupation Consumer­Directed Health Plans (CDHPs)  Individuals are provided with:  Incentives to control costs of health benefits and care  Greater freedom in spending health care dollars (up to designated amount)  Full coverage for in­network preventive care  Assume higher cost­sharing expenses after designated amount is spent CDHP Tiers  Tax­exempt account  Used to pay for health care expenses  Provides more flexibility regarding access to providers  Out­of­pocket payments for health care expenses  Made after tax­exempt account is expended and before deductible for high­deductible insurance is met  Actually represents gap in coverage  High­deductible insurance policy  Reimburses allowable health care expenses after high deductible has been paid Types of CDHPs  Customized Sub­Capitation Plan (CSCP)  Flexible Spending Account (FSA)  Health Savings Account (HSA) or Health Savings Security Account (HSSA)  Health Care Reimbursement Account  (HCRA)  Health Reimbursement Arrangement (HRA) Customized Sub­Capitation Plan (CSCP)  Health care expenses funded by customized insurance coverage  Individual selects one of each type of provider to create customized network  Each provider receives monthly sub­capitation payment to provide health care to an  individual Flexible Spending Account (FSA)  Tax­exempt account offered by employers  Employee contributes funds to FSA through salary (payroll) reduction agreement  Employees withdraw funds from FSA to pay medical bills  Employees forfeit unspent funds at end of year Health Savings Account (HSA)  Also called Health Savings Security Account (HSSA)  Participants enroll in high­deductible insurance plan  Tax­deductible savings account cover current and future medical expenses  Unused balances “roll over” from year to year Health Care ReimbursementAccount (HCRA)  Tax­exempt account used to pay for health care expenses  Individual decides, in advance, how much money to deposit in the HCRA  Unused funds are forfeited at end of year Health ReimbursementArrangement (HRA)  Tax­exempt account offered by employers with more than 50 employees  Employees enroll in high­deductible insurance  Individuals use HRA to pay health care bills  Individuals allowed to accumulate unspent money for future years Accreditation of Managed Care Organizations  Voluntary process (versus regulatory process)  Survey demonstrates that standards beyond those required by law have been met  National Committee for Quality Assurance (NCQA) accredits managed care  organizations Impact of Managed Care on a Physician’s Practice  Separate bookkeeping systems for each capitated plan  Tracking system for preauthorizations  Preauthorization for hospitalizations  List of referrals to participating providers  Administrative procedures for each managed care plan contract  List of copayments and fees for each managed care plan contract  Help patients understand preauthorization and out­of­network requirements  Paperwork for specialists to complete  Filing of treatment and discharge plans  Managed care organization case managers monitoring of services provided to enrollees  Preauthorization documentation must be included with some claims submissions


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