2INSURANCEThis chapter will talk about how to complete fee-for-service claims that are generally accepted nationwide by most commercial health insurance companiesCovers a portion of services, such as inpatient hospitalizations or physician office visits with patient paying the remaining costsAetna, United Health Care. Prudential, Cigna and others ---REMEMBER BCBS, Medicare, Medicaid, TRICARE, CHAMPVA, workman’s compensation handled differently chapters specifically on those
3Processing Commercial Claims Separate instructions for primary, secondary, and supplemental commercial insurance plansInstructions in a table format for completing claims
4Processing Commercial Claims A case study and completed claim to illustrate the instructionsA case study exercise, a blank claim, and the completed claim that allows the student to practice completing a claim
5Commercial InsuranceCommercial health insurance covers the medical expenses of individuals (e.g., private health insurance) and groups (e.g., employer group health insurance).
6Commercial InsuranceIndividual health insurance policies are regulated by individual states and include the following:fee-for-service (or indemnity) insurance: traditional health insurance that covers a portion of services, such as hospital inpatient hospitalizations or physician office visits, with the patient paying the remaining costsGroup health insurance usually costs less than individual private health insurance.
7Commercial Insurancehigh-risk pools: “last resort” health insurance for individuals who cannot obtain coverage due to a serious medical condition; certain eligibility requirements apply, such as refusal by at least one or two insurance companies.State high risk pools if you are denied health insuranceCurrently 34 states offer a health insurance risk pool, covering over 180,000 people. For many people, risk pools provide a bridge between jobs or becoming self-employed. Advantages of getting into a state run insurance plan include: Usually can't be turned downHelps you pay for large medical costDisadvantages: Have to prove state residency to enrollHow proof that you have been rejected for similar health insurance coverage to enrollCan not have enrolled in a high risk pool with the last 132 monthsThe state can end the plan - legislative riskLong waiting listsUsually much higher than private health insuranceHave to prove your current policy is rated to enrollYou can lose eligibility if you moveYou candon't qualify if are eligible for, or receiving, Medicare or MedicaidYou cannot be incarceratedPlan typically only accepts certain numbers of individualsRates can increaseThere are maximum benefit lifetime benefit ceilingYou may not qualify with certain diseases
8Commercial Insurancemanaged care (e.g., health maintenance organization, preferred provider organization)
9Commercial Insuranceassociation health insurance: offered to members of a professional association and marketed to small business owners as a way to provide coverage to employeesThe plans are not subject to the same regulations as group health insurance plans and, therefore, are more risky
10Group Health Insurance Available through employers and other organizations (e.g., labor unions, rural and consumer health cooperatives), and all or part of premium costs are paid by employers.
11Group Health Insurance Employer-based group health insurance:Covers all employees, regardless of health status, and cannot be cancelled if an employee becomes ill
12Group Health Insurance Limits exclusions for preexisting conditions:The payer can exclude an employee from coverage for a preexisting condition but only for 12–18 months, depending on the circumstances.
13Group Health Insurance Is portable:If an employee had insurance before enrolling in employer group health insurance, the payer must reduce the preexisting condition exclusion period by the amount of time covered on the previous plan.
14Group Health Insurance Offers COBRA continuation coverage:When an employee resigns (or has another qualifying event), the employee must be offered COBRA continuation coverage that lasts for 18–36 months, depending on the employee’s situation.Qualifying event..use Colleen as an exampleUse Collin as an example dental insurance
15Group Health Insurance Has employer-limited plan options (e.g., prescription drug plan that covers a certain list of medications, called a formulary)Will have name brand drugs one cost..generic another the four highest used drugs sometimes are not covered
16Automobile InsuranceA contract between an individual and an insurance company whereby the individual pays a premium and, in exchange, the insurance company agrees to pay for specific car-related financial losses during the term of the policy
17Automobile Insurance Available coverage: Collision (pays for damage to a covered vehicle caused by collision with another object or by an automobile accident; a deductible is required)Comprehensive (pays for loss of or damage to a covered vehicle, caused by fire, flood, hail, impact with an animal, theft, vandalism, or wind; a deductible may apply)Deductible different for no fault or at fault collisions
18Automobile InsuranceEmergency road service (pays expenses incurred for having an automobile towed as a result of a breakdown)Liability (pays for accidental bodily injury and property damage to others, including medical expenses, pain and suffering, lost wages, and other special damages; property damage includes damaged property and may include loss of use)Each body part has a monetary assessment
19Automobile InsuranceMedical payments (reimburses medical and funeral expenses for covered individuals, regardless of fault, when those expenses are related to an automobile accident)
20Automobile InsurancePersonal injury protection (PIP) (reimburses medical expenses for covered individuals, regardless of fault, for treatment due to an automobile accident; also pays for funeral expenses, lost earnings, rehabilitation, and replacement of services such as child care if a parent is disabled)Can also be used for pedestrians injured by a veh
21Automobile InsuranceRental reimbursement (pays expenses incurred for renting a car when an automobile is disabled because of an automobile accident)Underinsured motorist (pays damages when a covered individual is injured in an automobile accident caused by another driver who has insufficient liability insurance—not available in every state)Rental insurance monetary value of rental depends on your coverage plan some insurance policies you get the type veh you own. Others are straight base IE $30 a day…compact vehicle example my auto accident with Taurus injured wanted larger vehUnderinsured motorist use Dad’s examplehe chances are about 14 in 100 that, if an insured car occupant is injured in an auto accident in the U.S., an uninsured motorist caused the accident, 14% of Americans driving are uninsuredthe highest uninsured driver estimates were Colorado (32%), New Mexico (30%), South Carolina (28%), Alabama (25%), and Mississippi (25%).The five states with the lowest uninsured driver estimates were Maine (4%), North Carolina (6%), South Dakota (6%), Massachusetts (7%), and Wyoming (7%). Sixteen states and the District of Columbia had a ratio of uninsured
22Automobile InsuranceMedical payments and PIP coverage usually reimburses, up to certain limits, the medical expenses of an injured driver and any passengers in a vehicle that was involved in an automobile accident
23Disability InsuranceReimbursement for income lost as a result of a temporary or permanent illness or injury.When patients are treated for disability diagnoses and other medical problems, separate patient records must be maintained.Need to go to insurance company doctors not your personal doctor for assessment. Disability insurance generally does not pay for healthcare services, but provides the disabled person with financial assistance
24Disability InsuranceDisability benefits are usually paid if an individualHas been unable to do regular or customary work for a certain number of days (number of days depends on the policy)was employed when disabled (lost wages due to disability)
25Disability Insurance Has disability insurance coverage Was under the care and treatment of a licensed provider during initial disability; to continue receiving benefits, the individual must remain under care and treatmentProcesses a claim within a certain number of days after the date the individual was disabled (number depends on policy)
26Disability InsuranceHas the licensed provider complete the disability medical certification document(s)
27Disability Insurance Ineligibility for disability benefits due to Claiming or receiving unemployment insurance benefitsDisability occurred while committing a crime that resulted in a felony convictionReceiving workers’ compensation benefits at a weekly rate equal to or greater than the disability rate
28Disability InsuranceBeing in jail, prison, or a recovery home (e.g., halfway house) because of being convicted of a crimeFailure to have an independent medical examination when requested to do so
29Disability InsuranceA disability claim begins on the date of disability:Disability payer calculates an individual’s weekly benefit amount using a base period.Usually covers 12 months and is divided into 4 consecutive quarters.
30Disability InsuranceIncludes taxed wages paid approximately 6–18 months before the disability claim beginsDoes not include wages being paid at the time the disability began
31Liability InsuranceCovers losses to a third party caused by the insured or on premises owned by the insured.Claims are made to cover the cost of medical care for traumatic injuries and lost wages, and, in many cases, remuneration (compensation) for the “pain and suffering” of the injured party.
32Liability InsuranceMost health insurance contracts state that health insurance benefits are secondary to liability insurance.
33Liability InsuranceWhen negligence by another party is suspected in an injury claim, the health insurance company will not reimburse the patient for medical treatment of the injury until one of two factors is established:
34Liability InsuranceIt is determined that there was no third-party negligence.In cases in which third-party negligence did occur, the liability payer determines that the incident is not covered by the negligent party’s liability contract.
35Liability InsuranceSubrogation refers to the contractual right of a third-party payer to recover health care expenses from a liable party.
36Commercial Claims Determined by one of the following criteria: Patient is covered by one commercial plan.Patient is covered by a large employer group health plan (EGHP) and is also a Medicare beneficiary.Patient is covered by a small or large employer health plan and is the policy holder.Patient is also listed as a dependent on another EGHP.
37Commercial ClaimsWhen the patient is a child who is covered by two or more plansPrimary policyholder is the parent whose birthday occurs first in the year.
38Commercial Secondary Coverage Changes are made to the CMS-1500 claim when patients are covered by primary and secondary or supplemental health insurance plans.
39Commercial Secondary Coverage Secondary health insurance plans provide coverage similar to that of primary plans.Supplemental health insurance plans usually cover just deductible, copayment, and coinsurance expenses.
40Commercial Secondary Coverage When the same payer issues the primary and secondary or supplemental policies, submit just one CMS-1500 claim.If primary and secondary or supplemental policies are different, submit a CMS claim to the primary payer.
41Commercial Secondary Insurance When primary payer has processed the claim, generate a second CMS-1500 claim to send to secondary payer, and include a copy of primary payer’s remittance advice
42Medicare Secondary Payer Working aged coverage by an employer group health plan (EGHP) or an individual aged 65 years or older who is covered by a working spouse’s EGHP
43Medicare Secondary Payer Upon claims submission, amount of secondary benefits payable is the lowest ofActual charges by physician or supplier minus amount paid by primary payer
44Medicare Secondary Payer Amount Medicare would pay if services were not covered by the primary payerHigher of the Medicare physician fee schedule minus the amount actually paid by the primary payer
45Medicare Secondary Payer To calculate amount of Medicare secondary benefits payable on a given claim, the following information is required:Amount paid by primary payerPrimary payer’s allowable charge