1. C H A P T E R 9 9 Health Care Coverage

2. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 2 Fundamentals of Managed Care 1 1 U N I T

3. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 3 Changes in Health Care Coverage Variety of health care plans  Health maintenance organizations (HMOs)  Preferred provider organizations (PPOs)  Health savings accounts (HSAs)  Traditional health plans Variety offers choice and a way to cut costs

4. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 4 The Purpose of HMOs HMOs offer affordable health care plans designed to promote good health and encourage preventive medicine Provided through employers at a reasonable cost

5. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 5 The Concept of Managed Care Create an organized system of medical team members  Team members would provide quality and cost-effective care  Would cover both the delivery of the care and payment for these services Help to contain rising health care costs

6. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 6 Two Classes of Health Insurance 1. Individual  Bought by one person generally for a higher premium 2. Group  Bought by employers or unions generally at discounted premiums  Costs paid completely by the employer or shared with the patient

7. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 7 Types of Health Insurance Government sponsored  Medicare, Medicaid, and TRICARE Private insurance HMO PPO Workers compensation

8. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 8 The Birthday Rule If a dependent child is covered under the insurance policies of both parents, the birthday rule applies:  The parent whose birthday falls first in the calendar year is primary.  If parents have the same birthday, the insurance policy that has been in effect the longest is primary.

9. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 9 Divorce and the Birthday Rule If parents are divorced, the court order that dictates which parent is responsible for health care is primary. A court order supersedes the birthday rule.

10. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 10 Unit Summary What is the purpose of managed care? When would the birthday rule apply in the medical office?

11. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 11 Health Care Plans 2 2 U N I T

12. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 12 Indemnity-Type Insurance Plans Commercial plans in which the insurance company reimburses the physician for services

13. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 13 The Health Care Philosophy of an HMO To provide a wide range of health care services at a fixed fee schedule and to promote wellness and good health

14. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 14 How a PPO Differs from an HMO PPOs allow the physician to sign up to provide services at a discounted rate HMOs allow employers to arrange for group health care at discounted premiums

15. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 15 Federal Health Care Plans Workers compensation  Covers those injured on the job Medicaid  Covers individuals of limited or low income Medicare  Covers individuals over 65, those who receive Social Security benefits, and those who meet eligibility requirements (continued)

16. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 16 Federal Health Care Plans TRICARE  Covers dependents of active military personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty Easter Seals/Crippled Children’s Services  Covers disabled children under age 21

17. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 17 Centers Established by 2001 Changes The Center for Medicaid & Medicare Service (CMS) The Center for Beneficiary Choices The Center for Medicaid and State Operations

18. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 18 Unit Summary What is the difference between an HMO and a PPO? What are the five federal health care plans identified in this unit?

19. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 19 Preparing Claims 3 3 U N I T

20. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 20 The Development of Claim Forms As health care evolved from a system where the patient paid for all services, to a benefit that is offered by employers, health care companies grew and claim forms were designed to create the beginnings of the billing process we use today.

21. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 21 Primary and Secondary Coverage Primary coverage  The insurance policy that lists the patient as the insured Secondary coverage  Any supplemental insurance coverage, such as dual coverage under another insurance policy, or Medigap

22. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 22 Insurance Codes Coding by diagnosis  ICD-9-CM or International Classification of Diseases, 9th Revision, Clinical Modification Coding by procedures and services  CPT or Current Procedural Terminology code book

23. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 23 HCPCS Codes Healthcare Common Procedure Coding System  Identifies products and supplies that are not identified in the CPT book

24. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 24 The Reason Rule and Sequencing The reason rule states that the reason for the visit is always coded first. Sequencing means that the codes must be listed in an order that makes it possible to understand the chronology of events.

25. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 25 General Coding Rules Code all diagnoses, procedures, and services correctly and completely. Code the diagnosis that fully identifies the reason for the visit and the patient’s need for x-rays, treatment, procedures, or medications. (continued)

26. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 26 General Coding Rules Code each problem to the highest level of specificity. Sequence the code to make it possible to understand the chronology of events.

27. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 27 Two Things to be Done Before Completing Insurance Forms 1. Make sure you have a copy of both sides of the patient’s insurance card. 2. Verify that the patient has signed the “release of information” and the “assignment of benefits” sections of the claim form.

28. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 28 Common Errors Made When Filing Claims The certificate number listed is the patient’s, not the insured’s, number “Coordination of benefits” section is incomplete Use of incorrect ICD-9-CM code(s)

29. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 29 Common Claim Errors Incorrect CPT or place of service codes, PINs, spelling of the patient’s name, birthdates Attaching illegible superbills to the claim Incomplete request for clarification of insurance Lack of operative report when billing for unusual or complicated fees or procedures Inconsistent use of the patient’s name Placing middle name as the first name

30. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 30 Items to Enter in an Insurance Log Date claim was filed Insurance company information Patient’s name Amount of claim Date billed Amount paid Date patient was billed Follow-up date

31. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 31 Preparing to Follow Up Delinquent Claims Make sure you have the following information:  Patient’s name  Insured’s name (if other than the patient)  Identification number  Group name and/or number (continued)

32. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 32 Preparing to Follow Up Delinquent Claims Make sure you also have a copy of the claim, and be prepared to give:  The date of service  The total amount of the claim  The date the claim was submitted Make complete notes in the log on the insurance company’s responses.

33. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 33 Accepting Assignment An assignment is accepted when a physician agrees to treat persons enrolled in an insurance program for a specified rate. The physician may not bill the patient for any balance between the amount charged and the payment once the deductible is met.

34. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 34 Noncovered Procedures Guidelines Identify all noncovered procedures. Explain the procedure and the charges to the patient. Arrange for payment with the patient. The office may also have the patient sign a statement that verifies that he or she understands the charges and payments due.

35. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 35 Items Necessary for Adequate Documentation Complaints and symptoms Duration and course of illness Details of the illness Examination and findings Lab and x-ray findings Diagnosis Treatment

36. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 36 Staying Current with Medicare and Insurance Company Regulations Visit the CMS web site.CMS web site Sign up for their listing services so that each time there are news releases the announcement is sent to you via e-mail. Click on the link to view the release.

37. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 37 Unit Summary What is the reason rule? When would you use the ICD-9 and CPT codes? What is a HCPCS code?

38. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 38 Keys to Career Success The successful medical assistant understands the relationship between proper billing and coding and increased office revenue. When insurance forms are properly completed the first time, payment arrives promptly.

39. Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved. 9 - 39 Hot Links to Career Success www.ama-assn.org/cpt  American Medical Association www.cms.hhs.gov  Centers for Medicare & Medicaid Services