1. Insurance Lori Howard

2. Terms n Claim n Premium n Deductible n Benefits n Primary Coverage n Secondary Coverage n Rider n Exclusions n Provider n Co-pay n EOB n UCR n HCFA 1500 n Itemized Bill n UB 92 n CPT code

3. TYPES OF INSURANCE n Health »HMO »PPO »POS »Indemnity

4. TYPES OF INSURANCE Hospitalization Accident Athletic Insurance Accidental Self Insurance

5. TYPES OF INSURANCE n Catastrophic Insurance –NCAA »Benefits start after $50,000 and pay for lifetime »www.ncaa.org

6. n NFSHSA Membership benefits Benefits start after $25,000 www.nfhs.org

7. COORDINATE INSURANCE n (Ed Setting) –philosophy of administration –philosophy of physician –be familiar with your policy (exclusions)

8. –know NCAA rules –get to know insurance coordinators at your provider’s offices –Consider buying a CPT code book

9. COORDINATE INSURANCE –Be organized, have a system –Utilize time management –Get to know CSR at your insurance company

10. CLAIM PROCESSING (Ed) n get insurance info prior to athletic participation n keep insurance files separate from medical files

11. n Managed Care: find out how many athletes have it contact each one, speak to a manager, find out if athlete can see team MD, if he accepts UCR Coverage under Athletics Dept. policy

12. CLAIM PROCESSING (Ed) –Try to have local PC physician assigned –Mark the files of athletes with managed care –Have a follow up system for checking the status of claims

13. DO NOTS n wait until claim to get primary insurance information n say the institution will pay the claim n take responsibility for filing the primary claims n pre-pay from the athletic budget n wait to file the claim

14. DO NOTS n assume CPT codes are correct n fail to check claims carefully

15. IF A CLAIM IS DENIED n find out why n get statement from M.D. saying treatment was necessary n provide evidence from clinical studies n convince M.D. to waive fees above UCR n contact the state insurance commission and challenge denial

16. INS. BILLING (Clinic) n services are dictated by a physician (must have a script) n paid directly from insurance companies n wait until have authorization from insurance company before initiating treatment

17. CLAIM PROCESSING (Clinic) n fill out charge slip (super bill) n find out CPT codes n list charges & procedures daily n file claim on HCFA 1500 form n Have PT sign claim (not nec. In GA) n keep copy of pt claim in chart n enter claim into registry in patient chart

18. CLAIM PROCESSING (Clinic) n mail claim to insurance company n make a note of date submitted n have a follow up system for checking the status n usually takes 4-6 weeks to receive payment n New year = new deductible

19. PURCHASING INSURANCE n contact agents n get bids

20. n TO SELECT & PURCHASE n monetary limits n exclusions/riders n primary/secondary/HMO’s n deductible n co-payments n who is covered n out of season injury

21. TO SELECT & PURCHASE n annual premium n how to file claims