Introduction to Health Insurance Chapter 2 Introduction to Health Insurance

Types of Insurance Automobile Disability Liability Malpractice Property Life Health

Defining Health Insurance Contract between a policyholder and a third-party payer or government program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care provided by healthcare professionals.

Defining Health Insurance (cont.) Medical care Identification of disease and treatment of those who are sick, injured, or concerned about their health Health care Medical care + preventive services

Health Insurance Statistics About 64 percent of the U.S. population is covered by private health insurance. About 56 percent is covered by employment-based plans. About 31 percent is covered by government-sponsored plans. About 16 percent is covered by Medicaid. U.S. Census Bureau 2009

Developments in Health Care 1850 – First health insurance policy 1908 – FELA 1916 – FECA 1929 – First Blue Cross plan 1939 – First Blue Shield plan 1940s – Group health insurance 1948 – International Classification of Diseases

Timeline of Dates © Cengage Learning 2013

Developments in Health Care (cont.) 1966 – Medicare and Medicaid 1966 – Current Procedural Terminology 1970 – OSHA 1973 – CHAMPVA 1973 – HMO Act 1977 – HCFA 1983 – TEFRA

Developments in Health Care (cont.) 1985 – COBRA 1988 – TRICARE 1988 – CLIA 1991 – CPT E/M codes created 1992 – RBRVS 1996 – NCCI and HIPAA

Developments in Health Care (cont.) 2001 – HCFA became CMS 2003 – Medicare Prescription Drug, Improvement, and Modernization Act 2005 – NPI 2009 – American Recovery and Reinvestment Act of 2009 2010 – PPACA and HCERA 2011 – i2 Initiative

Medical Documentation A patient record (or medical record) documents healthcare services provided to a patient. – Healthcare providers are responsible for documenting and authenticating legible, complete, and timely entries according to federal regulations and accreditation standards.

Medical Documentation Records include Patient demographic data Documentation to support diagnoses and justify treatment provided Results of treatment provided

Medical Documentation Continuity of care involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment.

Medical Documentation Documentation includes dictated and transcribed, typed or handwritten, and computer-generated notes and reports recorded in the patient’s records by a healthcare professional. It must be dated and authenticated (with a legible signature or electronic authentication).

Medical Documentation In a teaching hospital, documentation must identify what service was furnished, how the teaching physician participated in providing the service, and whether the teaching physician was physically present when care was provided.

Medical Documentation Documentation in the patient record serves as the basis for coding. The patient’s diagnosis must also justify diagnostic and/or therapeutic procedures or services provided.

Medical Documentation Medical necessity Proper and needed for the diagnosis or treatment of a medical condition Provided for the diagnosis, direct care, and treatment of a medical condition Consistent with standards of good medical practice in the local area Not mainly for the convenience of the physician or healthcare facility

Medical Documentation “If it wasn’t documented, it wasn’t done.” If a provider performs a service but does not document it, the patient (or third-party payer) can refuse to pay for that service, resulting in loss in revenue for the provider.

Problem-Oriented Record Systematic method of documentation consists of four components Database Problem list Initial plan Progress notes

Problem-Oriented Database Chief complaint Present conditions and diagnoses Social data Past, personal, medical, and social history

Problem-Oriented Database (cont.) Review of systems Physical examination Baseline laboratory data

Problem-Oriented Problem List Three categories Diagnostic/management plans Therapeutic plans Patient education plans

Progress Notes SOAP format Subjective Objective Assessment Plan

Electronic Health Record The electronic health record (EHR) is a global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient.

Electronic Health Record (cont.) Provides access to complete and accurate patient health problems, status, and treatment data. Allows access to evidence-based decision support tools (e.g., drug interaction alerts) that assist providers with decision making.

Electronic Health Record (cont.) Automates and streamlines a provider’s workflow, ensuring that all clinical information is communicated. Prevents delays in healthcare response that result in gaps in care (e.g., automated prescription renewal notices).

Electronic Health Record (cont.) Supports the collection of data for uses other than clinical care (e.g., billing, outcome reporting, public health disease surveillance/reporting, and quality management).

Electronic Medical Record (cont.) Provides a more narrow focus because it is the patient record created for a single medical practice using a computer, keyboard, mouse, optical pen device, voice recognition system, scanner, and/or touch screen.

Electronic Medical Record (cont.) Includes a patient’s medication lists, problem lists, clinical notes, and other documentation. Allows providers to prescribe medications and order and view results of ancillary tests (e.g., laboratory, radiology).

Electronic Medical Record (cont.) Alerts the provider about drug interactions, abnormal ancillary testing results, and when ancillary tests are needed.

Total Practice Management Software Used to generate the EMR, automating the following medical practice functions Registering patients Scheduling appointments Generating insurance claims and patient statements

Total Practice Management Software (cont.) Processing payments from patient and third-party payers Producing administrative and clinical reports