Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 3 Understanding Managed Care: Medical Contracts and Ethics
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Compensation and Billing Guidelines The contract should clearly state how and when provider is to be paid. The forms used for claims submission should be clearly stated.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Compensation and Billing Guidelines All arrangements with regard to coordination of benefits and late payments should be clearly spelled out. Be aware of any “rebundle,” which means to cover services in a single bundled fee.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care Contracts Should List the Following: Schedule of benefits: A list of medical services covered under the contract Preventative medical services and types of office visits Capitated procedures: Which office procedures are, and are not, covered
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care Contracts Should List the Following: CPT codes: Procedure codes and rates for each service Time limit for submitting claims Which form to use for submitting claim Time limit for receiving payment and what reimbursement charges for late payment
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Clinton Administration Attempts to Change Healthcare The need for change was widely agreed upon. The type and scope of changes was widely disagreed upon. They advocated a strong governmental role. Proposal was soundly defeated by general populace.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care and Business Principles Corporate business values are influencing the traditional medical ethics and values of the solo practitioner: the one-on-one doctor-patient relationship and fee-for- service payment –Efficiency –Cost reduction –Inventory management –Competition –Profit
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Healthcare Limits System cannot support unlimited demands for care. Providers no longer manage practices. Practices are managed by accountants and managers. Medical and business values are merging.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Managed Care Plan Credentialing Governed by National Committee for Quality Assurance MCO reviews providers’ background for fraud, criminal activity, disciplinary actions, and malpractice history. There is no guarantee that one provider is better than another. The MCO grades physicians on services rendered.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Ethics of Medical Office Specialist Ethics are rules or standards governing the conduct of a person or members of a profession. The medical office specialist is the liaison between patient and provider, and provider and carrier. The specialist must know the Patient’s Bill of Rights and the MCO’s contractual guidelines.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Fraudulent Behavior The medical office specialist can be held liable for fraudulent billing. The provider and medical office specialist can both be prosecuted for fraudulent behavior.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Benefit plan: Contract issued by a payer, the plan document, or any other legally enforceable instrument under which a covered person may be entitled to covered services and which is in force with respect to such covered person.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Contracted services: Covered services provided by the physician that are consistent with the physician’s training, licensure, and scope of practice Coordination of benefits (COB): Determination as to which of two or more health benefit plans will provide health benefits for a covered person as primary or secondary payers
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Copayment: Charge the covered person is required to pay at the time of service Covered person: An individual who is an insured, enrolled participant or enrolled dependent under a benefit plan.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Emergency Services: –Services provided after a sudden onset of a medical condition –The absence of service would result in: Placing the person’s health in serious jeopardy Serious impairment to bodily functions Serious dysfunction of any bodily organ or part
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Fee maximum: Maximum allowable fee payable by the corporation or payer for the provision of a given contracted service by a physician to a covered person Medical director: The physician specified by the corporation as its medical director.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Medically Necessary: Refers to the use of services or supplies (or both) that: –Are accepted as appropriate and effective treatment for condition –Are based on recognized standards of healthcare specialty involved –Are not investigative, experimental, or unproven
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Medically Necessary: Refers to the use of services or supplies (or both) that: –Are not solely for the convenience of covered person or healthcare provider –Do not involve greater resources than required for adequate care
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Terms Used in MCO Contracts Participating hospital: State-licensed hospital designated as a participating provider Participating provider: A licensed healthcare provider, including a physician or a facility Payer: An insurance company, third-party administrator, or self-insured benefit plan that is contractually obligated to pay for services
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient’s Bill of Rights Information Disclosure: Right to accurate and easily understood information Choice of Providers and Plans: Right to choose healthcare provider Access to Emergency Services: If you are convinced your health is in jeopardy due to sudden onset of pain, accident, or illness, you may be treated without prior authorization and with financial penalty
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient’s Bill of Rights Participation in Treatment Decisions: The right to know your treatment options Respect and Nondiscrimination: The right to receive respectful, considerate, and nondiscriminatory care
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient’s Bill of Rights Confidentiality of Health Information: The right to talk in confidence with your physician, and to have your healthcare information protected Complaints and Appeals: The right to a fair, fast, objective review of your complaint