1. Introduction to Health Insurance
Chapter 2
Introduction to Health Insurance

2. Types of Insurance Automobile Disability Liability Malpractice
Property
Life
Health

3. 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.

4. 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

5. 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

6. 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

7. Timeline of Dates
© Cengage Learning 2013

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

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

10. 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

11. 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.

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

13. 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.

14. 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).

15. 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.

16. 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.

17. 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

18. 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.

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

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

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

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

23. Progress Notes
SOAP format
Subjective
Objective
Assessment
Plan

24. 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.

25. 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.

26. 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).

27. 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).

28. 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.

29. 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).

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

31. 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

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