1. Recap from Chapter 2
Compliance means to meet the federal and state regulations, recommendations, and expectations of organizations that pay for healthcare services
There are two provisions under HIPAA
Title I Insurance Reform
Title II Administrative Simplification

2. Recap from Chapter 2
There are many terms within the field of medical insurance with which you will need to become familiar
The Privacy Rule covers patient confidentiality and disclosure of protected health information
The HIPAA Security Rule contains three safeguards for protecting patient information: administrative, technical, and physical
Fraud is intentionally submitting false information, whereas abuse is performing in a way that is inconsistent with accepted medical or business practices

3. Recap from Chapter 2 Authorization versus Consent
Authorization – a patient’s formal, written permission to use or disclose personally identifiable health information for purposes other than treatment, payment, or healthcare operations (TPO)
Consent – verbal or written agreement that give approval to some action, situation, or statement
How do we know when we need authorization?
Turn to Workbook Assignment 2-4 Critical Thinking Consent vs Authorization

4. Basics of Health Insurance
Chapter 3
MA215 Medical Insurance

5. Chapter 3 Objectives Introduction to Health Insurance
Types of Health Insurance Coverage
Insurance Claim Submission and Follow Up

6. INTRODUCTION TO HEALTH INSURANCE

7. History of Health Insurance
Insurance is one of the world’s largest ____________
Health insurance offsets the _________ of illness and/or injury
Escalating ____________________________ have limited insurance coverage options
Patients may have more than one insurance policy to defray health care costs

8. Health Benefit Exchanges
Patient Protection and Affordable Care Act
Health Care and Education Reconciliation Act of 2010
State-based American Health Benefit Exchanges and Small Business Health Options (SHOP)
Clearinghouses will allow individuals to compare coverage and prices
Individuals can purchase through clearinghouses to take advantage of federal subsidies

9. Implied/Expressed Contracts
Implied contract
When a person becomes a patient in a practice, that patient enters into an _________________ contract with the provider
Implied because ______________________________________________________________
Ex: the patient agrees to pay their medical bills in exchange for services
Ex: the patient agrees to venipuncture because they put their arm out
Expressed contract:
A contract in which the patient and the provider ______________________________________________ before the care takes place, either verbally or in writing
Ex: the patient agrees to pay their financial responsibility in advance of a surgical procedure

10. The Insurance Policy
Major Medical: extended benefits contract to offset large medical expenses caused by prolonged illness or serious injury
Insured: individual or organization protected in case of loss under terms of the insurance policy – also known as the
________________________________

11. Policy Terms – Patient Responsibility
Premium: monthly, quarterly, or annual fee _________________________________________________
Deductible: annual financial responsibility that must be met _______________________________________________________________
Coinsurance: patient’s financial responsibility, ____________________________________________________________________
Copayment: patient’s financial responsibility, ____________________________________________________________________

12. Coordination of Benefits
Patient has ____________________________ insurance policy
One or both policies may have a coordination of benefits clause
Requires insurance companies to _______________________________________________________________________
Prevents duplication or overlapping of payment for the same expenses
Birthday Law
For __________________________ covered under both Mom and Dad’s insurance policies
The parent whose birthday is _________________________ is primary

13. General Policy Limitations
_____________________: injury or illness that is not covered by the insurance policy
Attempted suicide
Military service
On-the-job injuries
Fertility coverage
Pregnancy
Preexisting conditions

14. Financial Clearance Requirements for Financial Clearance
Eligibility & Benefits –_____________________________________________
Precertification – __________________________________________________
Preauthorization – ________________________________________________
Predetermination – ________________________________________________

15. TYPES OF HEALTH INSURANCE COVERAGE

16. Types of Health Insurance Coverage (p 65-66)
Civilian Health and Medical Program for the Dept of Veteran’s Affairs (CHAMPVA)
Competitive Medical Plan (CMP)
Disability Income Insurance
Exclusive Provider Organization (EPO)
Foundation of Medical Care (FMC)
Health Maintenance Organization (HMO)
Independent or Individual Practice Association (IPA)
Maternal and Child Health Program (MCHP)

17. Types of Health Insurance Coverage, cont’d
Medicaid (MCD)
Medicare (M or MCR)
Medicare/Medicaid
Point-of-Service Plan (POS)
Preferred Provider Organization (PPO)
TRICARE
Unemployment Compensation Disability (UCD)
Veteran’s Affairs Outpatient Clinic (VA)
Workers Compensation Insurance (WC)

18. INSURANCE CLAIM SUBMISSION AND FOLLOW UP

19. Basic Methods of Processing Insurance Claims
Contracting with an __________________________________
____________________________________________

20. Basic Steps in Handling an Insurance Claim
FIGURE 3-5 A, Revenue cycle overview showing the basic steps in processing an insurance claim in a physician’s office, to the third-party payer, and after payment is received.
Copyright © 2012, 2010, 2008, 2006, 2004, 2002, 1999, 1997, 1995, 1989, 1981, 1977 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Insurance Card

22. Patient Signature Release
FIGURE 3-10 Section 13 from the health insurance claim form CMS-1500 (08-05), illustrating authorization for assignment of benefits.
Copyright © 2012, 2010, 2008, 2006, 2004, 2002, 1999, 1997, 1995, 1989, 1981, 1977 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Encounter Form (Superbill, Router)
Attached to the patient’s medical record during an office visit
Combines a bill, insurance form, and routing document
Can also be a computerized multipurpose billing form to input charges and diagnoses into a patient’s account
Copyright © 2012, 2010, 2008, 2006, 2004, 2002, 1999, 1997, 1995, 1989, 1981, 1977 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Financial Statement (Ledger Card)
FIGURE 3-14 Financial accounting record illustrating posting of professional service descriptions, fees, payments, adjustments, and balance due.
Copyright © 2012, 2010, 2008, 2006, 2004, 2002, 1999, 1997, 1995, 1989, 1981, 1977 by Saunders, an imprint of Elsevier Inc. All rights reserved.

25. Minimum Information Required on CMS-1500 Claim Form
What was done ________________________________
Why was it done? _____________________________
When was it performed? _____________________
Where was it received? ______________________
Who did it? ____________________________________

26. Insurance Claim Follow-Up
Aging Report
Used to obtain total A/R amount
Shows a snapshot of ___________________________ from each patient
Also known as a “________________________” or “tracking report”

27. Activity Workbook Assignment 3-5
An identification card provides much of the information needed to establish a patient’s insurance coverage. You have photocopied the front and back sides of three patient’s cards and placed copies in their patient records, returning the originals to the patients. Answer the questions by abstracting or obtaining the data from the cards.
10 minutes

28. Homework Workbook Assignment 3-1 Review Questions
Workbook Assignment 3-6 Abstract Data from an Insurance Identification Card
Workbook Assignment 3-7 Abstract Data from an Insurance Identification Card
Read Chapter 4 Medical Documentation and the Electronic Health Record