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Insurance/Billing/Coding, fee for service - indemnity, Cost is determined…
Insurance/Billing/Coding
office / practice management
Making Appointments
Types
OV
- Acute
EOV
-New/Complex
FO
- rechecks on recurring
Consult
Hist & Phys exam
- maintenance
Procedure
Superbills: AKA encounter forms (
Visit/fee
- used for insurance
CPT & ICD)
Provider SOAP notes
Verifying Insurance
Referrals
Pre Authorizations
Remittance Advice =
EOB
Explanation of benefits (for patient)
Triage Notes (SOAP notes)
Flow Board: arivals/wait times/exam rooms
Understand types of insurance
Federal:
Medicare
Medicaid
Tricare
CHIP or SCHIP
...
group - employer sponsored
Employer CDHP - Consumer Directed Health Plans (like 401K)
(like 401K)
HRA - patients don't pay?
HCRA
HSA - health savings account
FSA - flexible spending account
Subsidized by employers & other orgs (labor unions, rural & consumer health co-ops) ACA of 2010 includes tax credit to help small business and tax exempt orgs afford the cost of covering their employees
individual (personal)
Do not have access to group health insurance (like Aetna)
Managed Care Org - "Prepaid"
Managed Care combines health care delivery w/financing of svs provided. Pts rec. care only fm. prov. who are mbrs. of a MCO
CoPays
most common
Can be: health plan, hospital, physician group, or health system
MCOs (6)
Alternative to traditional group health insurance - "prepaid"
HMO, 5 models
Provided by employees of the HMO
Closed panel model
2 more items...
Provided by those who do not belong to a group that serves the HMO
Open panel model
3 more items...
Point of service plan
POS
flexible
not an HMO
greater out of pocket expenses
characteristics of HMO with PPO
Preferred provider org
PPO
labs and pharmacies not included
discounted fee
reduced rate for specific hospitals
open ended plans
higher than HMO, lower than fee-for-service
Triple Option Plan
TOP
AKA
Flexible benefit plan
Cafeteria plan
Exclusive Provider Org: rec. svs from
network providers
EPO
Regulated: State insurance dept.
Each patient receives care from participating provider including hospitals and EDs
coordinate w/ PCP
Integrated Delivery System: offers joint health care svs
IDS
GPWW
- group practice without walls: establishes a contract that allows physicians to maintain to maintain their own offices and share services (e.g. appt scheduling and billing)
IPO
- Manages delivery of health care services offered by hospitals
medical foundation
s - nonprofit org that contacts with and acquires the clinical and business assets of physician practices
PHO
- Physician-Hospital Organization (owned by hospitals)
MSO
- Management service organization - owned by physician or hospital
Common commercial Insurances
BlueCrossBlueShield
Fee for service
Basic
Major
(In addition to basic)
Indemnity
full range of benefits. includes hospital or comprehensive. subscribers do not have to select primary care provider and don't need a referral to see a provider
Managed Care Plans
Home / hospice
EPO
HMO
OPAP
POS
PPO
SSO
LARGEST: UnitedHealth, Anthem, Centene, Humana, HCSC, CVS Health, Molina Healthcare, Cigna, Kaiser Permanente, GuideWell. MEMBERSHIP: UnitedHealth, Anthem, Aetna, Cigna, Humana. LARGEST IN TEXAS: Health Care Service Corp.
Billing and Coding References
HCPCS II - Supplies, DME, etc
CPT (HCSPCS I) - Outpatient procedures and services
ICD 10-CM - Classifies Morbidity - Diseases and Injuries
ICD 10-PCS - (Inpatient) - Classifies inpatient procedures and services
Notes & Pearls: pg. 483, 480, 484, 511
fee for service - indemnity
pick provider
Cost is determined by health status, age, sex, occupation
Capitation
Fee for Service
PCP
why was it done? Medical necessity
what was done in the clinic
what was done in the hospital
what was used?
Medicare & Medicaid both managed care (to control costs)
reference sheet
shows all patients scheduled for an office visit for a specified time period
Day sheet
provides a summary of financial transactions; for example, charges, payments, and adjustments (also known as a journal)
Face Sheets
SOAP? demographics, insurance, appointment info
Superbill
= Encounter Form
Hospitals/Ambulatory surgical center/physician groups
H
Monthly capitation paid by 3rd party
PCP
Copay
"wellness"
Coinsurance
Patients can self refer to out-of-network providers
$$$
effects on a physicians practice?
Some Non-Capitated
Managed Care - HMO & PPO
High Risk Pools
Association health insurance
COBRA
formulary
"In Network"
Ins. Co. gives discounts for groups of people at a business or company
deductible & co-insurance
commercial
not a preferred plan
"contract"