TOS are used to represent the different types of services and Supplies rendered by the provider.
TOS - Definitions
1 - Medical Care
2 - Surgery
3 - Consultation
4 - Diagnostic X-Ray
5 - Diagnostic Laboratory
6 - Radiation Therapy
7 - Anesthesia
8 - Assistance at Surgery
9 - Other Medical Service
0 - Blood or Packed Red Cells
A - DME
F - Ambulatory Surgical Center
H - Hospice
L - Renal Supplies in the Home
M - Alternate Payment for Maintenance Dialysis
N - Kidney Donor
V - Pneumococcal Vaccine
Y - Second Opinion on Elective Surgery
Z - Third Opinion on Elective Surgery
Tuesday, August 31, 2010
How to create charges?
Creating treatment details: (Charge Creation)
(i) Medical Record Number: This is the number allotted by the physician’s office to track the patient records after his visit.
(ii) Date of Service: The date(s) on which the provider has rendered the service to the patient. It should be entered in the software.
(iii) Provider: Person who provides the healthcare services is known as Provider and his name should be entered in the same software.
(iv) Type of service: It refers the type of treatment has done for the patient. (For e.g., Radiology, Cardiology)
(vi) Name of Clinic/ Facility: It is the place where services are furnished. i.e., in a hospital, clinic, laboratory etc.,
(vii) Referral Authorization Number: This number is issued by the PCP (Primary care Physician) while referring the patient to a specialist or another doctor. managed care plans require such referrals, without which payment may be denied for the services done by the specialist. This referral acts as a kind of a second opinion on the patient’s medical condition. It also helps in keeping the insurance co.’s costs down by filtering the number of patients who really require a specialist’s supervision
(vii) Referring Physician: The doctor who referred the patient to the rendering doctor. referring doctor information is very important if services require referral information, such as in managed care, consults, lab services etc., for diagnostic services such as Radiology (X-Rays), referring doctor is called the ordering
doctor who orders tests.
(viii) Admit Date and Discharge date: if the patient has been admitted to a hospital for treatment then the date on which the patient was admitted and date on which the patient was discharged need to be recorded and communicated to the payer.
(ix) Injury Date: The date on which the first symptoms began for the current illness, injury. This information is used in determining benefits or exclusions for pre- existing condition. In such cases, we need to mention is the injury is work related or due to accident.
(x) Prior Authorization Number: Insurance issues prior authorization number, authorizing the services to be provided if services require prior authorization, the charge sheet will indicate the prior authorization #, Services may not be paid without this number in the claim. This number is an important data element for claim processing.
(xii) Procedure Codes: These are the five digit alphanumeric codes (Common procedural Terminology), which represents the treatment performed for the patient. This might also include the services and supplies.
(xiii) Diagnosis Codes: These are the five digits alphanumeric decimal codes (ICD9CM- International Classification for Diseases-Version- 9 -Clinical modification), which represents the patient illness or condition or disease for which the treatment was rendered or diagnosed as result of the treatment. for e.g.. 486, 719.7, 728.87, v04.89
(xiv) Billed Amount: This is the amount charged by the physician for the particular service rendered to the patient.
(xv) Co payment : Amount that is paid by the patient at the front office before getting treatment. This amount is specific to the type of policy.
(xvi) Units: if the provider performs the same procedure for multiple times, then units should denote it whether it has been done for single time or double time or more.
(xvii) Modifier: Modifiers are the two digits alphanumeric codes that are adopted by the physician to reaffirm to the carrier that the procedure performed was altered or modified due to certain unavoidable circumstances. Below is the list modifiers
(i) Medical Record Number: This is the number allotted by the physician’s office to track the patient records after his visit.
(ii) Date of Service: The date(s) on which the provider has rendered the service to the patient. It should be entered in the software.
(iii) Provider: Person who provides the healthcare services is known as Provider and his name should be entered in the same software.
(iv) Type of service: It refers the type of treatment has done for the patient. (For e.g., Radiology, Cardiology)
(vi) Name of Clinic/ Facility: It is the place where services are furnished. i.e., in a hospital, clinic, laboratory etc.,
(vii) Referral Authorization Number: This number is issued by the PCP (Primary care Physician) while referring the patient to a specialist or another doctor. managed care plans require such referrals, without which payment may be denied for the services done by the specialist. This referral acts as a kind of a second opinion on the patient’s medical condition. It also helps in keeping the insurance co.’s costs down by filtering the number of patients who really require a specialist’s supervision
(vii) Referring Physician: The doctor who referred the patient to the rendering doctor. referring doctor information is very important if services require referral information, such as in managed care, consults, lab services etc., for diagnostic services such as Radiology (X-Rays), referring doctor is called the ordering
doctor who orders tests.
(viii) Admit Date and Discharge date: if the patient has been admitted to a hospital for treatment then the date on which the patient was admitted and date on which the patient was discharged need to be recorded and communicated to the payer.
(ix) Injury Date: The date on which the first symptoms began for the current illness, injury. This information is used in determining benefits or exclusions for pre- existing condition. In such cases, we need to mention is the injury is work related or due to accident.
(x) Prior Authorization Number: Insurance issues prior authorization number, authorizing the services to be provided if services require prior authorization, the charge sheet will indicate the prior authorization #, Services may not be paid without this number in the claim. This number is an important data element for claim processing.
(xii) Procedure Codes: These are the five digit alphanumeric codes (Common procedural Terminology), which represents the treatment performed for the patient. This might also include the services and supplies.
(xiii) Diagnosis Codes: These are the five digits alphanumeric decimal codes (ICD9CM- International Classification for Diseases-Version- 9 -Clinical modification), which represents the patient illness or condition or disease for which the treatment was rendered or diagnosed as result of the treatment. for e.g.. 486, 719.7, 728.87, v04.89
(xiv) Billed Amount: This is the amount charged by the physician for the particular service rendered to the patient.
(xv) Co payment : Amount that is paid by the patient at the front office before getting treatment. This amount is specific to the type of policy.
(xvi) Units: if the provider performs the same procedure for multiple times, then units should denote it whether it has been done for single time or double time or more.
(xvii) Modifier: Modifiers are the two digits alphanumeric codes that are adopted by the physician to reaffirm to the carrier that the procedure performed was altered or modified due to certain unavoidable circumstances. Below is the list modifiers
What are the functions of Charge entry?
Functions of Charge Entry:
(i) Registering the patient’s details from Front office
(ii) Status of the patient (Existing / New patient).
(iii) Cross Verification of Existing Patient’s details (address) with the already existing information.
(i) Registering the patient’s details from Front office
(ii) Status of the patient (Existing / New patient).
(iii) Cross Verification of Existing Patient’s details (address) with the already existing information.
What is Signature on File?
The INSURED and/or PATIENT may authorize the placing of their respective signatures on the medical claim form by the billing medical entity by signing an authorization known as “signature on file”.
What is Accept Assignment?
When a provider agrees to accept the carrier’s determination of the approved as the full fee for the services rendered it is called Accept Assignment. The provider also agrees to collect only the difference between the Medicare approved amount and actual Medicare payment made to the provider for the service. For example, Medicare pays 80% of the approved amount for inpatient psychological services. Therefore, the Medicare beneficiary is responsible for the remaining 20% of the approved amount.
Monday, August 30, 2010
What is Financial Class?
Financial classes are to track categories of patient purposes. It defaults at the patient demographic and ties to the charge. The AR Report will show how much income was generated by each class, as well as the outstanding receivables for each class.
Example of financial class:
M-Medicare
W-Worker Comp
T-Travelers
I-Insurance
S-Self A-Avmed
P-Prucare
D-Medicaid
They are needed to run the different kind of report like:
1.Aged Accounts Receivable Report
2.Detailed Accounts Receivable Report
3.Collection Report
Example of financial class:
M-Medicare
W-Worker Comp
T-Travelers
I-Insurance
S-Self A-Avmed
P-Prucare
D-Medicaid
They are needed to run the different kind of report like:
1.Aged Accounts Receivable Report
2.Detailed Accounts Receivable Report
3.Collection Report
What are the Contents of Demographics entry?
Contents of Demographics:
Patient Details:
Account Number: Generating the patients account number.
Patient Name: Patient name should be entered in the format of Last name, First
name, Middle Initial.
Date of Birth: DOB should be entered in the format of MMDDYYYY format. (For e.g. 21st July 1979 should be entered as 07/21/1979).
Sex: Patient Gender should be mentioned in this field. For e.g., Male/Female/Unknown.
Marital Status: This field should be filled with the details of his/her marital status. For e.g. Single/Married/Divorced/Unknown
SSN(Social Security Number): SSN number is issued by Social Security Administration. It is a 9 digit numerical number issued for all the citizens of US. For e.g., 232-65-3656
(First three number denotes the Area, and the next two number denotes the group and last four digit is the serial number.
Residential Details: Patient complete residential address should be entered. Patient street address should be entered in Address line 1 and if any (APT#, Unit#) should be entered in Address line 2 followed by city name, state and Zip code. Patient Zip code should contain only 5 digit numerics
Telephone Number: Telephone number should contain 10 digits numerics. (For e.g. (403)-243-6546. In this example, first three digit denote area code of the patient and the next three digits represents the group.
Email address: Patient email address should be entered if provided in the demographic sheet.
Spouse Information: If patient is married and spouse information is given, then his/her spouse information should be furnished.
Emergency Contact information: Emergency contact details if any should also be entered while registering demographics.
Employer Details: (a) Name of Employer: Patient employer name should be entered in case of billing WC (Workers Compensation) this field should be entered mandatorily.
(b) Employer address & phone number : Employer’s complete address & phone number should be entered.
(c) Type of business: Patient business or occupation details should be furnished while registering demographic details.
Guarantor Details: (a) Name of Guarantor: Person who is responsible for payment if patient fails to pay is known as guarantor. Name, address and telephone #, SSN should also be entered followed by his name.
Insurance Details:
• Name of the Insurance: Insurance name should be selected from the Insurance master provided in the software.
• Number of Insurance polices: If the patient has more than one Policy coverage, then it should be entered in the order of primary, Secondary and tertiary.
• Policy Id Number: Coverage id should be entered. This Identification number varies based on the insurances. (For e.g., Medicare-9 digit SSN + one Alpha)
• Group Number/Name: Group number or Group name should be entered to identify under which group the patient has enrolled.
• Name of Subscriber: Person who owns the policy is known as subscriber. Under his policy he or his dependents can enjoy the benefits. While registering insurance info policy details should be entered.
• Relation to subscriber: Here you have to mention the relationship to subscriber with the patient like self, spouse, child etc.,
• Effective date & Termination Date of the policy: Start date of policy should be entered. From this effective date only patient can enjoy his benefits on the coverage that he/she has enrolled. termination date should also be furnished while entering demographics details.
Patient Details:
Account Number: Generating the patients account number.
Patient Name: Patient name should be entered in the format of Last name, First
name, Middle Initial.
Date of Birth: DOB should be entered in the format of MMDDYYYY format. (For e.g. 21st July 1979 should be entered as 07/21/1979).
Sex: Patient Gender should be mentioned in this field. For e.g., Male/Female/Unknown.
Marital Status: This field should be filled with the details of his/her marital status. For e.g. Single/Married/Divorced/Unknown
SSN(Social Security Number): SSN number is issued by Social Security Administration. It is a 9 digit numerical number issued for all the citizens of US. For e.g., 232-65-3656
(First three number denotes the Area, and the next two number denotes the group and last four digit is the serial number.
Residential Details: Patient complete residential address should be entered. Patient street address should be entered in Address line 1 and if any (APT#, Unit#) should be entered in Address line 2 followed by city name, state and Zip code. Patient Zip code should contain only 5 digit numerics
Telephone Number: Telephone number should contain 10 digits numerics. (For e.g. (403)-243-6546. In this example, first three digit denote area code of the patient and the next three digits represents the group.
Email address: Patient email address should be entered if provided in the demographic sheet.
Spouse Information: If patient is married and spouse information is given, then his/her spouse information should be furnished.
Emergency Contact information: Emergency contact details if any should also be entered while registering demographics.
Employer Details: (a) Name of Employer: Patient employer name should be entered in case of billing WC (Workers Compensation) this field should be entered mandatorily.
(b) Employer address & phone number : Employer’s complete address & phone number should be entered.
(c) Type of business: Patient business or occupation details should be furnished while registering demographic details.
Guarantor Details: (a) Name of Guarantor: Person who is responsible for payment if patient fails to pay is known as guarantor. Name, address and telephone #, SSN should also be entered followed by his name.
Insurance Details:
• Name of the Insurance: Insurance name should be selected from the Insurance master provided in the software.
• Number of Insurance polices: If the patient has more than one Policy coverage, then it should be entered in the order of primary, Secondary and tertiary.
• Policy Id Number: Coverage id should be entered. This Identification number varies based on the insurances. (For e.g., Medicare-9 digit SSN + one Alpha)
• Group Number/Name: Group number or Group name should be entered to identify under which group the patient has enrolled.
• Name of Subscriber: Person who owns the policy is known as subscriber. Under his policy he or his dependents can enjoy the benefits. While registering insurance info policy details should be entered.
• Relation to subscriber: Here you have to mention the relationship to subscriber with the patient like self, spouse, child etc.,
• Effective date & Termination Date of the policy: Start date of policy should be entered. From this effective date only patient can enjoy his benefits on the coverage that he/she has enrolled. termination date should also be furnished while entering demographics details.
What are the documents submitted by a New patient at the Front Office?
Documents submitted by a New patient at the Front Office:
(a) Patient Demographic details
(b) Guarantor Details
(c) Patient & Guarantor Employer details
(d) Assignment of Benefits
(e) Release of Information
(f) Promissory Note
a) Patient Demographic Detail: The patient details will get registered in buck slip at the front office.
b) Guarantor Details: The details of the person who is going to accompany with the patient will also be registered at the front office.
c) Employer Information: Employer details of both patient and guarantor will also be collected at the front office.
d) AOB: (Assignment of Benefits): The Patient or guardian signs the assignment of benefits form so that the physician or medical provider will receive the insurance payment directly. This form will also be submitted at the front office.
e) ROI (Release of Information): The patient authorizes the provider to release his personal and medical information for the purpose of medical billing.
f) Promissory Note: Is a notice to maintain patient goodwill with extended payment plans.
(a) Patient Demographic details
(b) Guarantor Details
(c) Patient & Guarantor Employer details
(d) Assignment of Benefits
(e) Release of Information
(f) Promissory Note
a) Patient Demographic Detail: The patient details will get registered in buck slip at the front office.
b) Guarantor Details: The details of the person who is going to accompany with the patient will also be registered at the front office.
c) Employer Information: Employer details of both patient and guarantor will also be collected at the front office.
d) AOB: (Assignment of Benefits): The Patient or guardian signs the assignment of benefits form so that the physician or medical provider will receive the insurance payment directly. This form will also be submitted at the front office.
e) ROI (Release of Information): The patient authorizes the provider to release his personal and medical information for the purpose of medical billing.
f) Promissory Note: Is a notice to maintain patient goodwill with extended payment plans.
Anesthesia Code Modifiers
AA - Anesthesia services personally performed by anesthesiologist - Distinct fee schedule amount. Affects payment.
AD - Medical supervision by a physician: More than 4 concurrent anesthesia procedures -. Distinct fee schedule amount. Affects payment.
G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
G9 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
QK - Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by a physician or non-supervised CRNA.
QS - Monitored anesthesia care - No effect on payment. For informational purposes only. Must be used in conjunction with a pricing anesthesia modifier.
QX - CRNA service with medical direction by physician - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by physician or non-supervised CRNA.
QY - Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ - CRNA service without medical direction by a physician - No effect on payment. Payment is equal to the amount that would have been allowed if personally performed by a physician.
23 - Unusual anesthesia - Used to report a procedure which usually requires either no anesthesia or local anesthesia; however, because of unusual circumstances must be done under general anesthesia.Coverage /payment will be determined on a "by-report" basis.
47 - Anesthesia by surgeon - Used to report regional or general anesthesia provided by the surgeon (Not covered by Medicare).
AD - Medical supervision by a physician: More than 4 concurrent anesthesia procedures -. Distinct fee schedule amount. Affects payment.
G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
G9 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
QK - Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by a physician or non-supervised CRNA.
QS - Monitored anesthesia care - No effect on payment. For informational purposes only. Must be used in conjunction with a pricing anesthesia modifier.
QX - CRNA service with medical direction by physician - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by physician or non-supervised CRNA.
QY - Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ - CRNA service without medical direction by a physician - No effect on payment. Payment is equal to the amount that would have been allowed if personally performed by a physician.
23 - Unusual anesthesia - Used to report a procedure which usually requires either no anesthesia or local anesthesia; however, because of unusual circumstances must be done under general anesthesia.Coverage /payment will be determined on a "by-report" basis.
47 - Anesthesia by surgeon - Used to report regional or general anesthesia provided by the surgeon (Not covered by Medicare).
What are HCPCS Modifiers?
HCPCS code modifiers accompany HCPCS codes (e.g., CPT, level II) to provide additional information regarding the product or service identified. Modifiers are used when the information provided by a HCPCS code descriptor needs to be supplement to identify specific circumstances that may apply to an item or service.
What are HCPC codes?
Healthcare Common Procedure Coding System (HCPCS, pronounced as “hick-picks”) presents the procedure/service codes reference developed by CMS. HCPCS furnishes health care providers and suppliers with a standardized language for reporting processional services procedures, supplies, and equipment not included in CPT. These HCPCS codes are also five characters in length but begin with the letters A – V followed by four numbers. Most state Medicaid programs also use HCPCS.
List the ICD9 codes
The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems.
ICD-9 codes 001-139: Infectious and parasitic diseases
ICD-9 codes 140-239: Neoplasms
ICD-9 codes 240-279: Endocrine, nutritional and metabolic diseases, and immunity disorders
ICD-9 codes 280-289: Diseases of the blood and blood-forming organs
ICD-9 codes 290-319: Mental disorders
ICD-9 codes 320-359: Diseases of the nervous system
ICD-9 codes 360-389: Diseases of the sense organs
ICD-9 codes 390-459: Diseases of the circulatory system
ICD-9 codes 460-519: Diseases of the respiratory system
ICD-9 codes 520-579: Diseases of the digestive system
ICD-9 codes 580-629: Diseases of the genitourinary system
ICD-9 codes 630-676: Complications of pregnancy, childbirth, and the puerperium
ICD-9 codes 680-709: Diseases of the skin and subcutaneous tissue
ICD-9 codes 710-739: Diseases of the musculoskeletal system and connective tissue
ICD-9 codes 740-759: Congenital anomalies
ICD-9 codes 760-779: Certain conditions originating in the perinatal period
ICD-9 codes 780-799: Symptoms, signs, and ill-defined conditions
ICD-9 codes 800-999: Injury and poisoning
ICD-9 codes E and V codes: External causes of injury and supplemental classification
E Code ranges from E800 – E999.
V Code ranges from V01 – V85
ICD-9 codes 001-139: Infectious and parasitic diseases
ICD-9 codes 140-239: Neoplasms
ICD-9 codes 240-279: Endocrine, nutritional and metabolic diseases, and immunity disorders
ICD-9 codes 280-289: Diseases of the blood and blood-forming organs
ICD-9 codes 290-319: Mental disorders
ICD-9 codes 320-359: Diseases of the nervous system
ICD-9 codes 360-389: Diseases of the sense organs
ICD-9 codes 390-459: Diseases of the circulatory system
ICD-9 codes 460-519: Diseases of the respiratory system
ICD-9 codes 520-579: Diseases of the digestive system
ICD-9 codes 580-629: Diseases of the genitourinary system
ICD-9 codes 630-676: Complications of pregnancy, childbirth, and the puerperium
ICD-9 codes 680-709: Diseases of the skin and subcutaneous tissue
ICD-9 codes 710-739: Diseases of the musculoskeletal system and connective tissue
ICD-9 codes 740-759: Congenital anomalies
ICD-9 codes 760-779: Certain conditions originating in the perinatal period
ICD-9 codes 780-799: Symptoms, signs, and ill-defined conditions
ICD-9 codes 800-999: Injury and poisoning
ICD-9 codes E and V codes: External causes of injury and supplemental classification
E Code ranges from E800 – E999.
V Code ranges from V01 – V85
What are CPT Modifiers?
CPT modifiers clarify services and procedures performed by providers, and while the CPT code and description remains unchanged, modifiers indicate that the description of the service or procedure performed has been altered. CPT modifiers are reported as 2-digit numeric codes added to the 5-digit CPT code.
List the CPT Sections
Description Range of codes
Evaluation & Management 99200 – 99499
Anesthesiology 00100 – 01999
Surgery 10000 – 69999
Radiology 70000 – 79999
Pathology & Laboratory 80000 – 89999
Medicine 90000 – 99199
Evaluation & Management 99200 – 99499
Anesthesiology 00100 – 01999
Surgery 10000 – 69999
Radiology 70000 – 79999
Pathology & Laboratory 80000 – 89999
Medicine 90000 – 99199
List the categories of CPT codes
Category I Codes: Procedures/services identifies by a five-digit codes
Category II Codes: contain "performance measurements"
Category III Codes: contain "emerging technology"
Category II Codes: contain "performance measurements"
Category III Codes: contain "emerging technology"
When CPT codes are used?
CPT codes are used to report services and procedures performed on patients
by providers in offices, clinics, and private homes.
by providers in institutional settings such as hospitals, nursing facilities and hospices.
when the provider is employed by the health care facility (e.g., many of the physicians associated with Veterans Administration Medical Centers are employees of that organization).
by a hospital outpatient department (e.g., ambulatory surgery, emergency department, and outpatient laboratory or radiographic procedures).
by providers in offices, clinics, and private homes.
by providers in institutional settings such as hospitals, nursing facilities and hospices.
when the provider is employed by the health care facility (e.g., many of the physicians associated with Veterans Administration Medical Centers are employees of that organization).
by a hospital outpatient department (e.g., ambulatory surgery, emergency department, and outpatient laboratory or radiographic procedures).
What is CPT Code?
Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes for reporting medical, surgical, and diagnostic services to facilitate communication among providers, patients and insurers.
What is ICD?
The International Classification of Diseases (ICD) was developed by the World Health Organization (WHO) to classify mortality (death) date from the death certificates. Medical diseases, conditions are converted into ICD codes. The ICD is used to provide a standard classification of diseases for the purpose of health records.
ICD are only with Number, E Codes, V Codes
Diseases, Injuries, Impairments, Other health-related problems and their manifestations
ICD are only with Number, E Codes, V Codes
Diseases, Injuries, Impairments, Other health-related problems and their manifestations
Wednesday, August 25, 2010
What is Fee for Service Contract?
Providers will be paid based on the services rendered to the patients. Providers receive a fee for each service (office visit, procedures and other services). There is no pre-negotiated amount per month. Fee-for-service contract allow patients to obtain care from doctors and pay copayments / deductibles for the each care and then submit the claims to the insurance companies and the insurance will process the claim and make the payment.
What is CAPITATION contract?
Many HMO plans and some PPO plans signs Captation contract with the providers/doctors. When a provider signs capitation contract, he/she will be getting monthly payment from the insurance based on the number of enrollees in a location. Capitation contract will not specify the # of patients to be treated in a month.
What is Participating & Non-Participating?
Participating (PAR) - A doctor, hospital, group practice, nurse, nursing home, pharmacy, or other allied health professional or entity has agreed to accept a set fee for services provided to members of a specific health plan. A direct or indirect contractual arrangement with a managed care group to provide "In-Network" covered services to members. They receive re-imbursement of eligible charges directly from the carriers.
Non-Participating (NON-PAR) - A doctor, hospital, group practice, nurse, nursing home, pharmacy, or other allied health professional or entity that does not have a Participating Agreement with specific health plan. They provide out-of-network services to members. They may collect full charge(s) from the members at the time of service.
Non-Participating (NON-PAR) - A doctor, hospital, group practice, nurse, nursing home, pharmacy, or other allied health professional or entity that does not have a Participating Agreement with specific health plan. They provide out-of-network services to members. They may collect full charge(s) from the members at the time of service.
What is Crossover?
Piggyback or Cross over: Carriers (especially Medicare) after processing the claims, if there is a balance, Medicare will transfer the processing information of the claim to secondary carriers like Medicaid or state agencies and insurance companies that provide supplemental insurance benefits to Medicare beneficiaries electronically. The centers for Medicare & Medicaid Services (CMS) Co-ordination of Benefits (COB) program identifies the healthcare benefits available to a Medicare beneficiary and coordinates the payment process to ensure appropriate payment of Medicare benefits.
Tuesday, August 24, 2010
What is HOSPICE CARE?
Hospice is an interdisciplinary program of palliative and supportive services that addresses the physical, spiritual, social and economic needs of terminally ill patients and their families. Hospice empowers the patients who are dying to have peace, comfort and dignity. This program is for patients for whom there is nothing further the provider can do to stop the progression of disease, and the patient is treated only to relieve pain or other discomfort. In addition to medical care, a physician-directed interdisciplinary team provides psychological, sociological and spiritual care. Coverage includes drugs for pain relief and symptom management; medical, nursing, social services; and other covered services as well as services. The goal of Hospice is to control the pain and other symptoms and to live a pain free and comfortable life. Hospice care treats the person and quality rather than length of life.
A hospice patient is expected to live 6 months or less. Hospice care can take place:
• At home
• At a hospice center
• In a hospital
• In a skilled nursing facility
Hospice care at home may include the following:
Part-time or intermittent nursing care by a registered nurse (RN) or licensed practical nurse (L.P.N.)
Medical social services, under the direction of a physician
Part-time or intermittent home health aide, whose services consist mainly of caring for the family member, and
Medical supplies, drugs, and medicines prescribed by a physician
A hospice patient is expected to live 6 months or less. Hospice care can take place:
• At home
• At a hospice center
• In a hospital
• In a skilled nursing facility
Hospice care at home may include the following:
Part-time or intermittent nursing care by a registered nurse (RN) or licensed practical nurse (L.P.N.)
Medical social services, under the direction of a physician
Part-time or intermittent home health aide, whose services consist mainly of caring for the family member, and
Medical supplies, drugs, and medicines prescribed by a physician
What is CO-ORDINATION OF BENEFITS?
This is a benefit provision that applies when a person is covered under more than one group health plans. It requires that payment of benefits will be coordinated by all Insurers (group plans) to eliminate duplication of benefits or over payments of services. This is a practice which is used to ensure that insurance claims are not paid multiple times when someone is someone is insured under multiple insurance plans. This arrangement in health insurance is to discourage multiple payments for the same claims under two or more policies.
For example, when husband and wife are working, they might have separate plans (coverage) with their respective employers. In case if a claim arises on any one, the two plans will co–ordinate payments or benefits.
The Primary Payer pays the Normal Benefits (N/B) and the Secondary Payer usually pays less than their Normal benefits .
The rules for determining a Primary or Secondary Payor are:
Employee - primary on his/her plan, secondary on his/her spouse’s plan.
Spouse - primary on his/her plan, secondary on his/her spouse’s plan.
Children – Typically, apply Birth day Rule, unless otherwise stated in the plan.
Birth Day Rule - It is a rule that is applied when dependants are covered under two plans. Amongst the parent, whichever parent was born earlier in a calendar year becomes the Primary Payer, and the other parent pays the claim as the Secondary Payer
For example, when husband and wife are working, they might have separate plans (coverage) with their respective employers. In case if a claim arises on any one, the two plans will co–ordinate payments or benefits.
The Primary Payer pays the Normal Benefits (N/B) and the Secondary Payer usually pays less than their Normal benefits .
The rules for determining a Primary or Secondary Payor are:
Employee - primary on his/her plan, secondary on his/her spouse’s plan.
Spouse - primary on his/her plan, secondary on his/her spouse’s plan.
Children – Typically, apply Birth day Rule, unless otherwise stated in the plan.
Birth Day Rule - It is a rule that is applied when dependants are covered under two plans. Amongst the parent, whichever parent was born earlier in a calendar year becomes the Primary Payer, and the other parent pays the claim as the Secondary Payer
What is Clearing house?
A claims clearinghouse is an organization that receives clinical claims and other types of health care information from providers and then submits that information electronically to insurance companies that they are contracted with. It serves as the intermediary between the provider and the insurance company.
Claims can be sent to the clearinghouse electronically, on paper through the mail, or by fax Regardless of the method of transmittal, the clearinghouse will translate the data elements into a format that complies with the format required by the target insurance company.
Types of Reports from clearing house:
Payer Report
Denial Report
o Payer
o Clearing House
Scrubber Report
ERA – Electronic Remittance Advice
Sent File Status
Claim Status Reports
Rejection Analysis
Drop and Mail Paper Claims If Needed
Claims can be sent to the clearinghouse electronically, on paper through the mail, or by fax Regardless of the method of transmittal, the clearinghouse will translate the data elements into a format that complies with the format required by the target insurance company.
Types of Reports from clearing house:
Payer Report
Denial Report
o Payer
o Clearing House
Scrubber Report
ERA – Electronic Remittance Advice
Sent File Status
Claim Status Reports
Rejection Analysis
Drop and Mail Paper Claims If Needed
Who are eligible for Medicaid?
Generally, low income resources are applied for Medicaid. Many groups of people are covered by Medicaid. Within these groups, we should meet certain requirements like age, whether you are pregnant, disabled, blind, or aged; your income and resources (like real property or other items that can be sold for cash).
Mandatory Eligibility Groups:
Mandatory Eligibility Groups:
- Qualify for the Aid to Families with Dependent Children (AFDC) program
- Qualify for Supplemental Security Income (SSI)
- Pregnant women at FPL (Federal Poverty Level)
- Infants born to Medicaid-eligible pregnant women.
- Children under age 6 and pregnant women whose family income is at or below 133% of the Federal poverty level.
- Recipients of adoption assistance and foster care under Title IV-E of the Social Security Act
- Certain people with Medicare
- Special protected groups who may keep Medicaid for a period of time.
- Infants up to age 1 and pregnant women not covered under the mandatory rules whose family income is not more than 185% of the FPL.
- Optional targeted low-income children.
- Certain aged, blind, or disabled adults who have incomes above those requiring mandatory coverage, but below the Federal poverty level.
- Children under age 21 who meet income and resources requirements for the Aid to Families with Dependent Children (AFDC), but who otherwise are not eligible for the AFDC.
- Institutionalized individuals with limited income and resources.
- Persons who would be eligible if institutionalized but are receiving care under home and community-based services waivers.
- Tuberculosis-infected persons who would be financially eligible for Medicaid at the Supplemented Security Income (SSI) level.
- Low-income, uninsured women screened and diagnosed through a Center's for Disease Control (CDC) Breast and Cervical Cancer Early Detection Program (NBCCEDP) and determined to be in need of treatment for breast or cervical cancer.
- Temporary Assistance to Needy Families (TANF).
What is Medicaid?
Medicaid is a Federal health insurance program which provides medical assistance to certain individuals and families with low incomes and limited resources. The plan offers health insurance for disables, the blind, the aged and selected families with dependent children.
Medicaid is generally the “payer of last resort”. This means that if a person has other health insurance coverage, Medicaid will become the secondary payer. Medicaid will pay only after that other health insurance pays.
Medicaid is generally the “payer of last resort”. This means that if a person has other health insurance coverage, Medicaid will become the secondary payer. Medicaid will pay only after that other health insurance pays.
What is MEDICARE DEDUCTIBLES for the year 2010
Medicare Part A
1. 2010 Deductibles for Hospital stay
Days 1 to 60 - The deductible for the inpatient hospital for 1-60 days will be $1,100 for the year 2010.
Days 61 to 90 – An additional $275 should be paid per day.
For Life time – $550 should be paid for lifetime reserve days.
2. 2010 Deductible for Skilled Nursing Facility stay
Days 0 to 20 – No Deductible for first 20 days
Days 21 to 100 – $137.50 per day for days 21 to 100
100 and above – All costs for each day after day 100 in a benefit period
Medicare Part B
The Medicare Part B deductible for 2010 will be $155.00. Co-insurance is 20% of the Medicare approved amount. Lab charges are covered 100%.
1. 2010 Deductibles for Hospital stay
Days 1 to 60 - The deductible for the inpatient hospital for 1-60 days will be $1,100 for the year 2010.
Days 61 to 90 – An additional $275 should be paid per day.
For Life time – $550 should be paid for lifetime reserve days.
2. 2010 Deductible for Skilled Nursing Facility stay
Days 0 to 20 – No Deductible for first 20 days
Days 21 to 100 – $137.50 per day for days 21 to 100
100 and above – All costs for each day after day 100 in a benefit period
Medicare Part B
The Medicare Part B deductible for 2010 will be $155.00. Co-insurance is 20% of the Medicare approved amount. Lab charges are covered 100%.
Monday, August 23, 2010
When Medicare will act as secondary payer?
Medicare will act as secondary insurance when the patient is eligible for Medicare and is also covered by one or more of the following plans:
An employer-sponsored group health plan.
Disability coverage through an employer-sponsored group health plan.
An ESRD case covered by an employer-sponsored group plan.
A third-party liability policy, if the Medicare-eligible person is seeking treatment for an injury covered by such a policy (this category includes automobile insurance, no-fault insurance and self-insured liability plans).
A Workers’ Compensation program.
Veterans Administration (VA) preauthorized services for a beneficiary who is eligible for both VA benefits and Medicare.
An employer-sponsored group health plan.
Disability coverage through an employer-sponsored group health plan.
An ESRD case covered by an employer-sponsored group plan.
A third-party liability policy, if the Medicare-eligible person is seeking treatment for an injury covered by such a policy (this category includes automobile insurance, no-fault insurance and self-insured liability plans).
A Workers’ Compensation program.
Veterans Administration (VA) preauthorized services for a beneficiary who is eligible for both VA benefits and Medicare.
What is Medicare Part B Coverage?
Medicare part B is designed to cover outpatient services and professional services provided to inpatients. Medicare will not cover cosmetic surgery.
You must sign up for Medicare Part B and pay a monthly premium, and yearly deductible. You are responsible for a 20 percent co-pay. The premium cost increases each January.
Every Part B provides coverage for doctor services outside the hospital setting and other medical services that Part A doesn't cover. Additional services covered include:
• Physician services
• Professional services provided to inpatients.
• Services of nonphysician professionals such as nurses, certified registered nurse anesthetists, nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants.
• Diagnostic testing
• Radioactive isotope therapy
• Ambulance services
• Durable medical equipments (DME) and supplies used in the home and certified by a physician.
• Laboratory tests and X-rays
• Physical therapy or rehabilitation services,
• Some home health care.
You must sign up for Medicare Part B and pay a monthly premium, and yearly deductible. You are responsible for a 20 percent co-pay. The premium cost increases each January.
Every Part B provides coverage for doctor services outside the hospital setting and other medical services that Part A doesn't cover. Additional services covered include:
• Physician services
• Professional services provided to inpatients.
• Services of nonphysician professionals such as nurses, certified registered nurse anesthetists, nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants.
• Diagnostic testing
• Radioactive isotope therapy
• Ambulance services
• Durable medical equipments (DME) and supplies used in the home and certified by a physician.
• Laboratory tests and X-rays
• Physical therapy or rehabilitation services,
• Some home health care.
What is Medicare Part A Coverage
Medicare Part A is a hospital insurance provided by Medicare. Most people do not have to pay a premium for Part A because the individual or their spouse paid Medicare taxes while working.
It provides inpatient care in hospitals, nursing homes, skilled nursing facilities, and critical access hospitals. If you meet specific requirements then Medicare gives hospice and home healthcare eligibility. Part A does not include long-term or custodial care.
Medicare Part A coverage is available to individuals age 65 and over who:
are already receiving retirement benefits from Social Security or the Railroad Retirement Board (RRB).
are eligible to receive Social Security or Railroad benefits but who have not yet filled for them.
had Medicare-covered government employment.
Medicare Part A coverage is available to individuals under age 65 who:
are disabled per SSA or RRB guidelines.
have received SSA or RRB disability benefits for 24 months.
are kidney dialysis or kidney transplant patients.
Hospital stays must be at least 3 days (72 hours) and does not include any hours on the discharge date.
• Skilled Nursing Facility Stays: After a 3-day-minimum acute hospital say, some individuals require short-term skilled nursing care or daily rehabilitation services in a skilled nursing facility (SNF) before returning home. Medicare pays for up to 100 days of such "subacute" care for elderly and disabled beneficiaries who have been hospitalized for at least three days.
• Home Health Services: Medicare home health services must be prescribed by a physician. Home Health Services is limited to medically-necessary part-time or intermittent skilled nursing care, or physical therapy, speech-language pathology, or a continuing need for occupational therapy. A doctor must order your care, and a Medicare-certified home health agency must provide it. Medicare covered home health service have no deductible or coinsurance responsibilities for services provided. Patients must be confined to the home, but they do not have to be hospitalized in an acute care hospital before qualifying for home health benefits. The patient is responsible for a 20% deductible of the approved amount for durable medical equipment.
• Hospice Care: All terminally ill patients qualify for hospice care. Hospice is an autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients. This program is for patients for whom there is nothing further the provider can do to stop the progression of disease, and the patient is treated only to relieve pain or other discomfort. In addition to medical care, a physician-directed interdisciplinary team provides psychological, sociological and spiritual care. Coverage includes drugs for pain relief and symptom management; medical, nursing, social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling. A Medicare-approved hospice usually gives hospice care in your home (or other facility like a nursing home).
• End – Stage Renal Disease (ESRD) Coverage: End-stage renal disease (ESRD) refers to that stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life. Special coverage is available for Medicare-eligible persons in need of renal dialysis or transplant due to ESRD.
It provides inpatient care in hospitals, nursing homes, skilled nursing facilities, and critical access hospitals. If you meet specific requirements then Medicare gives hospice and home healthcare eligibility. Part A does not include long-term or custodial care.
Medicare Part A coverage is available to individuals age 65 and over who:
are already receiving retirement benefits from Social Security or the Railroad Retirement Board (RRB).
are eligible to receive Social Security or Railroad benefits but who have not yet filled for them.
had Medicare-covered government employment.
Medicare Part A coverage is available to individuals under age 65 who:
are disabled per SSA or RRB guidelines.
have received SSA or RRB disability benefits for 24 months.
are kidney dialysis or kidney transplant patients.
• Hospitalizations: Medicare pays only a portion of a patient’s acute care hospitalization expenses, and the patient’s out-of-pocket expenses are calculated on a “benefit period basis.” A benefit period begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.
Hospital stays must be at least 3 days (72 hours) and does not include any hours on the discharge date.
• Skilled Nursing Facility Stays: After a 3-day-minimum acute hospital say, some individuals require short-term skilled nursing care or daily rehabilitation services in a skilled nursing facility (SNF) before returning home. Medicare pays for up to 100 days of such "subacute" care for elderly and disabled beneficiaries who have been hospitalized for at least three days.
• Home Health Services: Medicare home health services must be prescribed by a physician. Home Health Services is limited to medically-necessary part-time or intermittent skilled nursing care, or physical therapy, speech-language pathology, or a continuing need for occupational therapy. A doctor must order your care, and a Medicare-certified home health agency must provide it. Medicare covered home health service have no deductible or coinsurance responsibilities for services provided. Patients must be confined to the home, but they do not have to be hospitalized in an acute care hospital before qualifying for home health benefits. The patient is responsible for a 20% deductible of the approved amount for durable medical equipment.
• Hospice Care: All terminally ill patients qualify for hospice care. Hospice is an autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients. This program is for patients for whom there is nothing further the provider can do to stop the progression of disease, and the patient is treated only to relieve pain or other discomfort. In addition to medical care, a physician-directed interdisciplinary team provides psychological, sociological and spiritual care. Coverage includes drugs for pain relief and symptom management; medical, nursing, social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling. A Medicare-approved hospice usually gives hospice care in your home (or other facility like a nursing home).
• End – Stage Renal Disease (ESRD) Coverage: End-stage renal disease (ESRD) refers to that stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life. Special coverage is available for Medicare-eligible persons in need of renal dialysis or transplant due to ESRD.
MEDICARE
The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation's largest health insurance program, which covers nearly 40 million Americans. It is a social insurance program administered by the United States Government, it operates as a single payer healthcare systems.
Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).
Medicare has 2 Part Programs:
Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).
Medicare has 2 Part Programs:
- Medicare Part A reimburses institutional providers for inpatient, hospice, and some home health services.
- Medicare Part B reimburses institutional providers for outpatient services and physicians for inpatient services.
General Medicare eligibility requires individuals to:
- Have worked at least 10 years in Medicare-covered employment.
- Be a minimum age of 65 years old.
- Be a citizen or permanent resident of the United States.
Primary v/s Secondary insurances
Primary coverage: When two or more coverage or policies apply to the same loss, the one that pays first, up to its limit of liability or the amount of the loss, whichever is less
Secondary coverage: Coverage that applies only after limits of the primary insurance have been exhausted or denied.
• Which is primary insurance when you and your spouse both have insurance from your employer:
In most cases, the insurance that is provided as a benefit of your primary job is your primary insurance. If you are listed as a dependent on your spouse’s insurance, your spouse’s insurance should be filed as your secondary insurance.
• Which is primary in case of two jobs
In case if you have two jobs and both of your employers have given you insurance, which you consider as your main occupation should be filed as your primary insurance and the other as the secondary insurance.
• Which is primary in case your spouse has employer insurance and you have insurance Medicaid or VA
If you have coverage through Medicaid or VA and your spouse has health insurance coverage through an employer, then your spouse’s policy is primary if primary insurance for you and Medicaid /VA is secondary insurance.
• Birthday Rule:
It is a method of determining which parent's medical coverage is primary for dependent children. Here we need to determine whose birthday comes first when you have two married people with dependents. The child's doctor will bill the primary health insurance provider of the parent whose birthday falls first in a calendar year. For example, one parent's birthday is March 22, and the other parent's birthday is October 10. The March 22 birthday is the primary coverage and the other is secondary coverage.
• Cobra insurance coverage:
Consider which parent has insurance under a current employer if one is retired. Consider which person has been with the same employer the longest when both birthdays fall on the same day. Coverage under a current employer is primary over COBRA insurance coverage. Otherwise, the coverage that started first is the primary insurance coverage when birthdays are the same.
Secondary coverage: Coverage that applies only after limits of the primary insurance have been exhausted or denied.
• Which is primary insurance when you and your spouse both have insurance from your employer:
In most cases, the insurance that is provided as a benefit of your primary job is your primary insurance. If you are listed as a dependent on your spouse’s insurance, your spouse’s insurance should be filed as your secondary insurance.
• Which is primary in case of two jobs
In case if you have two jobs and both of your employers have given you insurance, which you consider as your main occupation should be filed as your primary insurance and the other as the secondary insurance.
• Which is primary in case your spouse has employer insurance and you have insurance Medicaid or VA
If you have coverage through Medicaid or VA and your spouse has health insurance coverage through an employer, then your spouse’s policy is primary if primary insurance for you and Medicaid /VA is secondary insurance.
• Birthday Rule:
It is a method of determining which parent's medical coverage is primary for dependent children. Here we need to determine whose birthday comes first when you have two married people with dependents. The child's doctor will bill the primary health insurance provider of the parent whose birthday falls first in a calendar year. For example, one parent's birthday is March 22, and the other parent's birthday is October 10. The March 22 birthday is the primary coverage and the other is secondary coverage.
• Cobra insurance coverage:
Consider which parent has insurance under a current employer if one is retired. Consider which person has been with the same employer the longest when both birthdays fall on the same day. Coverage under a current employer is primary over COBRA insurance coverage. Otherwise, the coverage that started first is the primary insurance coverage when birthdays are the same.
What is Managed Care Plan?
This is a type of policy under which the insurance company plays an active role in facilitating the insured healthcare activities. It is responsible for the health of a group of enrollees (can be a health plan, hospital or a physician group). Managed care organizations generally negotiate agreements with providers to offer packaged health care benefits to covered individuals. Managed plan enrollees receive care from a primary care provider that is selected from a list of participating providers. The Primary care provider is responsible for supervising and co-coordinating health care services for enrollees and preauthorizing referrals to specialist and inpatient hospital admissions (Except emergencies).
The important features of Managed Care are:
3. Health Maintenance Organization (HMO)
4. Point of Service Plan (POS)
5. Preferred Provider Organization (PPO)
6. Triple Option Plan (TOP)
EPOs are regulated by state insurance plans.
PPO will cost a little more because it provides greater flexibility in choosing doctors and seeing specialists than does the HMO. The patient can see any doctor or visit any hospital of their choice. When the patient goes to no-participating or out of network providers, then he/she has to pay higher deductible & Coinsurance, Premiums, Co-pays etc.,
6) TRIPLE OPTION PLAN: Triple Option Plan is usually offered by either a single insurance plan or as a joint venture among two or more insurance carriers, providers, subscribers or employees with a choice of HMO, PPO, or Traditional fee-for-service plan.
The indemnity plan, even though more costly, would provide the patient with the greatest number of choices among physicians and hospitals. The PPO would allow the patient to have more choices among physicians and hospitals than the HMO and would not require the patient to go through the primary care physician or gatekeeper, as the HMO requires. The HMO would be the lowest cost option (no deductible) but the most restrictive as to the patient's choice.
Triple Option Plan is also called a Cafeteria plan because of different benefit plans and extra coverage options provided through the insurer or third party administrator.
The important features of Managed Care are:
- The liability of the insured is always a prefixed amount.
- A participating provider most often renders the service.
- Referral / Authorization plays major role here.
1. Exclusive Provider Organization (EPO)
2. Integrated Delivery System (IDS)3. Health Maintenance Organization (HMO)
4. Point of Service Plan (POS)
5. Preferred Provider Organization (PPO)
6. Triple Option Plan (TOP)
1) EPO PLAN: EPO Plan provides benefits to subscribers if they receive services from network providers.
Primary Care Physician plays a major role hereEPOs are regulated by state insurance plans.
2) INTEGRATED DELIVERY SYSTEM: IDS is an organization of affiliated providers sites (Physician Groups, Hospitals, etc.,) that offer joint health care services to subscribers.
3) HEALTH MAINTENANCE ORGANIZATION: An HMO is a comprehensive managed care plan that pays only for in-network care. HMO provides preventive care services to promote “Wellness” or good health, thus reducing the overall cost of Medical Care.
Annual physical examinations are encouraged for the early detection of health problems. If you need care from a physician specialist in the network or a diagnostic service such as a lab test or x-ray, your primary care physician (PCP) will have to provide you with a referral. HMO often requires patients to pay a Copayment/Copay (A fee the policyholder pays for an office visit, specific treatment or prescription), which is a fee paid by the patient to the provider/doctor at the time health care services are rendered.
4) POINT OF SERVICE PLAN: A Point of Service is a combination of HMO and the PPO. POS plans allow the covered person to choose to receive a service from Participating or Non-participating provider.
A POS plan also allows to choose a provider who is not in the network. However, if you choose to out-of network for your care, then you have to pay more deductible & Co-insurances.
If you need care from a physician specialist out side the network and if primary POS physician make referrals, then some compensation will be offered by your health insurance company.
5) PREFERRED PROVIDER ORGANIZATION: PPO is a network of physicians and hospitals that have joined together to contract with insurance companies, employers or other organization to provider health care to subscribers for a discounted fee.
PPO will cost a little more because it provides greater flexibility in choosing doctors and seeing specialists than does the HMO. The patient can see any doctor or visit any hospital of their choice. When the patient goes to no-participating or out of network providers, then he/she has to pay higher deductible & Coinsurance, Premiums, Co-pays etc.,
6) TRIPLE OPTION PLAN: Triple Option Plan is usually offered by either a single insurance plan or as a joint venture among two or more insurance carriers, providers, subscribers or employees with a choice of HMO, PPO, or Traditional fee-for-service plan.
The indemnity plan, even though more costly, would provide the patient with the greatest number of choices among physicians and hospitals. The PPO would allow the patient to have more choices among physicians and hospitals than the HMO and would not require the patient to go through the primary care physician or gatekeeper, as the HMO requires. The HMO would be the lowest cost option (no deductible) but the most restrictive as to the patient's choice.
Triple Option Plan is also called a Cafeteria plan because of different benefit plans and extra coverage options provided through the insurer or third party administrator.
How to get health Insurance?
We can get health Insurance by the following policies:
Group Policies: Sign on with the health insurance provided by your employer: it is likely to be the cheapest option you can find. Search for your own insurance if you're self-employed, or if your company doesn't offer it.
Individual Policies: If you do not have health insurance available to you through your job, you may be able to buy an individual policy.
Medicare: Insurance Medicare is for the people who are 65 years and older, disabled and suffering from end-stage renal failure requiring dialysis or kidney transplant. It is a social insurance program administered by the United States government.
Medicaid: Medicaid is health insurance that is provided to low-income people who otherwise would not be able to seek medical care. Medicaid is regulated by state and federal funding.
Group Policies: Sign on with the health insurance provided by your employer: it is likely to be the cheapest option you can find. Search for your own insurance if you're self-employed, or if your company doesn't offer it.
Individual Policies: If you do not have health insurance available to you through your job, you may be able to buy an individual policy.
Medicare: Insurance Medicare is for the people who are 65 years and older, disabled and suffering from end-stage renal failure requiring dialysis or kidney transplant. It is a social insurance program administered by the United States government.
Medicaid: Medicaid is health insurance that is provided to low-income people who otherwise would not be able to seek medical care. Medicaid is regulated by state and federal funding.
What are the types of Health Insurance
Types of Health Insurance coverage are
1. Hospital – Covers hospital and surgical charges.
2. Medical – Has greater coverage and benefits; does not cover supplemental Insurance.
3. Dental – Re-imbursement for expenses of dental services and supplies.
4. Pharmacy – Covers drugs and medicines prescribed by Physicians.
5. Vision – Benefits for routine preventive and corrective vision care.
1. Hospital – Covers hospital and surgical charges.
2. Medical – Has greater coverage and benefits; does not cover supplemental Insurance.
3. Dental – Re-imbursement for expenses of dental services and supplies.
4. Pharmacy – Covers drugs and medicines prescribed by Physicians.
5. Vision – Benefits for routine preventive and corrective vision care.
What is Health Insurance?
Health care insurance or health insurance is a contract between a policy holder and a third-party payer or government program to reimburse the policy holder for all or a portion of the cost of medically necessary treatment or preventive care provided by health care professionals. The type and amount of health care costs that will be covered by the health insurance company are specified in advance, in the member contract.
The insurance companies are governed by laws in terms of their operations and routine functioning. This is done to ensure that they do not abuse the insured by being unreasonable.
The insurance companies are governed by laws in terms of their operations and routine functioning. This is done to ensure that they do not abuse the insured by being unreasonable.
What is Advanced Beneficiary Notice?
An Advance Beneficiary Notice of Non-Coverage (ABN) is a written document from Medicare, given to a Medicare beneficiary by a physician, provider, or supplier before receiving services.
When a physician, provider, or supplier believes that Medicare will not cover a service that he/she are about to perform on a patient covered by Medicare and if the patient still wants the treatment, their signature on the form shows they may be responsible for payment. ABN will be issued for the following reasons.
• Medicare may deny the claim for that specific procedure or treatment.
• Medicare may deny for the frequency of the service.
• You will be personally responsible for full payment if Medicare denies payment.
The ABN is not designed for use when Medicare never covers a service. It should be used if Medicare does cover the service for some diagnoses, but the provider believes it will not be covered for a particular situation.
Please note that a separate form must be signed for each service for each date of service as the patient has the option to refuse the service. And this process is best if it is managed by the clinical team, instead of the front office as specificity is required.
Medicare Part B has combined the two different ABN forms and the Notice of Exclusions from Medicare Benefits (NEMB) form into a new form CMS-R-131 for providers to use.
When a physician, provider, or supplier believes that Medicare will not cover a service that he/she are about to perform on a patient covered by Medicare and if the patient still wants the treatment, their signature on the form shows they may be responsible for payment. ABN will be issued for the following reasons.
• Medicare may deny the claim for that specific procedure or treatment.
• Medicare may deny for the frequency of the service.
• You will be personally responsible for full payment if Medicare denies payment.
The ABN is not designed for use when Medicare never covers a service. It should be used if Medicare does cover the service for some diagnoses, but the provider believes it will not be covered for a particular situation.
Please note that a separate form must be signed for each service for each date of service as the patient has the option to refuse the service. And this process is best if it is managed by the clinical team, instead of the front office as specificity is required.
Medicare Part B has combined the two different ABN forms and the Notice of Exclusions from Medicare Benefits (NEMB) form into a new form CMS-R-131 for providers to use.
What are the functions of a Billing Company?
A Billing company gathers patient information like Insurance details and charges details from the provider/physician and submits the claims to insurance carriers for payment. The major functions of Billing company are:
Coding Department: Medical Coding is the process of assigning a code for Medical Diagnosis or procedure. This will help the doctors/providers, nurses, or hospitals to get proper payment from the insurance companies. People working in this department should be well versed with Medical Terminology, Anatomy, physiology, etc.
Demographics Entry: All-patient’s personal information like patients’ Name, DOB, address, Phone #, guarantor name, employer details, Insurance details will be entered in the billing software.
Charge Entry: Charge entry executive will create charges/claims for the patients based on the CPT and DX codes given by the coder and on billing rules pertaining to specific carriers and locations. All the charges should be created generally within 24 hours. A though audit and checking of the completed medical claims is done at multiple levels.
Transmission of Claims: Once the charge entry/Audit is over, claims will be transmitted to the Clearinghouse (For few insurance companies, we can directly submit the claims to them and we don’t have to go thru a clearinghouse).
Cash Posting: Once the insurance process the claims, they will issue payments. Payment posting executives will post the payments in respective patients’ account.
Insurance Calling: Following up with the Insurance companies on pending claims & denied claims.
Patient Calling / billing: Following up with the patients on their outstanding Bills, Coverage clarifications, etc.,
Center (Hospital) Calling: Contact the hospitals for clarification relating to treatment, Doctors, Authorization, Medical Records, etc.
Coding Department: Medical Coding is the process of assigning a code for Medical Diagnosis or procedure. This will help the doctors/providers, nurses, or hospitals to get proper payment from the insurance companies. People working in this department should be well versed with Medical Terminology, Anatomy, physiology, etc.
Demographics Entry: All-patient’s personal information like patients’ Name, DOB, address, Phone #, guarantor name, employer details, Insurance details will be entered in the billing software.
Charge Entry: Charge entry executive will create charges/claims for the patients based on the CPT and DX codes given by the coder and on billing rules pertaining to specific carriers and locations. All the charges should be created generally within 24 hours. A though audit and checking of the completed medical claims is done at multiple levels.
Transmission of Claims: Once the charge entry/Audit is over, claims will be transmitted to the Clearinghouse (For few insurance companies, we can directly submit the claims to them and we don’t have to go thru a clearinghouse).
Cash Posting: Once the insurance process the claims, they will issue payments. Payment posting executives will post the payments in respective patients’ account.
Insurance Calling: Following up with the Insurance companies on pending claims & denied claims.
Patient Calling / billing: Following up with the patients on their outstanding Bills, Coverage clarifications, etc.,
Center (Hospital) Calling: Contact the hospitals for clarification relating to treatment, Doctors, Authorization, Medical Records, etc.
What are the components of Medical Billing?
The following are the components of Medical Billing:
(a) Patient: A person who receives healthcare services from a physician is called patient
There are two types of patients.
New Patient: Any patient who is visiting the physician for the first time or subsequently after a break exceeding the period of 3 years is called a new Patient.
Established Patient: An established patient is one who is visiting the Physician within a period of 3 years from the date of his last visit.
(b) Provider: Any Healthcare professional (i.e. physician, registered nurse, therapist, etc.) who provides medical-related services to the patients.
(c) Insurance Company: This is the company, which takes care of the subscriber’s dependent’s healthcare costs.
(d) Billing Company: These are the third party offices which will take care of complete billing activities of providers/hospitals. In other word, these companies will manage financial data of physicians.
(e) Coding Agencies: There are two major agencies involved in coding. They are American Health \ Information Management Association (AHIMA) and American. Association for Professional Coders (AAPC), these associations set standards and Procedures for Coding.
(f) Transcription Agencies: There are lots of transcription agencies involved in billing Industry. Either these will be run as a separate entity or it runs in provider office itself.
(g) Clearing Houses: It is also referred to as Third Party Administrator (TPA). It is an entity that receives claims that are transmitted, separates the claims and sends each one to the correct insurance payer.
(a) Patient: A person who receives healthcare services from a physician is called patient
There are two types of patients.
New Patient: Any patient who is visiting the physician for the first time or subsequently after a break exceeding the period of 3 years is called a new Patient.
Established Patient: An established patient is one who is visiting the Physician within a period of 3 years from the date of his last visit.
(b) Provider: Any Healthcare professional (i.e. physician, registered nurse, therapist, etc.) who provides medical-related services to the patients.
(c) Insurance Company: This is the company, which takes care of the subscriber’s dependent’s healthcare costs.
(d) Billing Company: These are the third party offices which will take care of complete billing activities of providers/hospitals. In other word, these companies will manage financial data of physicians.
(e) Coding Agencies: There are two major agencies involved in coding. They are American Health \ Information Management Association (AHIMA) and American. Association for Professional Coders (AAPC), these associations set standards and Procedures for Coding.
(f) Transcription Agencies: There are lots of transcription agencies involved in billing Industry. Either these will be run as a separate entity or it runs in provider office itself.
(g) Clearing Houses: It is also referred to as Third Party Administrator (TPA). It is an entity that receives claims that are transmitted, separates the claims and sends each one to the correct insurance payer.
What is Medical Coding?
Medical Coding is the process of converting a diagnosis or symptoms, procedures, and drugs into codes. This will help the doctors/providers, nurses, or hospitals to get proper payment from the insurance companies. Medical Coding is also known as insurance coding. The American Health Information Management Association offers certification in this field.
Medical Billing and Medical Coding are actually two separate career paths. Some employers combine both the roles into one position; but most of the practices, Providers or hospitals employ specialists in each area.
Medical Billing and Medical Coding are actually two separate career paths. Some employers combine both the roles into one position; but most of the practices, Providers or hospitals employ specialists in each area.
What is Medical Billing?
The medical billing process is an interaction between a healthcare provider and the insurance company (payer). It is the process of submitting and following up on claims to various federal & private insurance companies in order to receive payment for services rendered by the doctors/providers, nurses, or any other healthcare provider.
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