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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 9.1 Compare employer-sponsored and self-funded health plans. Pages: 328-330 Teaching Notes:   Ask your students to explain why they think employers often sponsor medical insurance for their employees.
  • Learning Outcome: 9.1 Compare employer-sponsored and self-funded health plans. Pages: 328-330 Teaching Notes:   Have your students list the changes they think came about as a result of ERISA.
  • Learning Outcome: 9.1 Compare employer-sponsored and self-funded health plans. Pages: 328-330 Teaching Notes:   Ask your students to explain whether or not they think the number of people using IHPs is growing.
  • Learning Outcome: 9.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage. Pages: 331-333 Teaching Notes:   Have your students explain the concept of a Section 125 cafeteria plan, in their own words.
  • Learning Outcome: 9.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage. Pages: 331-333 Teaching Notes:   Ask your students to explain the difference between an individual deductible and a family deductible.
  • Learning Outcome: 9.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage. Pages: 331-333 Teaching Notes:   Have your students examine the value of COBRA.
  • Learning Outcome: 9.3 Discuss provider payment under preferred provider organizations, health maintenance organizations, point-of-service plans, and indemnity plans. Pages: 333-337 Teaching Notes:   Ask your students to explain why few employees choose indemnity plans. (They would have to pay more in an indemnity plan than in a PPO or an HMO.)
  • Learning Outcome: 9.3 Discuss provider payment under preferred provider organizations, health maintenance organizations, point-of-service plans, and indemnity plans. Pages: 333-337 Teaching Notes:   Have your students explain the concept of subcapitation, in their own words.
  • Learning Outcome: 9.4 Compare and contrast health reimbursement accounts, health savings accounts, and flexible spending accounts. Pages: 337-341 Teaching Notes:   Have your students explain how CDHPs empower consumers, in their own words.
  • Learning Outcome: 9.4 Compare and contrast health reimbursement accounts, health savings accounts, and flexible spending accounts. Pages: 337-341 Teaching Notes:   Quiz your students on the three different types of CDHP funding options. (See the three options on this slide.)
  • Learning Outcome: 9.5 List and discuss the major private payers Pages: 341-346 Teaching Notes:   Go over some of the key features of the major national payers with your students. (Refer to page 342.)
  • Learning Outcome: 9.5 List and discuss the major private payers. Pages: 341-346 Teaching Notes:   Ask your students to describe the breakdown of plan subscribers, by health plan type, in the BCBS program. (About 66% join PPOs; 13% are in indemnity plans; 16% are in HMOs; and 5% are in point-of-service plans.)
  • Learning Outcome: 9.5 List and discuss the major private payers. Pages: 341-346 Teaching Notes:   Have your students explain the difference between a host plan and a home plan, as defined under the BlueCard program. (See the slide above and page 345 for more information.)
  • Learning Outcome: 9.6 List the five main parts of participation contracts and describe their purpose. Pages: 346-350 Teaching Notes:   Examine the five main parts of participation contracts with your students. ((1) Introductory section; (2) contract purpose and covered medical services; (3) physician’s responsibilities; (4) managed care plan obligations; (5) compensation and billing guidelines.)
  • Learning Outcome: 9.6 List the five main parts of participation contracts and describe their purpose. Pages: 346-350 Teaching Notes:   Examine the five main parts of participation contracts with your students. ((1) Introductory section; (2) contract purpose and covered medical services; (3) physician’s responsibilities; (4) managed care plan obligations; (5) compensation and billing guidelines.)
  • Learning Outcome: 9.7 Describe the information needed to collect copayments and bill for surgical procedures under contracted plans. Pages: 350-355 Teaching Notes:   Review the example under the “Compiling Billing Data” heading on page 351 with your students.
  • Learning Outcome: 9.7 Describe the information needed to collect copayments and bill for surgical procedures under contracted plans. Pages: 350-355 Teaching Notes:   Ask your students to explain the reason(s) why they think most managed care plans distinguish between emergency and elective surgery.
  • Learning Outcome: 9.8 Discuss the use of plan summary grids. Pages: 355-358 Teaching Notes:   Review the plan summary grid in Figure 9.12 with your students.
  • Learning Outcome: 9.9 Describe the steps in the medical billing process that ensure correct preparation of private payer claims. Pages: 358-365 Teaching Notes:   Quiz your students on the seven steps of the medical billing cycle, and the details of those steps.
  • Learning Outcome: 9.9 Describe the steps in the medical billing process that ensure correct preparation of private payer claims. Pages: 358-365 Teaching Notes:   Quiz your students on the seven steps of the medical billing cycle, and the details of those steps.
  • Learning Outcome: 9.9 Describe the steps in the medical billing process that ensure correct preparation of private payer claims. Pages: 358-365 Teaching Notes:   Quiz your students on the seven steps of the medical billing cycle, and the details of those steps.
  • Learning Outcome: 9.10 Discuss the key points in managing billing for capitated services. Pages: 365-366 Teaching Notes:   Ask your students to name the things that a practice must pay careful attention to when it has a capitated contract. (Patient eligibility, referral requirements, encounter reports, claim write-offs, and billing procedures.)

Survey of Medical Insurance pp ch09 Survey of Medical Insurance pp ch09 Presentation Transcript

  • 9 Private Payers/Blue Cross and Blue Shield
  • Learning Outcomes
    • When you finish this chapter, you will be able to:
    • 9.1 Compare employer-sponsored and self-funded health plans.
    • 9.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage.
    • 9.3 Discuss provider payment under preferred provider organizations, health maintenance organizations, point-of-service plans, and indemnity plans.
    • 9.4 Compare and contrast health reimbursement accounts, health savings accounts, and flexible savings (spending) accounts.
    9-2
  • Learning Outcomes (Continued)
    • When you finish this chapter, you will be able to:
    • 9.5 List and discuss the major private payers.
    • 9.6 List the five main parts of participation contracts and describe their purpose.
    • 9.7 Describe the information needed to collect copayments and bill for surgical procedures under contracted plans.
    • 9.8 Discuss the use of plan summary grids.
    • 9.9 Describe the steps in the medical billing cycle that ensure correct preparation of private payer claims.
    • 9.10 Discuss the key points in managing billing for capitated services.
    9-3
  • Key Terms
    • administrative services only (ASO)
    • BlueCard
    • Blue Cross and Blue Shield Association (BCBS)
    • carve out
    • Consolidated Omnibus Budget Reconciliation Act (COBRA)
    • credentialing
    • creditable coverage
    9-4
    • discounted fee-for-service
    • elective surgery
    • Employee Retirement Income Security Act (ERISA) of 1974
    • episode of care (EOC) option
    • family deductible
    • Federal Employees Health Benefits (FEHB) program
  • Key Terms (Continued)
    • Flexible Blue
    • flexible savings (spending) account (FSA)
    • formulary
    • group health plan (GHP)
    • health reimbursement account (HRA)
    • health savings account (HSA)
    • high-deductible health plan (HDHP)
    9-5
    • home plan
    • host plan
    • independent (or individual) practice association (IPA)
    • individual deductible
    • individual health plan (IHP)
    • late enrollee
    • maximum benefit limit
    • medical home model
    • monthly enrollment list
  • Key Terms (Continued)
    • open enrollment period
    • parity
    • pay-for-performance (P4P)
    • plan summary grid
    • precertification
    • repricer
    • rider
    • Section 125 cafeteria plan
    • silent PPOs
    • stop-loss provision
    9-6
    • subcapitation
    • Summary Plan Description (SPD)
    • third-party claims administrator (TPAs)
    • tiered network
    • utilization review
    • utilization review organization (URO)
    • waiting period
  • 9.1 Private Insurance
    • People not covered by entitlement programs are usually covered by private insurance
    • Employer-sponsored medical insurance
      • Group health plan (GHP)— plan of an employer or employee organization to provide health care to employees, former employees, or their families
      • Rider— document modifying an insurance contract
      • Carve out— part of a standard health plan changed under an employer-sponsored plan
      • Open enrollment period— time when a policyholder selects from offered benefits
    9-7
  • 9.1 Private Insurance (Continued)
    • Federal Employees Health Benefits (FEHBP) Program— covers employees of the federal program
    • Self-funded health plans
      • Employee Retirement Income Security Act of 1974 (ERISA)— law providing incentives and protection for companies with employee health and pension plans
      • Summary Plan Description (SPD)— required document for self-funded plans stating beneficiaries’ benefits and legal rights
    9-8
  • 9.1 Private Insurance (Continued)
    • Self-funded health plans (continued)
      • Third-party claims administrator (TPAs)— business associates of health plans
      • Administrative services only (ASO)— contract where a third-party administrator or insurer provides administrative services to an employer for a fixed fee per employee
    • Individual health plan (IHP)— medical insurance plan purchased by an individual
    9-9
  • 9.2 Features of Group Health Plans
    • Section 125 cafeteria plan— employers’ health plans structured to permit funding of premiums with pretax payroll deductions
    • Eligibility for benefits:
      • GHP specifies the rules for eligibility and the process of enrolling and disenrolling members
      • Waiting period— amount of time that must pass before an employee/dependent may enroll in a health plan
      • Late enrollee— category of enrollment that may have different eligibility requirements
    9-10
  • 9.2 Features of Group Health Plans (Continued)
    • Eligibility for benefits (continued):
      • Individual deductible— fixed amount that must be met periodically by each individual of an insured/dependent group
      • Family deductible— fixed, periodic amount that must be met by the combined payments of an insured/dependent group before benefits begin
      • Maximum benefit limit— amount an insurer agrees to pay for lifetime covered expenses
      • Tiered network— network system that reimburses more for quality, cost-effective providers
    9-11
  • 9.2 Features of Group Health Plans (Continued)
    • Portability and required coverage:
      • Consolidated Omnibus Budget Reconciliation Act (COBRA)— law requiring employers with over twenty employees to allow terminated employees to pay for coverage for eighteen months
      • Creditable coverage— history of coverage for calculation of COBRA benefits
      • Parity— equality with medical/surgical benefits
    9-12
  • 9.3 Types of Private Payers
    • Under preferred provider organizations (PPOs), providers are paid under a discounted fee-for-service structure
      • Discounted fee-for-service— payment schedule for services based on a reduced percentage of usual charges
    • In health maintenance organizations (HMOs) and point-of-service (POS) plans, payment may be a salary or capitated rate
    • Indemnity plans basically pay from the physician’s fee schedule
    9-13
  • 9.3 Types of Private Payers (Continued)
    • Subcapitation— arrangement where a capitated provider prepays an ancillary provider
    • Episode-of-care (EOC) option— flat payment by a health plan to a provider for a defined set of services
    • Independent practice association (IPA)— HMO in which physicians are self-employed and provide services to members and nonmembers
    • Medical home model —plan that seeks to improve patient care by rewarding primary care physicians for coordinating patients’ treatments
    9-14
  • 9.4 Consumer-Driven Health Plans
    • CDHPs combine two components:
      • A high-deductible health plan (HDHP) —health plan that combines high-deductible insurance and a funding option to pay for patients’ out-of-pocket expenses up to the deductible
      • One or more tax-preferred savings accounts that the patient directs
    9-15
  • 9.4 Consumer-Driven Health Plans (Continued)
    • Three types of CDHP funding options may be combined with HDHPs:
      • Health reimbursement account (HRA)— consumer-driven health plan funding option where an employer sets aside an annual amount for health care costs
      • Health savings account (HSA)— consumer-driven health plan funding option under which funds are set aside to pay for certain health care costs
      • Flexible savings account (FSA)— consumer-driven health plan funding option that has employer and employee contributions
    9-16
  • 9.5 Major Private Payers and the Blue Cross and Blue Shield Association
    • The major national payers:
      • WellPoint, Inc.
      • UnitedHealth Group
      • Aetna
      • CIGNA Health Care
      • Kaiser Permanente
      • Health Net
      • Humana, Inc.
      • Coventry
    • Credentialing— periodic verification that a provider or facility meets professional standards
    9-17
  • 9.5 Major Private Payers and the Blue Cross and Blue Shield Association (Cont.)
    • The Blue Cross and Blue Shield Association (BCBS)— national organization of independent companies founded in 1930 to provide low-cost medical insurance
      • Pay-for-performance (P4P)— health plan financial incentives program based on provider performance
      • BlueCard— program that provides benefits for subscribers who are away from their local areas
    9-18
  • 9.5 Major Private Payers and the Blue Cross and Blue Shield Association (Cont.)
    • The Blue Cross and Blue Shield Association (BCBS) (continued)
      • Host plan— participating provider’s local Blue Cross and Blue Shield plan
      • Home plan— Blue Cross and Blue Shield plan in the subscriber’s community
      • Flexible Blue— Blue Cross and Blue Shield consumer-driven health plan
    9-19
  • 9.6 Participation Contracts
    • Participation contracts have five main parts:
      • The introductory section provides the names of the parties to the agreement, contract definitions, and the payer
      • The contract purpose and covered medical services section lists the type and purpose of the plan and the medical services it covers for its enrollees
      • The third section covers the physician’s responsibilities as a participating provider
      • The fourth section covers the plan’s responsibilities toward the participating provider
    9-20
  • 9.6 Participation Contracts (Continued)
    • Participation contracts have five main parts (continued):
      • The fifth section lists the compensation and billing guidelines, such as fees, billing rules, filing deadlines, patients’ financial responsibilities, and coordination of benefits
    • Utilization review— payer’s process for determining medical necessity
    • Stop-loss provision— protection against large losses or severely adverse claims experience
    9-21
  • 9.7 Interpreting Compensation and Billing Guidelines
    • Under participation contracts, most plans require copayments to be subtracted from the usual fees that are billed to the plans
    • Billing for elective surgery requires precertification from the plan
      • Precertification— preauthorization for hospital admission or outpatient procedures
    • Providers must notify plans about emergency surgery within the specified timeline after the procedure
    9-22
  • 9.7 Interpreting Compensation and Billing Guidelines (Continued)
    • Silent PPOs— MCO that purchases a list of participating providers and pays their enrollees’ claims according to the contract’s fee schedule despite the lack of a contract
    • Elective surgery— nonemergency surgical procedure
    • Utilization review organization (URO)— organization hired by a payer to evaluate medical necessity
    9-23
  • 9.8 Private Payer Billing Management: Plan Summary Grids
    • Plan summary grids— quick-reference tables for health plans
      • Summarize key items from the contract
      • List key information about each contracted plan and provide a shortcut reference for the billing and reimbursement process
      • Include information about collecting payments at the time of service and completing claims
    9-24
  • 9.9 Medical Billing Cycle
    • The steps of the medical billing cycle:
      • Step 1 – Preregister patients: Guidelines apply to the preregistration process for private health plan patients, when basic demographic and insurance information are collected
      • Step 2 – Establish financial responsibility for visit: Financial responsibility for the visit is established by verifying insurance eligibility and coverage with the payer for the plan, coordinating benefits, and meeting preauthorization requirements
      • Step 3 – Check in patients: Copayments are collected before the encounter
    9-25
  • 9.9 Medical Billing Cycle (Continued)
    • Steps of the medical billing cycle (continued):
      • Step 4 – Check out patients: Payments after an encounter, such as a deductible, charges for noncovered services, and balances due, are collected
      • Step 5 – Review coding compliance: Coding is checked, verifying the use of correct codes as of the date of service that show medical necessity
      • Step 6 – Check billing compliance: Billing compliance with the plan’s rules is checked
      • Step 7 – Prepare and transmit claims: Claims are completed, checked, and transmitted in accordance with the payer’s billing and claims guidelines
    9-26
  • 9.9 Medical Billing Cycle (Continued)
    • Repricer —vendor that processes a payer’s out-of-network claims
    9-27
  • 9.10 Capitation Management
    • Under capitated contracts, medical insurance specialists verify patient eligibility with the plan because enrollment data are not always up-to-date
    • Encounter information, whether it contains complete coding or just diagnostic coding, must accurately reflect the necessity for the provider’s services
    • Monthly enrollment list— document of eligible members of a capitated plan for a monthly period
    9-28