Issues and Trends in HBI Ch 8
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Issues and Trends in HBI Ch 8

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  • Teaching Notes: <br />  Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material. <br />
  • . <br />
  • Learning Outcome: 8.1 Compare employer-sponsored and self-funded health plans. <br /> Teaching Notes: <br />   <br /> People who are not covered under government sponsored health insurance are often covered by private insurance. <br /> Many employers offer their employees the opportunity to be covered under an employer-sponsored health plan. <br /> This is an important benefit to employees and gives employers federal income tax advantages. <br /> Riders may also be offered for complementary medical services such as chiropractic services, acupuncture, diabetic counseling, and massage therapy. <br /> The employer may also “carve out” certain benefits to reduce the cost to the employer. <br />
  • Learning Outcome: 8.1 Compare employer-sponsored and self-funded health plans. <br /> Teaching Notes: <br />  The federal government’s Office of Personnel Management receives and deposits premiums and remits payments to carriers, while the carrier is responsible for issuing identification cards, adjudicating claims, and maintaining records <br /> Ask students to provide three examples of changes that came about as a result of ERISA and explain how each improved healthcare. <br />
  • Learning Outcome: 8.1 Compare employer-sponsored and self-funded health plans. <br /> Teaching Notes: <br /> ERISA plans may hire TPAs or ASOs to handle paperwork. Employers may set up their own provider network or lease the use of an MCO’s network. <br /> Note that IHPs usually offer less in terms of coverage and cost more than do group or ERISA plans. <br />   <br />
  • Learning Outcome: 8.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage. <br /> Teaching Notes: <br />  A waiting period is the time between the date of hire and the date the insurance becomes effective. <br /> For example, an employee may have to wait 90 days after starting a new job for insurance coverage to begin. <br /> Different rules may apply for an enrollee that enrolls at a time other than the open enrollment period. <br />
  • Learning Outcome: 8.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage. <br /> Teaching Notes: <br />   <br /> Ask students to explain the difference between an individual deductible and family deductible. <br /> Examine and discuss with students the ethics of a maximum benefit limit from the patients’ and payers’ points of view. <br />
  • Learning Outcome: 8.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage. <br /> Teaching Notes: <br />   <br /> COBRA only applies to companies with 20 or more employees. <br /> Employees may pay for insurance through COBRA for 18 months after termination. <br /> Discuss with students how creditable coverage and preexisting conditions affect patients’ benefits. <br />
  • Learning Outcome: 8.3 Discuss provider payment under preferred provider organizations, health maintenance organizations, point-of-service plans, and indemnity plans. <br /> Teaching Notes: <br /> A small number of large insurance companies dominate the national market and offer all types of health plans to employers. <br /> Local or regional payers are often affiliated with one of these large companies. <br /> Related areas may include coverage such as dental, vision, and life insurance. <br />
  • Learning Outcome: 8.3 Discuss provider payment under preferred provider organizations, health maintenance organizations, point-of-service plans, and indemnity plans. <br /> Teaching Notes: <br />  Discuss why medical insurance specialists benefit from understanding the various business structures under which private payers operate. <br />
  • Learning Outcome: 8.4 Compare and contrast health reimbursement accounts, health savings accounts, and flexible spending accounts. <br /> Teaching Notes: <br />  CDHPs are increasing in popularity. Because of the high deductibles CDHPs require, medical insurance specialists need to understand their components and structure. <br />
  • Learning Outcome: 8.4 Compare and contrast health reimbursement accounts, health savings accounts, and flexible spending accounts. <br /> Teaching Notes: <br />   One of three funding options may be combined with a high-deductible health plan to form a consumer driven health plan. <br /> An HRA is a medical reimbursement plan set up and funded by the employer. <br /> Employees submit claims to the HRA to be reimbursed for out-of-pocket medical expenses. <br /> An HSA is a savings account created by an individual. It is the most popular type of account. <br /> The IRS sets the amount that can be saved each year. <br /> An FSA augments employees’ other health insurance coverage. <br /> Pretax dollars from the employee’s salary are deposited into the FSA. <br /> The funds can be used to pay for certain medical and dependent care expenses <br />
  • Learning Outcome: 8.5 List and discuss the major private payers. <br /> Teaching Notes: <br />   <br /> Go over some of the key features of the major national payers with students. <br /> Examine and discuss with students how credentialing benefits providers and patients. <br /> Optional Assignment: <br /> Ask students to visit at least three major national insurance plans’ websites and write a paragraph that discusses the differences between copayments and ER benefits. <br />
  • Learning Outcome: 8.5 List and discuss the major private payers. <br /> Teaching Notes: <br />  BlueCross BlueShield Association is often referred to as the “Blues.” <br /> BCBS also have freestanding dental, vision, mental health, prescription, and hearing plans. <br /> A subscriber’s identification card is used to determine the type of plan under which a member is covered. <br /> BCBS offers indemnity plans and many types of managed care plans. <br />
  • Learning Outcome: 8.5 List and discuss the major private payers. <br /> Teaching Notes: <br />   <br /> Examine and discuss with students the how the host plan, home plan, and Flexible Blue plan can improve the quality of healthcare coverage. <br /> Ask students to describe the advantages or disadvantages of each plan on this slide. <br />
  • Learning Outcome: 8.6 List the five main parts of participation contracts and describe their purpose. <br /> Teaching Notes: <br />   <br /> Examine and discuss with students the five main parts of participation contracts (introductory section, contract purpose and covered medical services, physician’s responsibilities, managed care plan obligations, and compensation and billing guidelines). <br />
  • Learning Outcome: 8.6 List the five main parts of participation contracts and describe their purpose. <br /> Teaching Notes: <br />   <br /> Ask students to describe how stop-loss and utilization review protects third-party payers and patients. <br />
  • Learning Outcome: 8.7 Describe the information needed to collect copayments and bill for surgical procedures under contracted plans. <br /> Teaching Notes: <br />   <br /> Examine and discuss the “Compiling Billing Data” subsection on page 298 with students. <br /> Ask students to describe how precertification protects third-party payers and patients. <br />
  • Learning Outcome: 8.7 Describe the information needed to collect copayments and bill for surgical procedures under contracted plans. <br /> Teaching Notes: <br />   <br /> Examine and discuss elective surgery and explain how it differs from emergency surgical procedures. <br />
  • Learning Outcome: 8.8 Discuss the use of plan summary grids. <br /> Teaching Notes: <br />   <br /> Examine and discuss major points on the plan summary grid in Figure 8.12 with students. <br />
  • Learning Outcome: 8.9 Describe the steps in the medical billing process that ensure correct preparation of private payer claims. <br /> Teaching Notes: <br />   <br /> Examine and discuss each of the seven steps of the medical billing cycle with students. <br /> Ask students to provide at least three strategies to ensure accuracy in the medical billing cycle. <br />
  • Learning Outcome: 8.9 Describe the steps in the medical billing process that ensure correct preparation of private payer claims. <br /> Teaching Notes: <br />   <br /> Ask students to write a paragraph that discusses common errors that can occur during the various steps when creating medical claims. <br />
  • Learning Outcome: 8.9 Describe the steps in the medical billing process that ensure correct preparation of private payer claims. <br /> Teaching Notes: <br />   <br /> Explain how repricers work and discuss why silent PPOs represent lost revenue for the physician. <br />
  • Learning Outcome: 8.10 Discuss the key points in managing billing for capitated services. <br /> Teaching Notes: <br />   <br /> Examine and discuss how patient eligibility, referral requirements, encounter reports, and claim write-offs affect capitated billing procedures. <br /> Ask students to discuss why monthly enrollment lists must be verified each time a patient visits. <br />

Issues and Trends in HBI Ch 8 Issues and Trends in HBI Ch 8 Presentation Transcript

  • CHAPTER 8 Private Payers / BlueCross BlueShield © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
  • Learning Outcomes When you finish this chapter, you will be able to: 8.1 Compare employer-sponsored and self-funded health plans. 8.2 Describe the major features of group health plans regarding eligibility, portability, and required coverage. 8.3 Discuss provider payment under the various private payer plans. 8.4 Contrast health reimbursement accounts, health savings accounts, and flexible savings (spending) accounts. 8-2
  • Learning Outcomes (continued) 8-3 When you finish this chapter, you will be able to: 8.5 Discuss the major private payers. 8.6 Analyze the purpose of the five main parts of participation contracts. 8.7 Describe the information needed to collect copayments and bill for surgical procedures under contracted plans. 8.8 Discuss the use of plan summary grids. 8.9 Prepare accurate private payer claims. 8.10 Explain how to manage billing for capitated services.
  • 8-4 Key Terms • administrative services only (ASO) • BlueCard • BlueCross BlueShield Association (BCBS) • carve out • Consolidated Omnibus Budget Reconciliation Act (COBRA) • credentialing • creditable coverage • discounted fee-forservice • elective surgery • Employee Retirement Income Security Act (ERISA) of 1974 • episode-of-care (EOC) option • FAIR (Fair and Independent Research) Health • family deductible
  • 8-5 Key Terms (continued) • Federal Employees Health Benefits (FEHB) program • 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) • home plan • host plan • independent (or individual) practice association (IPA) • individual deductible • individual health plan (IHP) • late enrollee • maximum benefit limit • medical home model
  • 8-6 Key Terms (continued) • • • • • • • • • • monthly enrollment list open enrollment period parity pay-for-performance (P4P) plan summary grid precertification repricer rider Section 125 cafeteria plan silent PPOs • stop-loss provision • subcapitation • Summary Plan Description (SPD) • third-party claims administrators (TPAs) • tiered network • utilization review • utilization review organization (URO) • waiting period
  • 8.1 Private Insurance 8-7 • 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 healthcare 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
  • 8.1 Private Insurance (continued) 8-8 • Federal Employees Health Benefits (FEHBP) Program—covers employees of the federal program • Self-funded health plans – Employee Retirement Income Security Act of 1874 (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
  • 8.1 Private Insurance (continued) • Self-funded health plans (continued) – Third-party claims administrators (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 8-9
  • 8.2 Features of Group Health Plans 8-10 • 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
  • 8.2 Features of Group Health Plans (continued) 8-11 • 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
  • 8.2 Features of Group Health Plans (continued) 8-12 • 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 for coverage of other treatments or services with medical/surgical benefits
  • 8.3 Types of Private Payers • Under preferred provider organizations (PPOs), providers are paid under a discounted fee-forservice 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 8-13
  • 8.3 Types of Private Payers (continued) 8-14 • 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
  • 8.4 Consumer-Driven Health Plans 8-15 • CDHPs combine two components: 1. A high-deductible health plan (HDHP)—health plan that combines high-deductible insurance and a funding option to pay patients’ out-of-pocket expenses up to the deductible 2. One or more tax-preferred savings accounts that the patient directs
  • 8.4 Consumer-Driven Health Plans (continued) 8-16 • Three types of CDHP funding options may be combined with HDHPs: 1. Health reimbursement account (HRA)— consumer-driven health plan funding option where an employer sets aside an annual amount for healthcare costs 2. Health savings account (HSA)—consumer-driven health plan funding option under which funds are set aside to pay for certain healthcare costs 3. Flexible savings account (FSA)—consumer-driven health plan funding option that has employer and employee contributions
  • 8.5 Major Private Payers and the BlueCross 8-17 BlueShield 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
  • 8.5 Major Private Payers and the BlueCross 8-18 BlueShield Association (continued) • The BlueCross BlueShield Association (BCBS)—national organization of independent companies founded in the 1930s to provide lowcost 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
  • 8.5 Major Private Payers and the BlueCross BlueShield Association (continued) • The BlueCross BlueShield Association (BCBS) (continued) – Host plan—participating provider’s local BCBS plan – Home plan—BCBS plan in the subscriber’s community – Flexible Blue—BCBS consumer-driven health plan 8-19
  • 8.6 Participation Contracts 8-20 • Participation contracts have five main parts: 1. The introductory section provides names of parties to the agreement, contract definitions, and the payer 2. The contract purpose and covered medical services section lists the type and purpose of the plan and medical services it covers for enrollees 3. The third section covers the physician’s responsibilities as a participating provider 4. The fourth section covers the plan’s responsibilities toward the participating provider 5. The fifth section lists compensation and billing guidelines, such as fees, billing rules, filing deadlines, patients’ financial responsibilities, and coordination of benefits
  • 8.6 Participation Contracts (continued) • Utilization review—payer’s process for determining medical necessity • Stop-loss provision—protection against large losses or severely adverse claims experience 8-21
  • 8.7 Interpreting Compensation and Billing Guidelines 8-22 • 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
  • 8.7 Interpreting Compensation and Billing Guidelines (continued) • Silent PPO—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 8-23
  • 8.8 Private Payer Billing Management: Plan Summary Grids • Plan summary grid—quick-reference table for health plan – Summarizes key items from the contract – Lists key information about each contracted plan and provides a shortcut reference for the billing and reimbursement process – Includes information about collecting payments at the time of service and completing claims 8-24
  • 8.9 Preparing Correct Claims 8-25 • 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 is 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
  • 8.9 Medical Billing Cycle (continued) 8-26 • Steps of the medical billing cycle (continued): – Step 4 – Review coding compliance: Coding is checked, verifying the use of correct codes as of the date of service that show medical necessity – Step 5 – Check billing compliance: Billing compliance with the plan’s rules is checked – Step 6 – Check out patients: Payments after an encounter, such as a deductible, charges for noncovered services, and balances due, are collected – Step 7 – Prepare and transmit claims: Claims are completed, checked, and transmitted in accordance with the payer’s billing and claims guidelines
  • 8.9 Medical Billing Cycle (continued) • Repricer—vendor that processes a payer’s outof-network claims 8-27
  • 8.10 Capitation Management 8-28 • Under capitated contracts, medical insurance specialists verify patient eligibility with the plan because enrollment data are not always up-todate • 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
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