Interactive 3A

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School

Ultimate Medical Academy, Tampa *

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ME2550

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Mechanical Engineering

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Dec 6, 2023

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docx

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Uploaded by mommacinco2023

ME2550 Healthcare Settings Week 3 Interactive A Commercial Insurance Health Insurance What is a contract? Legal document between two or more parties involved Who is the policy holder? The insured member or subscriber who pays premiums to obtain Choice of health insurance Individual: contract/policy(personal insurance) Any insurance plan issued directly to an individual with a direct contract with health plan Group: contract/policy Any insurance plan offered to a group of employees through a participating employer plan Individual Health Insurance Individual health insurance policies are regulated by individual states, Key Terms

Fee-for-service (or indemnity) insurance Refers to traditional health insurance that covers a portion of services, such as inpatient hospitalizations or physician office visits, with the patient paying the remaining costs not covered by insurance. Fee-for-Service reimbursement increases payment if health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services, like brand name prescriptions versus generic prescriptions. Managed Care Involves a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), requires policyholders to visit specific doctors and health care facilities and it combines health care delivery with the financing of services provided. High-risk Pools Which are sometimes referred to as “last resort” health insurance plans, are for individuals who cannot obtain coverage due to a serious medical condition. Certain eligibility requirements apply, such as refusal by at least one or two insurance companies. However, under the Affordable Care Act, health insurance companies cannot refuse to cover someone or charge someone more money just because that person has a “pre- existing condition”

Association Health Insurance Typically offered to members of a professional association and marketed to small business owners as a way to provide coverage to employees. However, these plans are not subject to the same regulations as group health insurance plans and, therefore, are riskier to consider Group Health Insurance Available through employers and other organizations Covers all employees, regardless of health status Offers COBRA continuation for 18-36 months Has employer-limited plan options (ex. Drug plan that covers a certain list of medications called a formulary) Primary Vs. Secondary Insurance Plans Primary Insurance Subscribers can have primary insurance as the only insurance, through a private or group health plan Secondary Insurance Are covered on another plan in addition to primary plan The patients’ employer insurance is always the primary if there are two group insurance coverages involved Individual Health Insurance

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Commercial claims have specific coverage guidelines for reimbursement per plan policy Claim completion instructions are based on coverage criteria Child with multiple plan coverage When the patient is a child and is covered by two or more plans, the primary policyholder is the parent whose birthday occurs first in the year. It’s important to remember that the birthday rule for a child covered by two or more plans states that the policyholder whose birth month and day occur earlier in the calendar year holds the primary policy when each parent subscribes. EGHP and Medicare The patient that is covered by an employer group health plan (EGHP), and the patient is also a Medicare beneficiary. In this case, EGHP is the primary insurance. Health Insurance Claim form (CMS1500) Guidelines CMS-1500 claim form: standard health care claim form for outpatient professional services Claims are completed and submitted as required by payer rules Each insurance carrier has their own timely filing guidelines Failure to comply with rules claim may not be reimbursed

Commercial Group Health Plan Coverage Claim Instructions CMS1500 Claim has 33 blocks (form locators) for information Blocks 1-8: Patient Information Blocks 4-7-11 Insured Information Blocks 9-10 Other Insurance Information Blocks 12-13 Insured Signatures Blocks 14+24 Dates of Service Blocks 21 ICD Codes Blocks 24D CPT Codes Blocks 24F+28 Charges Block 25 Fed Tax ID # Block 27 Accept form of Payment Block 29+30 Amount and Balance Block 31 Physician Signature on file Block 33 Billing Provider Information

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