Learning Objectives Flashcards
1 - Health insurance claims processing and parties involved
Coders, health insurance or reimbursement specialists, claims examiners, and health information technicians
1 - career opportunities available for health insurance specialists
Insurance companies, government agencies, legal offices, private insurance offices, medical societies, health care organizations, training schools, writers of healthcare textbooks, consumer claims assistance professionals, and private billing practices dedicated to help patients with disabilities.
1 - education and training requirements for a health insurance specialist
Opportunities will be best for one with a college degree. Coursework in general education and health insurance specialist education.
1 - job responsibilities of health insurance specialist
Review patient record documentation to accurately code all diagnoses, procedures and services using ICD-10-CM for diagnoses and CPT and HCPCS Level II for procedures and services ICD-10-PCS. codes are reported for inpatient hospital procedures only). Research and apply knowledge of all insurance rules and regulations for major insurance programs in the local or regional area. Accurately post charges, payments and adjustments to patient accounts and accounts receivable records. Prepare or review claims generated by the practice to ensure that all required data are accurately reported and to ensure prompt reimbursement for services provided. Review all insurance payments and remittance advice documents to ensure proper processing and payment of each claim. Patient receives the EOB and the provider receives the remittance advice. Correct all data errors and resubmit all unprocessed or returned claims. Research and prepare appeals for all underpaid, unjustly recoded or denied claims. Rebill all claims not paid within 30-45 days, depending on individual practice policy. Inform health care providers and staff of changes in fraud and abuse laws. Assist with timely updating of the practices internal documents, patient registration forms, and billing forms. Maintain an internal audit system to ensure that required pretreatment authorizations are received and entered into the billing and treatment records. Perform audits to compare provider documentation with assigned codes. Explain insurance benefits, policy requirements, and filing rules to patients. Maintain confidentiality of patient information.
1 - differentiate between types of insurance purchased by contractors and employers
Independent contractors should carry professional liability insurance or errors and omissions insurance. Bonding insurance, business liability insurance (medical malpractice insurance), property insurance, and workers’ compensation.
1 - explain the role of workplace professionalism for a health insurance specialist
Attitude, self-esteem, and etiquette. Appearance.
1 - telephone skills for healthcare settting
Empathy, Be professional, ethical, reliable, self-motivated, adaptable, detail-oriented, communicate, team player
1 - coding and reimbursement professional associations and credentials offered
AAPC, AAMA, AHIMA
2 - Basic health insurance and managed care concepts
A prepaid health plan establishes a capitation contract between a managed health case plan and network providers who provide specified medical services for a predetermined amount paid on a monthly or yearly basis. Managed care are prepaid health plants that combine health care delivery with the financing services provides. Certain restrictions apply in a managed care plan. Managed care is organized to manage cost, quality and utilization.
2 - major developments in US healthcare
2002… QIOs to perform utilization and quality control review of health care furnished, or to be furnished to Medicare beneficiaries.
2008… MIPPA to help lower costs of Medicare premiums and deductibles to benefit eligible Medicare beneficiaries, and the MHPAEA prevents group health plans and health insurance issues that provide mental health or substance use disorder benefits from imposing less-favorable benefit limitations on those benefits than on medical/surgical benefits.
2022… NSA implemented to mandate new billing protections for consumers to ban surprise bills for emergency services received in or out of network and without prior approval; out of network cost sharing for all emergency and some nonemergency services; and out of network charges and balance bills for supplemental care by out of network providers who work at an in network facility; consumers cannot be charged more than in network cost-sharing for these services.
2010… PPACA (aka ACA) provides better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, and extend the life of the Medicare Trust fund by at least 12 years. Goal was to provide Americans with quality affordable health care, improve the role of public programs, improve the quality and efficiency of health care, and improve public health.
The HCERA amended the PPACA to increase tax credits, eliminate special deals to senators, closed the Medicare “donut hole”
2 - effects of managed care in healthcare
Separate bookkeeping systems for each capitated plan to ensure financial viability of the contract; tracking system for pre-authorization of specialty care and documented request for receipt of the specialist’s treatment plan or consultation report; fee authorization and/or pre-certification for all hospitalizations and continue to certification if the patients condition requires extension of the number of authorized days; up-to-date list for referrals to participating healthcare providers, hospitals, and diagnostic test facilities used by the practice; up-to-date list of special administrative procedures required by each managed care plan contract; up-to-date list of patient, copayments, and fees for each managed care plan contract; special patient interviews to ensure pre-authorization to explain out of network requirements if the patient is self referring; additional paperwork for specialist to complete in the filing of treatment and discharge plans; some case managers employed by the MCO monitor services provided to enroll release and to be notified if the patient fails to keep a pre-authorized appointment; the attachment of pre-authorization documentation to health insurance claim submitted to some MCOs.
2 - characteristics of managed care and healthcare
PCP
Quality assurance, and performance measurement
Utilization management
Case management
Second surgical opinions
Second and third opinions
Prescription management
2 - describe consumer-directed health plans
Higher employee contributions for health care… they include flexible spending accounts, health care reimbursement accounts, HRA, HSA
2 - healthcare documentation methods
Patient record (aka medical record) which is a communication tool for continuity of care of the patient.
2 - impact of electronic health record on healthcare
Provides access to complete patient information plus streamlines the entire process.
3 - three common methods of healthcare reimbursement
Fee for service - providers are paid by government programs and insurance companies for services provided (using a fee schedule)
bundled payment - a single payment for all services associated with an episode of care
capitation - fixed prepayment for the number of patients enrolled in plan.
3 - why was managed care created
To control the rising costs of healthcare
And has introduced changes to the US healthcare delivery system that include cost-effective awareness, access to care, and quality of care.
3 - medical providers associated with managed care
Called network providers and managed care plan enrollees must select a pcp who is the gatekeeper for providing services at lowest cost.
3 - four managed care models
HMO
PPO
POS
EPO
3 - goals of consumer-directed health plans and coverage choices they offer
Designed to put more responsibility on the employee for their healthcare spending. These plans tend to attract younger individuals with healthy lifestyles and a desire to control more they’re spending. These plans cost less than traditional health insurance and have fewer limitations associated with manage care plans in addition off they often include a high deductible health plan that is paired with the health savings account.
3 - characteristics of revenue management
Ensures health care facility and provider financial in viability by increasing revenue, improving, cash flow, and enhancing the patient’s experience. In a physician practice, it is also called accounts receivable management.
3 - how are new and established patients managed
New patient info is much more extensive… need to register to create financial and medical records. This includes getting insurance info and verifying. An established patient have an encounter form generated.
3 - use of an encounter form and a charge master
Both are starting points for medical coding, impatient billing of outpatient and physician, office healthcare services and procedures.
3 - processing of an insurance claim from patient appointment through claims submission
Initiated when patient contacts a health care provider office and schedules an appointment. The provider documents visit in encounter form then provider generates a CMS-1500 claim to submit to the insurance company. In hospital it’s called a UB-40. CPT and HCPCS level II codes and charges for procedures and or services, and ICD – 10 – CM codes for diagnosis treated and or managed during the encounter.
