Training Environment

Let’s Discuss Terms Related to

Healthcare

Patient Physician/Doctor
Diseases/Health Condition Treatment/Procedure

Hospitals
Departments and Setups
Medical Equipment

Medical Expenses
Health Insurance
Let’s Understand – USA Medical Billing

4
Slide *
 HealthCare Process In India
In India when a Patient is insured:

Patient visits Doctor's Office Treatment Patient pays to the doctor

Ins reimburses to PT PT claims from Ins

 HealthCare Process in U.S.
How it works in U.S.

Appointment Patient details are Sent To

Doctor Treats
Medical Billing Organization

Ins Reimburses Dr. MBO Submits The Claim To Ins

Slide *
 3Ps of RCM

Patient

Provider
Payor
 3Ps of RCM

Patient

Provider

Payor
 3Ps Of US Healthcare

Provider:
Any individual who provides medical services eg-General
physician,Surgeon,Nurses,Hospitals,
Laboratory etc..

Patient:
Any individual with a health complaint or illness is known
as a patient.

Payor/Insurance:
Coverage that is been given for any risk in the current or
future conditions.

9
 Terms-Related to Patient

New Patient:
A patient who is visiting the provider's office for the first
time or after the 3 years or 36 months.

Established Patient:
A patient who is visiting the provider's office within the
period of 3 years or 36 months.

In-Patient:
A patient who is in the hospital for more than 24 hours.

Out-Patient:
A patient who is in the hospital for less than 24 hours.
 Terms related to Patient

Assignment of Benefits :
The patients assigns the benefits by authorizing the insurance
to make the medical payments to the providers.

Release of Information :
The patients authorizes the provider to release the medical
information only for billing purpose.

Promissory Note :
A signed document containing a written promise to pay a
stated sum to a specified person or the bearer at a specified
date or on demand.
 Types of Provider

PCP/Referring Provider Attending Provider Ordering Provider

Specialist

12
 Types Of Facilities

Skilled Nursing Ambulatory Home Health

Facility Surgical center

Hospice
13
 Provider Related Terms

A primary care physician is a physician who is the first point of

contact if anything happens to an [Link] is also known as the
gatekeeper between a patient and a specialist,he is also known as a
referring physician.

Ordering physicians is defined as a physician or when appropriate a

non-physician practitioner who orders services for the [Link]
eg: X-rays,Blood test , Urine test etc..

Specialist is defined as doctors who have completed advanced

education and clinical training in a specific area of medicine or a
specific organ of a body: for eg: Dentist, Pediatrician, Gynaecologist
etc...
 Provider Related Terms

Ø A health-care institution that meets federal criteria for Medicaid

and Medicare reimbursement for nursing care including especially
the supervision of the care of every patient by a physician, the
employment full-time of at least one registered nurse, the
maintenance of records concerning the care and condition of every
patient, the availability of nursing care 24 hours a day.

ØAmbulatory surgery centers (ASC), also known as outpatient

surgery centers or same day surgery centers, are health care
facilities where surgical procedures not requiring an overnight
hospital stay are performed. Such surgery is commonly less
complicated than that requiring hospitalization.

GeBBS Presentation Name

 Provider Related Terms

Home health care is a wide range of health care services that can
be given in your home for an illness or injury. Home health care is
usually less expensive, more convenient, and just as effective as
care you get in a hospital or skilled nursing facility (SNF).

Hospice care is a type of care and philosophy of care that focuses on

the palliation of a chronically ill, terminally ill or seriously ill patient's
pain and symptoms, and attending to their emotional and spiritual
needs.
Payer Related Terminologies

• Insurance
• Coverage given for any risk in current or future
conditions.

• Health Insurance
• It’s risk coverage given for any health issues for any
current or future condition.

• Policy
• Contract or Agreement between an individual or
payor.
Payer Related Terminologies

• Subscriber
• Individual who buys the policy from the
Insurance Company.

• Dependent
• The spouse & children of the subscriber who all
are eligible to take health care benefits under the
policy.

• Beneficiary
• The person who is eligible to the benefits under
the insurance coverage. He is either the
subscriber or the dependent

Slide *
Payer Related Terminologies

• Individual Health Insurance

• Individual buys the plan and pays the premium
• Single Subscriber and 1 or more dependent

• Group Health Insurance

• Employer pays the premium
• Employer and Worker’s compensation ins.

• Premium
• Any amount paid monthly/quarterly/yearly by
the subscriber to the insurance to avail the
benefits of the policy.

Slide *
Payer Related Terminologies

• Federal Health Insurance

• Insurance run by Govt.
• Eg. Medicare, Medicaid, Tricare, Champva

• Commercial Health Insurance

• Insurance by private insurance organizations
• Eg. BCBS, Aetna, Cigna, UHC, Horizon BCBS etc.

• Employer Insurance – This insurance is a group insurance

provided by the employer to their employees.
• Employee is the Subscriber and can have 1 or more
dependents (family members).

• Worker’s Compensation - This insurance is for

work-related injury/illness.
• Employee will be the Subscriber and cannot have
dependents. Slide *
Payer Related Terminologies

Date of Service
•The date when the patient rendered
service/treatment from the provider

Enrollment Date
•The date when the subscriber enrolls with the
insurance

Effective Date
•The date when the insurance starts to cover the
healthcare expenses (aka Start Date)

Termination Date
•The date when the policy expires or terminates
( aka Expiration Date)
Slide *
General Health Insurance Terminologies

• Pre-existing condition
• The similar illness ( Disease- Diabetes, Cancer &
Asthma etc.) which the patient was having before
taking the policy.

• Waiting period
• A waiting period is a period of time (Start & End
date) which a patient must wait in order to get
covered their pre-existing diseases by the
insurance.

Slide *
General Health Insurance Terminologies
• Co Pay:
• A fixed value which is paid by the patient as an
advance payment every time he visits the providers
office (At Front office)

• Co Insurance ( Coins.):
• Percentage cost shared with the payor & subscriber
as per the plan or contract. Example - 80% : 20%

• Deductible:
• A fixed annual dollar value which is to be paid by
the subscriber to the provider before his/her
insurance company starts reimburse the health care
cost.

Slide *
General Health Insurance Terminologies
COB: Coordination of Benefit
It is the determination of benefits among the insurance
which decides the order in which Insurance plans pay
claims when an individual has more than one plans
or policies.(Classified as Primary, Secondary
& Tertiary. The deciding party is the patient).

Claim
A predefined document or template submitted
to the insurance by the providers
for Reimbursements

Scrubber Report
It is a report submitted by clearing house to the provider
for accounts on number of claims received from
the provider office, numbers of claims drop/rejected
because of incomplete or incorrect information’s
and numbers of claims sent to the Insurance office
Slide *
What 's next????
RCM
 Appointment
scheduling/
Pre-registration Eligibility
check and Benefit
Patient Collections Verification

Encounter
Credit Balance Pa
tie
nt

PA
DE R

T IE
NT
Medical Coding
Denial PROVI RCM
Management

er
R Demo/Charge
E

id
PAY

ov
Entry

Pr
Accounts
Receivable
Claims
Submission

Payment posting
Insurance Clearing House
Adjudication Rejections 27
Appointment Scheduling
 Appointment Scheduling/Pre registration
Flow Process
Accumulation of
Collection of relevant
information for
demographics and
Eligibility and Benefit
insurance information
Verification with
and appointment
Insurance
scheduling with Pre-
registration 3
Putting notes for
2 4 reminder call to be
placed to the patient one
day prior to appointment

Process
Flow

1 Eligibility &
Benefit Verification
Patient makes an
appointment with
the provider
Appointment
Scheduling/Pre-registration
 Registration Process

Are you a new

patient I'm a new
or Established patient
patient? Hope Clinic

Registration
Form

Filling up of Registration
Form Encounter
 Registration Form or Facesheet

n ow
et ’sK
L w a
Ho eet
c e Sh e
Fa s lik
k
L oo

r a t ion
e g is t
R m
F or
Eligibility Check & Benefit Verification

32
 Eligibility Check & Benefit Verification Process

Documenting the correct

Cross checking the details by calling eligibility & benefits &
Insurances and verifying Eligibility taking patient’s
and plan benefits in regards to the
service to be rendered by our
3 acknowledgment

provider
Provider’s Office

2 4 enters
information to
be sent to the
MBO

Process Flow

1
Overview of
insurance
Encounter
information
collected during
appointment Eligibility &
Benefits Verification
 Encounter

Encounter : A health care contact between the patient and the

provider who is responsible for diagnosing and treating the patient.
 Encounter Process Flow
Diagnosis concluded
and Treatment plan
is designed

3
Dr. meets the Pt Treatment rendered and
(Encounter) registration document is
Discussions & sent to MBO
probing on the

4
health condition
2

Process Flow

Patient after
filling up the 1
documents waits
to meet the Medical Coding
provider
Encounter 35
Day 2
 Appointment
scheduling/
Pre-registration Eligibility
check and Benefit
Patient Collections Verification

Encounter
Credit Balance Pa
tie
nt

PA
DE R

T IE
NT
Medical Coding
Denial PROVI RCM
Management

er
R Demo/Charge
E

id
PAY

ov
Entry

Pr
Accounts
Receivable
Claims
Submission

Payment posting
Insurance Clearing House
Adjudication Rejections 37
 Medical Transcription_Old Method of
creating Medical Record.

Voice files Converted to Text files

 EMR & EHR ( New Method )

An electronic health/medical record (EHR/EMR): An electronic medical

record (EMR) is a digital version of a paper chart that contains all of a
patient's medical history from one practice. An EMR is mostly used by
providers for diagnosis and treatment.

GeBBS Presentation Name

 Medical Coding

Diagnosis Procedure
code (Dx) Medical code (Px)
Eg. S35.2
Eg. 54264
M54.54
A98.123
Coding A6985
6587F
 Medical
Coding

Procedure Diagnosis
Modifiers
Codes Codes

41
Slide *
 Diagnosis Code – ICD 10 CM

How ICD 10 CM Codes look?

üConsists of 3-7 Characters

üFirst Digit is Alpha

üSecond and Third digits are Numeric

üFourth, Fifth, Sixth and Seventh digits can be Alpha or Numeric

üAll letters are used except for “ U”-Future use.

üDecimal placed after the First Three characters Slide *

 CPT - (Current Procedural Terminology)

ü The Current Procedural Terminology (CPT) is

020
71 developed by the American Medical Association
22950
(AMA)

ü Procedure codes are always have 5 digit characters.

ü CPT codes are mostly Numeric

ü There are three types of CPT code: Category I,

Category II, and Category III.

ü Category II codes consists 4 digits followed by the

letter F. Used for Provider Performance
Measurement

ü Category III CPT Code(s) – Emerging technology

Slide *
 Modifiers

59
RT Modifiers represents any kind Pricing Modifier
of alteration or modification done
in the treatment rendered to the lAlso Known as CPT
patient. Modifier
lShows change in price.
Modifiers are two digits- Alpha,
numeric or Alpha-numeric codes 22
77 when added to the procedure codes L1
which gives additional information. Informative Modifier

Common Modifiers used are lAlso known as HCPCS

26, TC, 76, 77, 50, 59, LT, RT etc. Modifier
lShows information about
26 procedure performed.

TC
LT 50
Slide *
 Medical Coding Flow
Coders convert medical Coded files along with
record into registration documents
alphanumeric
codes(ICD, CPT and
2 are sent for Charge Entry
in the form of a
Modifier) Superbill.

Process Flow

1
Demo/Charge
EMR uploaded on
Entry
server

Medical
Coding
45
 Charge Entry

Charge Entry: Process of entering Encounter details (diseases and treatment) in Client Software for
claim processing purpose.

a Patient Name
a DOS
a POS
a ICD
a CPT

Superbill Client Software

 Demographic Entry
Demo Entry: Process of entering New Patient’s Personal info in Client Software for
claim processing purpose.

Patient Info Facesheet

Client Software
 POS- Place of Service

Place of service: Location where services are rendered. Eg: Inpatient, outpatient,
Emergency department [Link] can be rendered at any location either in facility or out
of facility.

Office-11 Home-12 Ambulatory Delivery

Surgical Center-24 Center-25

Hospice-34 Inpatient-21 Outpatient-22 Emergency room 23

48
Slide *
 Specialties

Branch of medical science that deals with the treatment of

specific body system.

Presentation Date:
Presentation Date: 3/16/2017
3/16/2017 GeBBS Presentation Name
 Charge Capture Process Flow
Verification & selection of
location, type of service
Patient is searched in the
and date of service and charge
system with Name, DOB etc
3 is entered in the client
software

2 Final check done,

before the claim is

4 forwarded to
Insurance company

Process Flow

Charge entry team

receives the Coded
1 Billing & Claims
Information / Charge Processing
Ticket/Superbill
Charge Capture

Presentation Date: 3/16/2017 50

 Claim Submission & Transmission

Types of Claim forms

CMS 1500 UB 04

Presentation Date: 3/16/2017

 Claim Submission & Transmission

Provider sends Patient’s data

and insurance info to MBO

MBO prepares the patient

claim data for electronic
processing and transmittal to
Insurance company process clearing house
the claims and pays to the
provider

Clearing House audits/scrubs

the claims for errors before
sending/submitting it to
Presentation Date: 3/16/2017
Insurance company
 Claim Submission & Transmission Flow

Clearing house report

review

Claim 4 Submission of claims to

transmission
Insurance company
5
(Electronically)
3 (Electronically)

Process Flow
Correction of 2
claims edits

Insurance

System kicks out

1 Adjudication.

claims with invalid Claim Submission

information and
Presentation Date: 3/16/2017 Transmission 53
 Claim Lifecycle and Adjudication

Presentation Date: 3/16/2017

 Insurance Adjudication

Claims adjudication refers to the determination of the insurer's payment or financial

responsibility after the member's insurance benefits are applied to a medical
[Link] follows the standard payor guidelines.

Adjudication responses

Partially
Paid Denied No response
Paid

Insurance Send following References to inform the payment information

EOB-Explanation of benefit
ERA – Electronic Remittance Advice
Correspondence
Check / Credit Card slip / EFT details
Presentation Date: 3/16/2017
 Insurance Adjudication flow
Documented response is
sent to Provider and
Patient in the form of
Adjudication is EOB
done based on
standard payor
3
Payment is processed
guidelines: if claim
4
through check or
should be Paid,
Denied, Partially 2 electronic payment
paid or require
additional
information to be
paid

Process Flow

Payment Posting
Insurance reviews the 1
claim and adjudicate
Insurance Adjudication
Presentation Date: 3/16/2017 56
 Payment Posting

Payment Posting can be done:

Manually or Electronically

Posting Payment Received from Patient:

Called as Patient Payment Posting
*For this we need Check/Credit card/ EFT details

Posting Payment Received from Insurance:

Called as Insurance Payment Posting
*For this we need Payment details Check / EFT details and EOB.

Presentation Date: 3/16/2017

 Payment Posting
Payment Posting: Insurance may Pay or Deny the claim and when we enter this
Payment details in Client Software for claim processing purpose.

a Patient Name
a DOS
a Billed Amt
a Allowed Amt
a Paid Amt

EOB/ERA/Check Client Software

EOB- An explanation of benefits (commonly referred to as an EOB form) is a statement sent

by a health insurance company to provider/patient explaining what medical services were
paid/denied. The EOB is commonly attached with a check.

ERA -Electronic Remittance Advice (ERA) is an electronic report in a standard, computer-

readable format sent by insurance companies to providers/patient as an explanation of
payment and adjudication of medical claims
Presentation Date: 3/16/2017
 References used for Payment Posting
EOB/ERA
Let’s know the contents of an EOB/ERA:

Presentation Date: 3/16/2017

 References used for Payment Posting
Check
Let’s know the contents of an Check:

üCheck issuer
üCheck receiver
üCheck number
üCheck amount

We will Learn More about these in Later Sessions!!!!

Presentation Date: 3/16/2017

 Payment Posting Process Flow
Batch
Reconciliation Audits for Correct entry
3 4
of Payments

Posting of insurance Reports

payments/denials generated
in the system 5
2
Process Flow

Receipt of 1 Accounts
Receivables
Correspondence (EOB,
Check, ERA, Credit
cards) for posting
Payment Posting

Presentation Date: 3/16/2017 61

 Accounts Receivable and Denial Management

Accounts Receivable which is defined as the total amount of money owed to a

practice for services rendered but not yet paid for,is an indicator of what is
happening within the economic structure of a practice.

Denied Claim Paid Claim Partially Paid No Response Claims

Presentation Date: 3/16/2017

 Denied Claim: A claim that has been refused to be paid by the
insurance company.

Paid Claim: A claim that has been approved and paid

by the insurance company.

Partially Paid: A claim that has been paid partially by the

insurance company.

No response claim: A claim that has been sent to the insurance

and no response has been received from the insurance
after normal processing time.
Presentation Date: 3/16/2017
 Accounts Receivable Process Flow
Denial
Management Claims with

4
Credit
Balance
AR follow up transfered to
with insurances CB team.
3 5

Process Flow
AR Analysis 2

Credit Balance
1
Generation of reports
for AR Accounts Receivable
(Outstanding
Payments)
Presentation Date: 3/16/2017 64
 CREDIT BALANCE

Credit balance: Accounts in system with payments or allowances exceeding total

charge amount is called as Credit Balance.

What are the possible reasons of credit balance:

ØPatient Overpayment.
ØInsurance overpayment.
ØInsurance paid twice.
ØPatient paid twice.
ØCob conflicts.

Presentation Date: 3/16/2017 65

 Patient Collection

ØPer contract the patient is liable to pay certain

amount.
ØPost insurance payment any amount that is
due from patient needs to be collected.
ØIf provider fails to collect the money from the
patient, the account is referred to collection
agency.

Collection Agency, a third party hired by provider

follows up with the patients by personally visiting Payment
his house or sends letters (called Dunning or Due
Demand Letter or Patient Statement)
for collecting outstanding* balance.

Presentation Date: 3/16/2017

 Credit Balance Process Flow
Processing of

3
refunds where
applicable.
Identification
of the reason Accounts with
for Credit
Balance
2 pending patient
payments
transfered to the
4 Patient Collection
dept.

Process Flow

Patient
1 Collection

CB team works
Credit balance
on accounts
with credit
balance.
Presentation Date: 3/16/2017 67
 Let’s know what is “Patient Statement”
A document sent by provider to the Patient in case of any payment to be
received from the patient.

It may look like this

Billing Organization initiates this Letter on Provider’s behalf and follows up with the Patient for
thePresentation
Payment due.
Date: 3/16/2017
 Patient Collection Process Flow
If no response
received then
Reviewed if patient is followed

3
response is by up Collection
received. If not Team/Agency
then multiple
statements are
2
sent per policy.

Process Flow

Completion
1 of Cycle

Patient statement is Patient Collection

generated by provider
via MBO

Presentation Date: 3/16/2017 69

 Classification of American Insurance
Companies
Presentation Date: 3/16/2017
 Types Of Insurance

Let’s Know ……..

v Individual Insurance
v Group Insurance
v Federal and Commercial

Presentation Date: 3/16/2017

 Types Of Insurance

v Individual and Group Insurance

Individual health insurance is coverage that is purchased

on an individual or family basis.

Group Insurance is a health plan that provider health coverage to employees,

former employees, and their families and supported by an
employer or employee organization.
Presentation Date: 3/16/2017 72
Slide *
 Types Of Insurance

v Primary Vs Secondary

The insurance that pays first and pays up to the limits of its coverage.
Primary. Usually it gives maximum coverage.

The one that pays remaining amount if there is any post the payment
of primary payor is called Secondary Insurance.

Supplementary insurance- is sold by private companies and can help

pay some of the health care costs that a primary plan doesn't
cover, like copayments, coinsurance, and deductibles.

Presentation Date: 3/16/2017 73

Slide *
 Types Of Insurance

v Federal Insurance
v Commercial Insurance
v Liability Insurance

Federal Insurance- Insurances run and managed by U.S. government providing healthcare
benefits to older citizens, retirees, disabled, and children of deceased workers, and
government employees etc. Federal government is the largest single payer of U.S.
CMS determines which treatment and technologies are worth covering and how much the are
willing to reimburse. AHRQ mandating quality and safety standards.

Commercial health insurance- can be categorized according to its renewal provisions

and type of medical benefits [Link] policies can be sold individually or as part of a
group plan.

Liability insurance- is any type of insurance policy that protects an individual from the risk of
Presentation Date: 3/16/2017
injuries, lawsuit or any other claim resulting from an accident. Slide *
 Group Plan

• Employer-sponsored health insurance is paid for by businesses on behalf of their

employees as part of an employee benefit package.
• Most private (non-government) health coverage in the U.S. is employment-based.
• Nearly all large employers in America offer group health insurance to their employees.

• Features of Group Plan:

• a. Multiple Subscribers (Employees of the organization).
• b. Premium is paid by Employer.
• c. Each Subscriber can have their one or more Dependents.
• d. Employees and their families are Beneficiaries and are covered.

Presentation Date: 3/16/2017

 Example of Group and Individual
Insurance Cards……

Presentation Date: 3/16/2017 76

Slide *
 Types of Insurance

Insurance

Federal Commercial Liability

Presentation Date: 3/16/2017

 Let’s know Federal Insurances

Presentation Date: 3/16/2017 78

Slide *
 Federal Insurances
1. Medicare

2. Medicaid

3. Tricare/Military Health System (CHAMPUS)

4. Veterans Health Administration (VHA/CHAMPVA)

5. State Children's Health Insurance Program (CHIP)

6. Federal Employees Health Benefits Program

7. Indian Health Service

8. Program of All-inclusive Care for the Elderly (PACE)

Presentation Date: 3/16/2017
 Medicare

Medicare is the federal health insurance program for

people whose criteria are:

ØAbove 65 years of age.

ØDisabled for than more than two years.
ØPeople with End-Stage Renal Disease.

Presentation Date: 3/16/2017

Slide *
 Medicare –
ØBiggest Federal Insurance
ØMeant for people- Above 65 years old, Physically Disabled or Suffering from ESRD
ØIt’s the Central Policy, rules are same across US.
ØCMS governs Medicare
ØHas four parts – Part A, Part B, Part C and Part D

Let’s know more about Medicare in upcoming slides………………..

Presentation Date: 3/16/2017

Slide *
 Federal Insurances....Contd

Medicare consists of 4 Parts:

Medicare Part A
Covers: Inpatient services (Hospital stay, ASC, SNF,Home Health, Hospice)

Medicare Part B
Covers: Physician Charges

Medicare Part C
Covers: Medicare Advantage Plans/Managed care plans

Medicare Part D
Covers: Prescription drugs and DME
Presentation Date: 3/16/2017
 Medicare Deductibles

üDeductible is the amount the

patient must pay out-of-pocket
each year before Medicare starts
covering them.

üDeductible amount may vary

every year.

üIn 2016, Part A deductible was

$1,288 and Part B deductible was
$166

üIn 2017, Part A deductible was

$1,316 and Part B deductible was
$183

Presentation Date: 3/16/2017

Slide *
 Medicare-RR and MCR Supplement

ØMedicare Supplement – A Medicare Supplement Insurance (Medigap) policy, sold by

private companies, can help pay some of the health care costs that Original Medicare
doesn't cover, like copayments, coinsurance, and deductibles.
Medicare ID consists of 9 numeric digits (individual's SSN) followed by an Alpha or
Alpha and a Number as Suffix.
Eg.- 452565455A/ 784885754B/ 455776321C2 /254658797M1

ØMedicare Rail Road - Railroad Medicare is the health plan designed for railroad
workers ages 65 and above and certain railroad workers under 65 with disabilities, end
stage renal disease (ESRD).
It consists of 9 numeric digits (Individual’s SSN) and alpha as Prefix.
Eg. –A512586587 /MA254658475

Presentation Date: 3/16/2017

Slide *
 Concepts of Medicare

ABN
Medicare
Medicare Eligibility
Coinsurance
Medicare It is a Criteria
MSP Crossover written
Medicare notice from Medicare
Secondary given to the patient
Payer Medicare will pay
Crossover is the process before receiving certain Ø65 years or above.
80% of its fee
by which Medicare items or services, ØMore than 2 years
This is a program schedule amount
as the primary payer notifying them of disability.
where another and patients are
automatically forwards that, Medicare ØEnd stage Renal
party pays first responsible for
claims to the may deny payment disease.
and Medicare the other 20%.
secondary payer for for that specific
is only responsible processing. procedure or
for qualified [Link]
secondary patient will be
payments. personally responsible
for full payment
if Medicare
denies payment
Presentation Date: 3/16/2017
Slide *
 Medicaid
ü State run policy administered by CMS
ü Program for people below poverty line
ü Medicaid is a monthly enrollment plan

What is Medicaid Spend

down?
When a person is earning above the
poverty line, but as he spends on
Medical expenditure and remaining
amount falls below poverty line, he
gets eligible for Medicaid.

Presentation Date: 3/16/2017

 Medicaid Benefits

üPrimary care visits (Physical

check ups)
üHealth screenings (Blood
tests or x-rays)
üYearly exams, birth control,
and full pregnancy care for
women (OB/GYN visits)
üEmergency care
üComplete medical care for
infants and children
üDental, vision, and hearing
care
üHome Health Care

Presentation Date: 3/16/2017

 Medicaid Cards of Different States

ØThe member ID of Medicaid does not have any set pattern

ØIt’s an Individual Insurance
ØThis is for U.S. citizens who are Below Poverty line
ØMedicaid is always the Last Payor
ØIt’s Issued by State Government. Check below the Insurance cards of
different states

Presentation Date: 3/16/2017

Slide *
 Day 3

Presentation Date: 3/16/2017

 TRICARE
TRICARE is a health care program of the United States Department of
Defense Military Health System.

Formerly known as the Civilian Health and Medical

Program of the Uniformed Services(CHAMPUS)

Tricare covers:
üU.S Armed Forces
üMilitary personnel
üMilitary retirees and their dependents

Presentation Date: 3/16/2017

 Tricare Health Plans

Tricare is divided into three large regions, known as :

üTricare North
üTricare South
Tricare Health
üTricare West
Plans

Services in these regions are provided by:

North – Health Net Federal Services, LLC

South – Humana Military Healthcare Service, Inc.

West – United Healthcare

Presentation Date: 3/16/2017

 Veterans Health Administration

VHA Eligibility:

Veterans with service-connected

disabilities

VHA covers:

üActive military
üNaval personnel
üAir Force personnel

Presentation Date: 3/16/2017

 State Children's Health Insurance Program (CHIP)

The State Children's Health Insurance Program (SCHIP) is a program administered by the United
States Department of Health and Human Services.

The program was designed to cover uninsured children below 18 years of age, in families with
incomes that are modest but too high to qualify for Medicaid.

üRoutine check-ups
üImmunizations
üDoctor visits
üPrescriptions
üDental and vision care
üInpatient and outpatient hospital care
üLaboratory and X-ray services
üEmergency services

Presentation Date: 3/16/2017

 Federal Employees Health Benefits Program

üThe FEHB program allows some insurance companies, employee associations, and labor unions to
market health insurance plans to governmental employees.

üThe program is administered by the United States Office of Personnel Management (OPM).

üFEHB program will supplement Medicare by paying for costs not covered by Medicare, such as
deductible and coinsurance, and by providing additional benefits not provided under Medicare A
and B, such as prescription drugs. However it is not counted as a Medigap plan.

Federal Employees

Presentation Date: 3/16/2017

 Indian Health Service

IHS is responsible for providing medical and public health services to members of
federally recognized Tribes and Alaska Natives.

Presentation Date: 3/16/2017

 Program of All-inclusive Care for the Elderly (PACE)

PACE (Program of All-inclusive Care for the Elderly) is a Medicare and Medicaid program that
helps elderly people meet their health care needs in the community instead of going to a nursing
home or other care facility.

Who can get PACE?

You can have either Medicare or Medicaid, or both, to join PACE.

To qualify for PACE, you must:

üBe 55 or older
üNeed a nursing home-level of care (as certified by your state)
üBe able to live safely in the community with help from PACE

Note: If you join a PACE program, you'll get your Part D-covered drugs and all other necessary medication
from the PACE program. You don't need to join a separate Medicare Prescription Drug Plan. If you do, you'll
be disenrolled from your PACE health and prescription drug benefits.
Presentation Date: 3/16/2017
 What is
Obamacare?
The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable
Care Act (ACA) or Obamacare, is a United States federal statute enacted by President
Barack Obama on March 23, 2010.

ACA makes healthcare more accessible and affordable :

üPreventive Care

üFamily Planning

üRelated healthcare services

üNo discrimination due to pre-existing conditions or gender

The Affordable Care Act was intended to increase health insurance quality and affordability, lower the
uninsured rate by expanding insurance coverage and reduce the costs of healthcare
Presentation Date: 3/16/2017
 Worker's Compensation

• Workers' compensation insurance that ensures medical bills and some lost wages are
paid for employees injured on the job or who have work-related diseases or illnesses.
Employees covered by workers' compensation receive benefits based on the type and
severity of their injuries.

• Features of Worker Compensation Plan:

• a. Multiple Subscribers (Workers of an company/factory).
• b. Premium is paid by Employer.
• c. There are no Dependents.
• d. Worker never pays his Medical bills for work-related injuries/diseases/illness

• We will learn Individual Plans with few examples in coming up slides.......

Presentation Date: 3/16/2017
 Types of Liability Plan

No-Fault or Auto-accident insurance:

Type of insurance contract under which insured is

indemnified for losses by their own insurance company,regardles of fault in the in
cident generating losses.

It is no different from first-party coverage. However, the term "no-fault" is most

commonly used in the context of state/provincial automobile insurance laws in
the United States, Canada, and Australia, in which a policyholder (and his/her
passengers) are not only reimbursed by the policyholder’s own insurance
company without proof of fault, but also restricted in the right to seek recovery
through the civil-justice system for losses caused by other parties

Presentation Date: 3/16/2017

 Commercial Insurance / Payor

Presentation Date: 3/16/2017

Slide *
 Commercial Insurance –BCBS

üBCBS ID always starts from 3 Alphabets

üBCBS Can be an Individual or a Group Plan
üHorizon Blue cross Blue Shield, Premera BCBS, Anthem
BCBS are from BCBS Groups only
üBCBS IDs of Prefixes-NJX3HZN, YHR3HZN, YHW3HZN,
YHQ3HZN, YHP3HZN, LBW belong to NJ State
üBCBS IDs with Prefix R denotes BCBS Federal Plan
üBCBS IDs with Prefix
YHR3HZN and YHW3HZN denote BC Medigap

Presentation Date: 3/16/2017

Slide *
 Commercial Insurance –Aetna

üAetna ID usually starts from W Alphabet

üAetna Medicare is MCR commercial plan

Presentation Date: 3/16/2017

Slide *
 Commercial Insurance –Others

Here are few examples of some of other major Commercial

insurances.

United Healthcare- United Health Group is a leader worldwide

in helping people live healthier lives.

Cigna-
A global health insurance service company, offers health, dental, supplemental insurance.

Presentation Date: 3/16/2017

Slide *
 Managed Care Plans

Managed care plans are a type of health insurance. They have

contracts with health care providers and medical facilities to
provide care for members at reduced costs.

Let’s know and understand few terminologies ………

Participating (par) providers:

Healthcare providers who have entered into an agreement

with your insurance [Link] insurance carrier agrees
to direct "clients" to the provider and, in exchange, the
provider accepts a lower fee for their services.

Non Participating Provider:

Providers have declined entering into a contract with

insurance company. One reason may be the fee offered
by carrier is less than what they are willing or able to accept
Presentation Date: 3/16/2017
 Terminologies related to Par and Non-Par Providers

• Contractual Adjustment:
• The difference between billed amount and allowed
amount in case of par providers which is
adjusted(not billed to patient)

• Write-Off:
• The difference between billed amount and allowed
amount in case of non - par providers which is
adjusted(not billed to patient)

• Balance Bill: The difference between billed amount

and allowed amount in case of non - par providers
which is billed to patient

Presentation Date: 3/16/2017

Slide *
 Types of Managed Care Plan

Presentation Date: 3/16/2017 106

Slide *
 Types of Managed Care Plan
Health Maintenance Organization (HMO)

üPCP required

üReferral authorization required

üVisits to OON physicians not covered

üLower healthcare costs

Patient

Exception:

Women don’t need a referral to see an obstetrician/gynecologist, or OB/GYN, in their

network for routine services such as Pap tests, annual well-woman visits and obstetrical
care.

Presentation Date: 3/16/2017

 Managed Care Plans

Preferred Provider Organizations (PPO)

üPCP not required

üReferral authorization not required

üVisits to OON physicians covered

üIn network- smaller OOPs and full coverage

üOut of network- big OOPs and limited coverage

Patient
üLower healthcare costs

Presentation Date: 3/16/2017

 Managed Care Plans

Point of Service (POS)

üPCP is required
Patient
üReferral authorization required

üCoverage is greater

üOut of pocket costs are lower for in network providers

üOut of pocket costs are higher for out of network providers

Presentation Date: 3/16/2017

 Recap

Presentation Date: 3/16/2017

 Types of Liability Plan

Worker Compensation insurance:

Workers' compensation insurance that ensures medical bills and some lost wages
are paid for employees injured on the job or who have work-related diseases or
illnesses. Employees covered by workers' compensation receive benefits based on
the type and severity of their injuries.

Features of Worker Compensation Plan:

a. Multiple Subscribers (Workers of an company/factory).

b. Premium is paid by Employer.
c. There are no Dependents.
[Link] compensation will pay in full and patient will have no responsibility.

Insurance providing medical benefits to employees injured in the course of employ

ment.

Date of Injury (DOI): Is the date when the employee met with an accident or injured while
at work.

Presentation Date: 3/16/2017

Slide *
 Coordination of Benefits – COB

The process of coordinating the benefits within the Insurance company,

when the individual has more than one insurance company, it is known as
COB.

Primary Insurance: An Insurance who agrees to pay the maximum portion

of the bill is known as Primary Ins.

Secondary Insurance: An Insurance who agrees to pay the left over by the
primary Ins. is known as secondary Ins.

Tertiary Insurance: An Insurance company, who agrees to pay the left over
by the secondary ins. is known as Tertiary Ins.

Presentation Date: 3/16/2017 112

Slide *
 Coordination of Benefits – COB
Payer COB Guidelines

Presentation Date: 3/16/2017 113

Slide *
 Coordination of Benefits – COB
Payer COB Guidelines

Presentation Date: 3/16/2017

 Thank You.

Presentation Date: 3/16/2017 115