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Chapter 13 Managing Medical Ofce Finances 261
Note that all of the details pertaining to the visit(s)
appear at the bottom of the screen, including the procedures, diagnoses, insurance information, and charges.
Clicking on Save causes the charges associated with the
visit(s) to be entered into CareTracker.
This process is repeated for each separate day listed,
until all charges have been saved.
You’ll get a chance to practice this task in Case Study
10: Entering Coding, Billing, and Payment Information.
To access Case Study 10, go to http://thepoint.lww.
com, log in using your username and password, search
for The Complete Medical Assistant, click on “Student
Resources,” nd the Harris CareTracker materials, and
click on “Case Study 10.”
Health Insurance and
14
Processing Claims
Chapter Objectives
● Describe the differences between group, individual,
and government-sponsored health benet plans.
● Explain the difference between Medicare and
Medicaid.
● Explain how managed care programs work.
● Point out similarities and differences between
HMOs and PPOs.
● Apply third-party guidelines.
● Apply managed care policies and procedures.
● Summarize how to le claims with Medicare,
Medicaid, workers’ compensation, and private
insurance.
● Complete insurance claim forms.
CAAHEP & ABHES Competencies
CAAHEP
● Identify types of third-party plans.
● Demonstrate understanding of information required
to le a third-party claim.
● Identify the steps for ling a third-party claim.
● Outline managed care requirements for patient
referral.
● Describe processes for verication of eligibility for
services.
● Describe processes for precertication and
preauthorization.
● Dene a patient-centered medical home (PCMH).
● Differentiate between fraud and abuse.
● Interpret information on an insurance card.
ABHES
● Process insurance claims.
● Differentiate between procedures of private, federal,
and state payers.
● Understand the difference of HMO, PPO, and IPA
managed care programs.
● Explain the process for obtaining referrals and
precertication.
Chapter Terms
Chapter 14 Health Insurance and Processing Claims 263
Assignments of benets
Balance billing
Birthday rule
Clearinghouse
Coinsurance
Coordination of benets
Copayment
Crossover claim
Deductible
Dependents
Gatekeeper
Medicaid
Medicare
Medigap
Abbreviations
CHAMPVA
EOB
EPO
Case Study
Sally, an 85-year-old patient, called the ofce to
schedule an appointment. She recently changed
her insurance from Medicare to Coventry. Sally
asked the medical assistant if the ofce partici-
pated in Coventry. The medical assistant assured
her that the physician was a participating pro-
vider in the Coventry system. An appointment was
scheduled. When Sally arrived for her appointment,
the medical assistant noticed that her insurance
was with Coventry One. Although Coventry One
HDHP
HMO
PCP
Participating provider
Preauthorization
Precertication
Preexisting conditions
Referrals
Third-party administrator
Third-party payer
POS
PPO
UM
is a plan offered by Coventry, it was not a plan that
the physician participated with. The medical assistant explained to Sally that the physician did not
take her particular plan. Sally was very upset, as
she had asked when she made the appointment if
the doctor took her plan. She waited 2 weeks to see
the doctor and now will not be seen due to a serious misunderstanding of insurance. The medical
assistant was very apologetic and offered to help
Sally nd a provider within her plan.
Third-party payments
TRICARE
Utilization management
Utilization review
UR
Health insurance, third-party payment, is constantly
changing. There are numerous types of plans offered
by a vast number of companies. The increase in
options, at times, causes confusion for patients, thus
making things more complicated for you. This chapter will present information about different types of
plans and the procedures necessary to insure proper
payment.
C
O
G
Health care insurance is categorized into three general
groups:
r
r
r
HEALTH BENEFIT PLANS
Group health plans
Individual health policies
Government-sponsored benets
Group plans are offered through employers or other
groups. These plans usually provide a lower cost for benets for its’ participants and their families. Individual
policies can be purchased through an insurance broker or
from a state Marketplace. Government-sponsored benet
plans include Medicare, Medicaid, and Children’s Health
Insurance Program (CHIP). The federal government
sponsors TRICARE and CHAMPVA are benet plans
for military members, retirees, and their families.
Case Question
A
F
F
How would you interact with this
patient if you are the medical assistant
who made the appointment?
264 Section III Administrative Medical Assistant Skills
In addition, group plans and individual policies offer
four common types of plans:
Health maintenance organizations (HMO)
r
Preferred provider organizations (PPO) or exclusive
r
provider organizations (EPO)
Point of service (POS)
r
High-deductible health plans (HDHP)
r
Handling insurance matters effectively is of great
importance in operation of the practice, as well as to the
patients your ofce serves. There are many differences
between plans and knowing where to nd individual
requirements will aid in efciency. Most insurance companies offer provider access to Web sites where you will
be able to view the insurance accounts of your patients.
These sites provide information regarding patient
deductible (including amounts met), coinsurance, or
copayment amounts, along with requirements for referral or preauthorization. Due to the vast number of plans
and policies available, sometimes it is necessary to use
the insurance payer identication number when assigning insurance to a patient’s account. The payer identication number is listed on the patient’s identication
card. Figure 14-1 shows a typical patient insurance card
that is scanned on both sides when the patient checks in
the ofce. This ensures that all the necessary information will be accessible.
Group Health Plans
A group health plan is sponsored by an organization.
Any person who is a member of the organization is eligible to be covered by the plan. If they choose to have
this health coverage, they become part of the group.
Members can usually add their dependents to the group
too.
Dependents generally include the member’s spouse
and minor children.
Associations and labor unions are among the kinds of
organizations that offer these plans. Employers sponsor
most group health plans. Employers offer insurance as a
benet to their employee.
Third-Party Payer
A payment from any source other than the patient is
referred to as a third-party payer. Therefore, payments
received from health insurance policies are considered
third-party payments. Other examples of third-party
payers include liability cases, in which another individual’s liability insurance covers expenses, or legal cases
where payments are received directly from the attorney. Time should be spent learning your ofce policy
regarding liability cases and how the ofce wants them
handled. Remember, the physician is not required to
accept payment from all third-party payers (especially in liability cases); she can elect to require payment directly from the patient or the patient’s health
insurance.
Insurance companies charge a fee for benets.
The employer, employee, or both pay this monthly
premium.
Self-Funded Plans
With self-funded plans, the employer itself is the insurer.
It hires an insurance company or other company to
review claims and make payment from the employer’s
funds. In this case, the company is only the agent for the
plan. Therefore, it’s a
not a third-party payer.
third-party administrator (TPA),
Marketplace Health Insurance
Varieties of insurance plans are available to individuals without other insurance options. Just as with other
plans, it is important for to you verify a patient’s insurance prior to the appointment. If a patient has a policy
that the ofce doesn’t participate in, there will be additional (unanticipated) costs to the patient.
01/04/16
Figure 14-1 Patient identication card. (Reprinted from Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Chapter 14 Health Insurance and Processing Claims 265
Determining Eligibility
Group insurance policies often have requirements that
must be met prior to participant enrollment in the plan.
Eligibility requirements are dened in the policy or plan
document. They often include the following:
Work requirement—The employee must work a mini-
r
mum number of hours per week.
Waiting period—A stated length of time must pass
r
from the date of employment before health benets
take effect.
The employee also must have enrolled in the group.
This usually means completing required forms during an enrollment period. Not all employees will necessarily be members of the group health plan. Group
membership is not automatic with employment.
Employees must choose coverage by their employer’s
health benefits.
The eligibility of a dependent is based on the employee’s eligibility. Children of the insured can be covered
until the age of 27. Spouses and domestic partners can
also be included in coverage. Additional premiums will
apply to spouses and children based on rates set by the
group policy contract.
Individual Health Plans
People buy individual health policies from an insurance
company. They pay their premiums directly to the insurance company. The insurance company may:
Pay the doctor or hospital directly
r
Reimburse the person for eligible medical expenses
r
The process and requirements for ling claims under
individual health plans are the same as those for group
health plans. Individual policies, however, often offer
less coverage than group plans do. For example, the
deductible for an individual policy may be higher. The
patient must pay this amount before insurance starts
paying.
Case Questions
A
F
F
Why should the medical assistant ask about the
patient’s insurance payer identication number
on the patient’s insurance card? Do you think
patients should know this information to avoid
issues or problems?
When the patient in the case study
called the ofce, she was informed her
insurance was accepted by the ofce.
C
O
G
The Health Insurance Portability and Accountability Act
of 1996 (HIPAA) brought major changes to the health
care and health insurance industries. Some ways HIPAA
has affected health insurance include the following:
r
r
r
r
r
r
r
denies or limits benets for certain
tions
the policy took effect. Sometimes, these conditions are not
covered by the policy even if the patient was not being
treated for them at the time. Preexisting conditions generally won’t apply to most patients covered by group health
plans. That’s because the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) severely limited
this exclusion in employer-sponsored plans.
HEALTH INSURANCE AND
HIPAA
Limited exclusions for preexisting conditions in
employer-sponsored health plans
Banned the use of genetic testing information to deny
health coverage
Eased condentiality requirements for providing
patient information to insurance companies
Required standards for the electronic transmission of
insurance claims
Required standards for attachments to insurance
claims
Required diagnostic and procedural coding to be
standardized
Strengthened protections against fraud and abuse in
insurance billing
An individual policy also may have a provision that
preexisting condi-
. These are injuries or illnesses the patient had before
Government Health Plans
Government-sponsored health benet programs are
funded and operated by the federal government and the
individual states. These programs are designed to provide health benets for the elderly, the poor, and others
who might not be able to get benets on their own. Also
included in government health plans are those offered to
military members, retirees, veterans, and their families.
These programs include the following:
Medicare
r
Medicaid
r
TRICARE
r
CHAMPVA
r
Medicare
Congress created Medicare in the 1960s as a health benet
plan for persons age 65 and over. At the time, only about
half of elderly Americans had health insurance coverage.
266 Section III Administrative Medical Assistant Skills
All persons who are entitled to receive Social Security
retirement benets become eligible for Medicare when
they reach age 65. This is true even if they don’t retire. As
long as they are covered by an employer’s group health
plan, that plan is the primary coverage and Medicare is
secondary.
In the 1970s, Congress expanded the Medicare
program to cover other groups who had difculty
obtaining health insurance. These groups include the
following:
Disabled persons who cannot work and are receiving
r
Social Security disability benets; they must receive
these benets for 24 months before they are eligible
for Medicare.
Persons suffering from end-stage renal disease; these
r
are persons whose kidneys have failed permanently
and who are receiving dialysis.
In recent years, Congress changed Medicare again, to
create more choices for coverage. The early Medicare
program (now called Original Medicare) consisted of
two parts:
Medicare Part A—Covers hospital expenses
r
Medicare Part B—Covers outpatient services (includ-
r
ing physician services)
Eligible persons still may enroll in Original Medicare,
or they may choose to elect coverage through one of the
Medicare Advantage plans.
Medicare Advantage
Medicare Advantage offers a variety of managed care
and traditional insurance plans through private insurance companies. Patients who qualify for Medicare may
choose between traditional Medicare and any of the
advantage plans. These plans operate much like other
managed care and traditional insurance plans.
Medicare Part D
Part D is a prescription plan that Medicare beneciaries
can elect to purchase to help offset the costs of medications. Similar to other pharmaceutical plans, patients will
pay a copayment based on the tier level of the medication.
People enrolled in Medicare Advantage plans may already
have drug benets within their selected plan. Medicare
Part D plans are offered through private companies.
Medigap
Medigap is the name given to policies that private com-
panies sell to ll the gaps in original Medicare. These
policies are voluntary and cost the patient an additional
monthly fee. They pay for things Medicare Parts A and
B do not. For example, a Medigap policy may pay the
following gaps in Part B coverage:
The annual deductible
r
Coinsurance for physicians’ services
r
An annual physical examination
r
Other services, treatments, and supplies not covered
r
by Medicare
Medicare Part A
Everyone enrolled in Original Medicare is covered by
Part A. There’s no monthly charge for this coverage,
although the plan has deductibles and coinsurance.
Coinsurance is money a patient must pay as his share
of the cost of treatment. Part A covers hospital expenses
(inpatient).
Medicare Part B
Medicare Part B is optional. All Part B charges are subject to deductibles and coinsurance.
Patients who have this coverage pay a monthly fee for
this benet. Part B pays physicians’ fees for both inpatient and outpatient care and outpatient services. These
services include the following:
Diagnostic testing
r
Certain immunizations such as inuenza and
r
pneumonia
Specic screening tests such as PSA, mammograms,
r
Pap smears, bone density testing, and colorectal
screening
Medical equipment such as canes, crutches, walkers,
r
commodes, and chairs
Electronic Medicare claims can automatically crossover to Medigap or other secondary plans. When claims
crossover information from Medicare, including contracted amounts, nonallowable fees, coinsurance, and
deductible amounts are electronically forwarded to secondary insurances. Figure 14-2 is a copy of a printed
CMS-1500 form. All insurance claims are formatted
using the CMS-1500 standard.
Patient Education
Insurance can be very complex and confusing, es-
pecially to patients. When patient requires special
testing, imaging or certain medications that require
preauthorization take time to explain this pro-
cedure to the patient. Sometimes, the patient can
assist in the authorization process by calling the
insurance company directly and discussing their
symptoms and past treatments. Prior to suggesting
any patient, call their insurance company check
with the physician and insure that the patient is
comfortable speaking with them.
Chapter 14 Health Insurance and Processing Claims 267
Figure 14-2 Sample CMS-1500 claim form indicating proper sequencing. (Reprinted from Kronenberger
J, Ledbetter J. Lippincott Williams & Wilkins’ Comprehensive Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
268 Section III Administrative Medical Assistant Skills
Medicaid
Medicaid is a health assistance program funded by both
federal and state governments. The federal government
sets general guidelines that must be followed. Each state
government can set additional eligibility standards and
benets. Federal guidelines require that every state offer
a Medicaid program. Some states offer several options
for coverage with policies available through various
independent insurance companies. You will need to
learn the various plans available in your area and the
specic plans your ofce participates in.
The federal government sets Medicaid’s minimum
coverage. However, states can provide coverage beyond
the minimum. Therefore, like eligibility for Medicaid,
benets vary from state to state. All states provide at
least these areas of coverage:
Inpatient hospital care
r
Outpatient treatment and services
r
Diagnostic services
r
Family planning
r
Skilled nursing facilities
r
Diagnostic screenings for children
r
Cultural Connection
Bias can affect not only your feelings about a group
of individuals but also the manner in which you
treat them. Frequently, bias is based on thought
or opinion with limited factual information. Many
people, including those in health care, have biased
opinions of individuals covered under the Medicaid
program. Regardless of the reasoning behind this
bias, there is no place for it in a professional envi-
ronment. Every patient regardless of economic
background or insurance should be treated with
respect and receive the best care possible.
TRICARE and CHAMPVA
Dependents of veterans who have total and perma-
r
nent service-connected disabilities
Dependents of veterans who died from service-con-
r
nected disabilities
CHAMPVA patients can choose their own civilian
physician. This allows them the same benets as a traditional insurance program.
The provider also may bill the patient for any other
amounts not paid by insurance. For example, the insurance company’s maximum allowable payment for a service may be less than the provider’s fee. In some cases,
the provider can require the patient to pay the difference. Also, an insurance plan may not cover certain
equipment or supplies.
C
O
G
There are various types of insurance coverage. Let’s take
some time to review the various types of coverage:
r
r
r
r
TYPES OF INSURANCE
COVERAGE
Basic medical benets pay all or part of a physician’s
charges for nonsurgical services. These include ofce,
hospital, and home visits as well as most lab tests and
x-rays.
Hospitalization coverage pays all or part of the costs
for a patient’s hospital room, food, and health care
services that don’t involve a physician. It also pays for
use of hospital facilities, such as an operating room.
Surgical coverage pays all or part of a surgeon’s fees.
The surgery can take place in the hospital or the physician’s ofce. If the procedure requires anesthesia,
this is paid by the surgical benets as well.
Major medical coverage pays for very large bills
that can result from a long or extremely serious illness. This coverage usually takes effect when benets
under the plan’s other coverage have been exhausted.
Deductibles and coinsurance usually apply to most of
the coverage. If major medical coverage is in effect,
however, the patient may have already paid his maximum required amount.
TRICARE formerly known as CHAMPUS is a govern-
ment program sponsored by the U.S. Department of
Defense. It provides health benets for:
Dependents of active duty military personnel
r
Dependents of military personnel who died while on
r
active duty
Retired military personnel and their dependents
r
The TRICARE system provides health care through
civilian hospitals and clinics.
Civilian Health and Medical Program of the Veterans
Administration. It covers dependents of two types of
military veterans. These are:
CHAMPVA stands for the
C
O
G
Health care plans control costs in several ways including:
r
COST MANAGEMENT
Precertication (preauthorization)—Most insurance
plans require that certain procedures are precertied or preauthorized before the patient can receive
the treatment. These usually include hospitalization
and other procedures except in emergencies. The
goal is to provide services in the most cost-effective
way. For example, surgeries for which patients were
once hospitalized are now performed in outpatient
Chapter 14 Health Insurance and Processing Claims 269
settings. Precertication is sometimes called utiliza-
tion management (UM)
Referrals—Many health care plans will not pay for
r
or utilization review (UR).
treatment by specialists, unless the patient is referred
by his Primary Care Physician (
PCP). Some plans
require preapproval by the plan administrator as
well. The goal is to ensure that a specialist’s services
are medically necessary. Insurance-required referrals
are assigned a referral number, outline the number of
treatments (frequently including CPT codes), and the
time frame for completion of these treatments.
Health Maintenance Organizations
(HMO)
Health Maintenance Organizations contract with providers at a contracted rate to provide services to those
covered under the plan. Patients select a Primary Care
Physician (PCP), or
gatekeeper, who coordinates the
patients’ care. The PCP would be responsible for any
referral to specialists as needed. Such referrals must be
completed prior to the patient being seen by the specialist and the referral authorization number should
be recorded on the claim form. Patients usually pay
a set
copayment for services. Copayments can vary
based on service provider, for example, the PCP copayment might be $20 with a specialist copayment of $50.
Deductibles and coinsurance generally do not apply to
such services.
Preferred Provider Organizations
A preferred provider organization (PPO) is a network
of physicians, hospitals, and other providers that contract with one or more health plans. The PPO’s provider
members agree to accept less than their normal charges
and to follow the plan’s requirements for providing services. Unlike an HMO, patients in a health plan with a
PPO can go to any provider they wish. The plan generally offers two levels of service, called in-network and
out-of-network.
If the provider is in-network, referred to as a
participating provider, the plan’s benets are greater.
Providers that are out-of-network (called a nonparticipating provider) will cost the patient more. Although
the PPO system gives patients free choice, they have a
strong nancial incentive to see in-network providers.
Table 14-1 lists the basic PPO guidelines.
Exclusive Provider Organizations
(EPO)
EPO, exclusive provider organization, is similar to the
PPO in that a PCP is not required. The patient can
choose to see any provider they would like as like as the
Table 14-1
Benet In-Network Out-of-Network
Yearly patient
deductible
Patient
coinsurance
Routine care
benet
Mental health
benet
Ofce visit—
patient share
PPO Guidelines
$100 $300
10% 30%
$200 per year 0
80% of charges 50% of charges
$10 copay; no
deductible
70% of charges
provider in the EPO network. No benets are paid if the
patient uses a provider outside of the network.
Point of Service (POS)
POS, point of service, is similar in nature to the HMO in
the PCP are required. The patient was limited to providers within the plan. Additionally, referrals are required
for the patient to see a specialist.
High-Deductible Health Plan (HDHP)
HDHP plans have lower monthly premiums, however,
come with high deductible. Since the deductibles are
very high, the patient will pay for most routine care out
of pocket. As with all plans, the policy will not pay until
the deductible liability has been paid.
Ethics
Most insurance companies require preauthorization prior to the performance of expense testing, including MRI. Often insurance companies
will require specic information in regard to the
patient’s symptoms, diagnosis, and treatments.
This information must be true and documented
in the patient EHR. Always verify symptoms,
diagnosis, and treatment. Do not exaggerate any
of the information. For example, if eight physical
therapy sessions are ordered but the patient has
only attended one session, you could not state the
patient has had eight physical therapy sessions. All
information should be accurate and well documented in the EHR. Remember, if it’s not documented, it didn’t happen.
270 Section III Administrative Medical Assistant Skills
C
O
G
Many pieces of information are necessary to process insurance claims. It’s of extreme importance that this information be entered into the electronic health record accurately
and completely. The patient’s ID card is your basic resource
for processing insurance. This card contains information
that’s essential to the accurate ling of claims including:
r
r
r
r
le. Update it at least yearly. Also, verify the information at each visit, since the patient’s employment and
eligibility may change.
FILING CLAIMS
The name of the plan that provides the patient’s
coverage
The patient’s plan ID number and group number if
it’s group coverage
Phone numbers for questions about benets, coverage, and approval requirements
Directions on where to le claims
Keep a copy of the patient’s ID card in the patient’s
Coordination of Benets
It’s not uncommon for a patient to be eligible for benets from more than one health plan. For example, a
patient may be covered under her employer’s plan and
also as a dependent on her spouse’s group plan. The plan
that pays rst—the primary plan—is the plan provided
by the patient’s employer. The spouse’s group plan is secondary. It will consider any amounts up to the allowable
limit for the policy not paid by the primary insurance.
This is called
coordination of benets.
If the parents are divorced or legally separated, the
primary plan is usually the plan of the parent who has
custody. In some instances, however, a court order or the
divorce decree may make the other parent’s plan primary.
Electronic Claims Submission
The size of the ofce you are working in will dictate
how frequently you will submit claims. Claims can be
submitted anywhere from daily to weekly. Files will
electronically be prepared for submission. This process
takes the information entered during charge entry and
converts it into the standard format, referred to as CMS-
1500. The CMS-1500 is the industry standard for claim
submission. HIPAA requires that all claims are electronically led by computer. Several regional and national
clearinghouses receive these claims and electronically
direct them to the proper claims administrators. A
inghouse
ance claims process by providing electronic submission
and translation services between doctor ofces and
insurance companies. This system allows you to send all
claims to one place instead of ling each one separately
with many different claims administrators.
receipt. Any claim that is missing information or does
not meet the requirements of the patient’s health plan
will be rejected. When this occurs, the claim is returned
electronically to the sender for correction. Figure 14-3 is
a sample of an electronically submitted claim that can be
previewed prior to submission.
is a company that simplies the medical insur-
The clearinghouse system reviews all claims upon
clear-
Assignment of Benets
Study Skill
Create key points that break down the information
you are trying to learn. By dividing large or complicated information into small simpler pieces of information, it will be easier to learn.
The Birthday Rule
Dependent children may be covered under the insurance
plans of both parents. When this happens, the primary
plan is usually the plan of the parent whose birthday
occurs rst during the year, not necessarily the older parent. This is known as the birthday rule.
Consider this example of a married couple:
Brad’s birthday is December 20, 1963.
r
Maria’s birthday is October 11, 1965.
r
Whose insurance would be primary? It would be
Maria because the month and day of her birthday come
before Brad’s birthday. It doesn’t matter that Brad is the
older of the two.
Assignment of benets means that the patient allows
the insurance company to send payments directly to
the physician. Additionally, accepting the assignment of
benet also commits the provider to accepting the allowable fee as payment in full. Meaning, if the physician
charged $425.00 and the insurance’s allowable fee is
Figure 14-3 Screenshot of insurance information
“form” in an electronic version. (Courtesy of Harris
CareTracker™.)