Published on February 18, 2014
Training and Development Program Insurance Fundamentals Module 1 and 2 By Idalmis Fernandez and James Gonzalez
Learning Objective Define health insurance terminology and concepts Describe the most common types of managed care products and programs Understand health insurance documents, forms and publications Identify and resolve common health insurance problems that impact clinical practice
Health BIBLE CONTRACT SUMMARY Finding the Contract Summary Online: Log on to UMMG website: www.umdoctors.com Click on “Employee Intranet” - top greymenu bar Pop-up login window username and password (enter UM sign-in Outlook email domain name and password) Click on “Healthplan Contract Summary” The Contract Summary has information about … UMMG Contracts Effective dates UChart Registration Coverage Contract limitations Authorization Policies Type of managed care product Level of care participation Primary Routine Specialty Tertiary Telephone numbers Contracted hospitals and labs Specialty Networks participation
Insurance Terms INSURANCE TERMS Insurance: Is protection against a loss. In health insurance, an insurer guarantees to pay a sum of money to health professionals or facilities for prevention or treatment of a health problem. Health Insurance Payors - A company licensed to sell health insurance (i.e. AvMed, BCBS, Cigna, Humana, etc…) Health Insurance Plan - A defined program of insurance with specific benefits, specific costs and specific rules (i.e. AvMed H.MO., BCBS P.P.O., Cigna E.P.O., Humana Open access, etc…) Indemnity Plans - A health care plan that allows members to see virtually any doctor that they choose and to receive coverage for services without any authorization. Popular, prior to the widespread introduction of Managed Care Plans Managed Care Plans - A health care payment system that attempts to manage utilization and reduce healthcare costs (HMO/PPO/POS/EPO) Individual Insurance or Self-insured – An individual who is not part of an employee group or organization that purchases individual insurance coverage Group Insurance – An organization or company that is contracted with an insurance company to provide coverage for employees or organization members. (e.g. University of Miami group plan)
Health Plan Comparison Product Type HMO EPO Exclusive Provider Health Maintenance Organization Organization Gatekeeper HMO A health plan that functions like a PPO, A health plan in which the patient in which patients receives medical services that are must visit a physician delivered by a Primary Care Physician in their Network, but (PCP) do NOT have coverage for out-ofnetwork services PCP selection required No Out-of Network benefits or No PCP coverage (exception only in required case of emergency) Self-refer or PCP referrals are required to direct access see specialists to specialists Health plan authorization is No Out-of required for most medical Network services benefits Co-payments for doctor’s visits Co-payments and Coinsurance HMO OPEN ACCESS Allows direct access or self-referral (“referral free”) to specialist For some HMO Open Access plans a PCP selection may be required but no referral is needed to see Specialist. PPO Preferred Provider Organization A plan that contracts with a limited network of physicians and facilities to provide services to patients at a discounted rate POS Point of Service A health plan works like an HMO with an out-of-network or “PPO” option. Indemnity Indemnity Traditional Plan A plan that allows members to see virtually any doctor When an In-Network that they choose to physician is selected: receive coverage for services without Works like an No PCP authorization HMO (PCP, required Fee-forReferral, etc…) Self-refer or Service type In-Network direct access to plan benefits specialists NO PCP applied Out-of Network requirement benefits Not When an Out-ofDeductible, Co- Network physician is restricted to payments and selected: network of Co-insurance physicians Works like a NO PPO Authorization required Out-ofNetwork benefits applied POS Open Access direct access or selfreferral (“referral free”) to specialist for in-network and outof-network coverage.
Medicare MEDICARE Medicare is a Federal entitlement program, authorized by Congress to provide medical benefits to individuals who are over 65, who meet certain criteria. Federal workers and anyone eligible for Social Security benefits are automatically enrolled in Medicare Part A. Enrollment in Part B is voluntary and requires a monthly premium. The following are eligible for Medicare services: • People age 65 or older • Some people under age 65 with disabilities • People with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant • Afflicted spouses and afflicted dependent children of workers who pay Social Security Benefits. • Retired federal employees enrolled in the CSRS (Civil Service Retirement system) and their spouses over 65. The Center for Medicare and Medicaid Services (CMS) is the federal agency responsible for managing the Medicare program. For additional information on Medicare visit www.medicare.gov or www.ssa.gov
The Social Security number followed by one of these codes is often referred to as a claim number. We assign these codes once you apply for benefits. These letter codes may appear on correspondence you receive from Social Security or on your Medicare card. They will never appear on a Social Security card. For example, if the wage earner applying for benefits and your number is 123-45-6789, then your claim number is 123-45-6789A. This number will also be used as your Medicare claim number, once you are eligible for Medicare. Code A Identification Primary claimant (wage earner) B B1 Aged wife, age 62 or over Aged husband, age 62 or over B2 B3 Young wife, with a child in her care Aged wife, age 62 or over, second claimant B5 Young wife, with a child in her care, second claimant B6 BY Divorced wife, age 62 or over Young husband, with a child in his care C1-C9 Child - Includes minor, student or disabled child D D1 Aged Widow, age 60 or over Aged widower, age 60 or over D2 D3 Aged widow (2nd claimant) Aged widower (2nd claimant) D6 Surviving Divorced Wife, age 60 or over E E1 E4 E5 F1 F2 F3 F4 F5 F6 Widowed Mother Surviving Divorced Mother Widowed Father Surviving Divorced Father Parent (Father) Parent (Mother) Stepfather Stepmother Adopting Father Adopting Mother HA Disabled claimant (wage earner) HB Aged wife of disabled claimant, age 62 or over M Uninsured – Premium Health Insurance Benefits (Part A) M1 Uninsured - Qualified for but refused Health Insurance Benefits (Part A) T Uninsured - Entitled to HIB (Part A) under deemed or renal provisions; or Fully insured who have elected entitlement only to HIB TA Medicare Qualified Government Employment (MQGE) TB W W1 W6 MQGE aged spouse Disabled Widow Disabled Widower Disabled Surviving Divorced Wife
Medicare Medicare Part A Inpatient hospital Skilled Nursing Facility Hospice care Home health care Blood transfusions Medicare Part B Medicare Supplemental Plan (Medigap) Medicare Advantage (Medicare Replacement Plans) Outpatient hospital Physician services Diagnostic Tests Durable Medical Equipment An insurance plan that covers the patient’s Medicare deductible and 20% coinsurance obligations Advantage Plans include: Ambulance services Policies may be purchased: Offers wider range of benefits. Health Maintenance Organization (HMO) Preferred Provider Organization Plans (PPO) Private Fee-for-Service Plans (PFFS) Offer prescription drug benefits Enrollment is automatic for those who turn 65 and have worked the required amount of time paying into Social Security or Railroad Retirement. Enrollment is voluntary and requires a monthly premium payment. Individually May be paid through an employer-sponsored program, for retirees of a company *Annual deductible $163 *Reimburses 80% of covered services *Patient responsible for deductible and 20% coinsurance Patients with an Advantage Plan do not need a supplemental plan All supplemental plans cover the following core services: Part B - 20% coinsurance Hospital co-insurance from day 61-90 Additional hospital days after the reserve days Examples of 2nd payors are: Mail Handlers Insurance, BCBS , AARP HOSPITAL Inpatient MANAGED CARE PHYSICIANS Outpatient SECONDARY PAYOR MEDICARE IMPORTANT: For Medicare beneficiaries who continue to work after age 65 and maintain coverage under an employer health plan, if the employer group has more than 20 members, the group plan is primary for the employee and spouse and Medicare is the secondary payer.
Medicaid MEDICAID The Medicaid program provides health coverage to low-income families individuals. and to some elderly and disabled Medicaid Basic Eligibility Aid to Families and Dependent Children (AFDC) Children and adults who meet Medicaid (AFDC) eligibility criteria Supplemental Security Income (SSI) Provides payments to low income, elderly, blind and disabled individuals Pregnant Women and Children Provides coverage to: *Pregnant Women *Children up to age 6 - eligible if family income is below 133% of poverty line *Children age 6-11 - family income is below 100% poverty line *Children age 12-18 - family income is below AFDC levels Medicare Beneficiaries Supplemental to Medicare Part B. For low income Medicare beneficiaries
Medicaid Managed Care Eligible recipients may choose to receive health services through, Medicaid Provider Access System (MediPass), Medicaid HMOs, Provider Service Network (PSN) or the Children's Medical Service Network (CMSN) Managed Care MediPass Medicaid HMOs Provider Service Network (PSN) Children’s Medical Services Network(CMSN) (N OT AN I NSURANCE P LAN ) Definition MediPass is a statewide provider network run by Florida Medicaid. Form of managed care designed to: Ensure access to Primary Care Reduce inappropriate utilization Control program costs Primary Care Providers are responsible for providing or arranging for the recipient's primary care and for referring the recipient for other medically necessary services (e.g. Specialty Care). Under this program, Florida contracts with HMOs to provide prepaid services to Medicaid recipients. There are currently 14 HMOs providing Medicaid services throughout Florida. Product Names N/A A Provider Service Network (PSN) is an integrated health care delivery system owned and operated by Florida physician groups. The principal health insurance provider for children with special health care need (CSHCN) due to long term chronic physical, behavioral or emotional conditions Medicaid (Title 19) eligible CSHCN up to age 20 Florida KidCare (Title 21) eligible CSHCN up to age 19 Safety Net – eligible CSHCN who do not qualify for Medicaid or KidCare Children’s Medical Services (CMSN) Network
KidCare Program Through Florida KidCare, the state of Florida offers health insurance for children from birth through age 18, even if one or both parents are working. It includes four different parts. When you apply for the insurance, Florida KidCare will check which part your child may qualify for based on age and family income. MEDIKIDS: children ages 1 through 4. HEALTHY KIDS: children ages 5 through 18. CHILDREN’S MEDICAL SERVICES NETWORK: children birth through 18 who have special health care needs. MEDICAID: children birth through 18. A child who has other health insurance may still qualify for Medicaid.
Healthcare Acronyms •CMS - Centers for Medicare and Medicaid Services VETERANS ADMINISTRATION & TRICARE •Veterans Administration Health Care System – The VA system operates hospitals, outpatient clinics and nursing homes, nationwide. The program is intended to provide comprehensive health care to those veterans with severe service-related disabilities. For other veterans, the program is intended to provide care for service-connected disabilities and to act as a safety net for veterans with limited access to health care. The VA administers a health benefits program that covers services defined by the individual veteran's benefit eligibility. For additional information, visit the VA System website at http://www.va.gov/health_benefits/ •TRICARE Military (Civilian Health and Medical Programs of the Uniformed Services) This program of health care delivery provides insurance coverage for active duty military personnel, their dependents and military retirees. The TRICARE program is managed by the military in partnership with civilian contractors. (i.e. Humana) The program provides two options: 1. TRICARE Prime: managed-care option, similar to a civilian HMO plan. 2. TRICARE Standard (PP0): a fee-for-service option, offering comprehensive health care coverage, for those not enrolled in TRICARE Prime. Standard offers the greater flexibility in choosing a provider, but it will also involve greater out-of-pocket expenses (annual deductible, copayments and co-nsurance) for the patient. TRICARE Extra: can be used by any TRICARE eligible beneficiary, who is not active duty, and not enrolled in Prime. Extra is essentially a supplemental plan for an for TRICARE Standard members who want to save on out-of- pocket expenses by making an appointment with a TRICARE Prime network provider. Several of these programs require the services of a primary care case manager. For more details visit the TRICARE website at - http://www.tricare.osd.mil/ • JCAHO - Joint Commission on Accreditation of Healthcare Organizations •OSHA Occupational Safety and Health Administration •SNF - Skilled Nursing Facility •PHT - Public Health Trust •SCHIP - State Children's Health Insurance Program •WIC - Women's, Infants, and Children Program at the US Dept of Agriculture •HIPPA - Health Insurance Portability and Accountability Act •CDC - Center for Disease Control and Prevention •VA - Veterans Affairs
CASE SCENARIO Directions: In groups, discuss and then present how you would handle the following scenarios: 1. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Patient has CarePlus (noncontracted HMO). What should the receptionist tell the patient? 2. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Care PPO (non- contracted PPO). What should the receptionist tell the patient? 3. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Patient has Mutual of Omaha Indemnity plan. What should the receptionist tell the patient? 4. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Patient has Care POS, (noncontracted POS) and is authorized to see UM physician as in-network. What should the receptionist tell the patient?
Levels of Medical Care PRIMARY CARE (PCP) - total health of the patient (e.g. Internal Medicine, Family Medicine, Pediatrics, OB/GYN) SECONDARY CARE (SPECIALTY) - routine specialty care (e.g. Dermatology, Cardiology, Surgery, Ortho/Reh ab etc…) TERTIARY CARE - is complex medical treatment rarely available in the community, outside of academic medical centers (i.e. Specialist referrals to Specialist, transplants, revisions).
SINGLE CASE NEGOTIATIONS (SCN) The University of Miami conducts a SCN when the patient has a noncontracted HMO and needs specific care that is not commonly found in the community. WE DO NOT DO SINGLE CASE NEGOTIATIONS FOR: •Non-contracted PPO - members have out of network benefits •Indemnity plans •Self pay patients If the patient needs a SCN do not give them an appointment, have them call their HMO health plan representative who will call our nurse case manager to coordinate the authorization. If the service is approved the patient will call back to schedule an appointment with an authorization number.
Via telephone calls, faxes or email from: PCPs Specialists Insurance Company Hospital Admissions UMMG Departments Physician Referral Office - PRO BPEI appointments UMMG case management notified of need for Single case Notification from insurance company? YES Letter of Agreement is generated Letter is signed? NO Appropriate departments are notified YES Create case in UChart System
Best Practices • • • • • • Always verify member eligibility and plan benefits Always check to see if referral or authorization is required for the service Always collect member copayment or deductible Always send consult report back to referring physician Always use the Contract Summary as a reference tool Always treat patients with respect and courtesy • • • • Always accept all contracted plans, non-contracted PPOs and indemnity plans Always notify Health Plan Relations of problems, issues and changes with any of the insurance plans (#243-7141) Always notify UMMG Credentialing office (#243-7688) of changes, additions and deletions to faculty practice Always notify UMMG Business Dev. (#243-5273) of problems with online services (i.e. Medifax, Availity, jhsdomc.org, unitedhealthcareonline, et c…)
On-line Activity Directions: Answer the following questions using the Contract Summary online. 1. AvMed •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this health plan? 2. BCBS – Health Options •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this health plan? 3. Cigna •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this health plan? 4. Humana •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this health plan?
5. JHS Division of Managed Care (JMH Health Plan) •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this health plan? 6. Aetna •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this health plan? 7. Neighborhood Health Partnership - NHP •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this healthplan? 8. Vista Health Plan of South Florida •At what LEVEL OF CARE do we accept patients? •List the UChart Registration Coverage •List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY. •What Specialty Networks contract for this healthplan?
Module 2 UCHART
Scheduling Registration Work Flow http://www.youtube.com/watch?v=oypYhRyiCg8 Private Link Video Demonstration
UChart Sched/Reg Flow Universal Registration Appointment Entry Screen Specific Appointment Registration
Difference between Hospital Visits and Non Hospital. The Difference between
Guarantors Who is the Guarantor for Medical Bills ? Who the guarantor is for medical bills depends on a couple things. An adult that obtains medical care is responsible for their own medical bills, so they are the guarantor. If a child is taken for medical care then there are a couple things that can determine who is guarantor. The parent who takes the child for care normally signs a paper that states they are responsible for any expenses. Of course, if there are court orders stating a certain parent is responsible for all medical expenses, then it can be enforced.
Guarantor Summary Screen Example of Multiple Accounts
Guarantors Coverage & Add Add’l Coverage Info for Specific Account
Coverage Summary Example with multiple Guarantors
Reg-Appointment Screen Universal Specific Appt registration
POS-22 and POS-11 Hospital Accounts vs. Visit Accounts
Reg-Appt Specific CheckList
UChart Coverage Field
Calcification Inhibitors in CKD and Dialysis Patients
Insurance1.2 uchart - SlideShare Feb 18, 2014 Full Name. Enrollment is voluntary and requires a monthly premium payment. BCBS , AARP HOSPITAL Inpatient ...