CHAA Examination Preparation

1
CHAA Examination Preparation

• Pre-Encounter - Session V
• Pages 62-69
• University of Mississippi Medical Center

2
What to Expect

• This module covers various aspects of Patient
  Access knowledge found in pages 62-69 of the
  Pre-Encounter section of the 2010 CHAA Study
  Guide.
• A quiz at the end will measure your understanding
  of the content covered.

3
Medicaid

• Medicaid was established by federal legislation
  in 1965 to provide health care coverage for
  categories of low-income people.
• States have the freedom to design their program
  and decide
• Eligibility standards
• What benefits and services to cover
• What payment rates to charge

4
Medicaid Qualifications

• Medicaid Qualifications Include
• Certain low income families with children
• Aged, blind or disabled people on Supplemental
  Security Income
• Certain low income pregnant women and children
• Certain people who would not otherwise be
  eligible but qualify as the result of
  catastrophic medical expenses

5
Medicaid Miscellaneous

• Qualifying for Medicaid coverage is determined by
  the patient MEETING SPECIFIC FINANCIAL CRITERIA.
  Therefore, after eligibility is granted, the
  beneficiarys FINANCIAL STATUS is EVALUATED on a
  REGULAR BASIS.
• Medicaid can contract with HMOs as determined by
  each individual State.
• MEDICAID IS A SECONDARY PAYER WITH RESPECT TO
  MEDICARE

6
Workers Compensation

• This insurance coverage is for services needed as
  a result of a work related accident or injury.
• It is paid by the patients employer or their
  Workers Compensation insurance company.
• The EMPLOYER MUST AUTHORIZE workers compensation
  services.

7
Workers Compensation Key Information

• When registering a patient with a work related
  injury/illness, be sure to obtain
• -Time and Date of Injury
• -Type of Injury
• -Name of employer and contact person
• -Immediate Supervisor
• -Employee Insurance Info (in case injury is
  deemed not work-related)
• Classify patient as Workers Compensation and
  note who should receive the bill.

8
Auto Insurance

• This is coverage for injuries that are the result
  of an auto accident.
• If injuries are auto-related and patient has
  Medicare or Medicaid as their primary insurance,
  the AUTO INSURANCE would be primary.

9
Liability Insurance

• Liability insurance is for injuries resulting
  from the NEGLIGENCE of another party.
• If a patient slips and falls on a wet floor that
  WASNT POSTED WITH A SIGN, then the business
  could be determined liable for the accident and
  therefore responsible for the medical bills.
• For Medicare Patients, liability should be
  IDENTIFIED by the MEDICARE SECONDARY PAYER
  QUESTIONNAIRE.
• Liability Insurance should be billed PRIOR TO
  BILLING MEDICARE.

10
COMMERCIAL INSURANCE

• This is any insurance that IS NOT
• Medicare/Medicaid
• Federal, State, or County Programs
• Workers Compensation
• BLUE CROSS
• Auto
• PPO or HMO
• Patients with commercial insurance are NOT
  REQUIRED to select a PRIMARY CARE PHYSICIAN or go
  to a SPECIFIC PROVIDER.

11
Preferred PROVIDER Organization (PPOs)

• PPOs are contracts between EMPLOYERS, DOCTORS,
  and HOSPITALS.
• For PPOs
• Doctors and hospitals agree to provide their
  services at a discount in return for getting a
  large volume of patients who are PPO members.
• Members are NOT REQUIRED to select a Primary Care
  Physician.
• However, they MUST use a PARTICIPATING PROVIDER
  to obtain FULL COVERAGE.

12
Health MAINTENANCE Organization (HMOs)

• HMOs are insurance plans that strive to control
  health care costs by requiring members to receive
  services at DESIGNATED FACILITIES.
• For HMOs
• Typically, patients must choose a PRIMARY CARE
  PHYSICIAN (PCP) who will be responsible for the
  oversight of all the patients healthcare.
• All services, except those in life threatening
  situations, must be approved by the PCP.
• Most HMOs identify the policy holder with a
  suffix of -00, the spouse as -01, and subsequent
  dependants as -02, -03, etc.

13
PPO vs. HMO

• PPO
• Between employers, doctors, and hospitals
• Beneficiaries must use Participating Providers to
  obtain full coverage

• HMO
• Strive to control health care costs by using
  Designated Facilities
• Members must choose a PCP
• Use suffix -00, -01, -02, etc.

14
Tricare

• Tricare is a health care program overseen by the
  Department of Defense.
• Tricare Prime all active duty service members
  are enrolled in this program which is similar to
  an HMO.
• Tricare Extra Similar to a PPO
• Tricare Standard Fee for service option
• Tricare for Life Provides expanded coverage for
  Medicare eligible beneficiaries
• CHAMPVA Health coverage for families of
  veterans with 100 service connected disability
  and the surviving spouse or children of a veteran
  who dies from service related disability

15
Payer Websites

• Its acceptable to verify only basic information
  via website. Information such as
• -Date coverage began
• -Is the policy active or inactive
• -Is patient the policy holder or a dependant
• -Deductible and co-pay information
• Its preferable to speak to a representative for
  accurate coverage information regarding specific
  service coverage and if pre-certification/authoriz
  ation is needed.

16
Common Working File (CWF)

• This verification system is LINKED TO MEDICARE
  and is a tool for verifying
• Part A and B status and effective dates
• If the patient has Medicare Advantage Plan (Part
  C)
• If the patient or spouse is employed and/or
  covered by employee insurance
• If a case is open for a patient where they were
  involved in an accident where a third party may
  be responsible for payment
• Number of full/partial days remaining in the
  benefit period or the number of SNF days
  remaining
• If the patient is on Hospice care

17
Verifying Medicaid

• Medicaid can be verified through your States
  website and/or their Common Working File
  Verification System

18
Verification of Benefits

• The first step in verifying benefits is calling
  the insurance company to confirm eligibility.
  The insurance company will tell you what services
  are covered and if the member is currently
  eligible.
• The following items need to be confirmed
• 1. PRE-CERTIFICATON/PRE-AUTHORIZATION some
  insurance companies require this from the PCP
  prior to services.

19
Verification of Benefits

1. OUT-OF-POCKET MAXIMUM the maximum amount of
   money toward eligible expenses that A COVERED
   PERSON MUST PAY for themselves and/or dependants
   in a year. Once this limit is reached, benefits
   will increase to 100.
2. DEDUCTIBLE the amount of eligible expenses a
   covered person must pay each year from their own
   pocket before the plan begins paying for eligible
   expenses.
3. CO-PAYMENT A predetermined payment that must be
   made by the covered beneficiary at the time of
   service.

20
Verification of Benefits

1. CARVE OUT this is where certain benefits are
   offered by a specialized vendor on a stand-alone,
   as needed basis.
2. LIFETIME MAXIMUM Many payers have a calendar
   year and lifetime maximum on benefits paid. Once
   maximum is reached, benefits are exhausted.
3. VERIFICATION OF PHYSICIAN This is making sure
   the attending physician is on the panel for the
   patients insurance. If not, patient may have to
   pay more.

21
Coordination of Benefits (COB)

• COORDINATION OF BENEFITS is the term used to
  describe determining the order in which benefits
  are paid, and the amounts that are payable WHEN A
  PATIENT IS COVERED BY MORE THAN ONE HEALTH
  INSURANCE PLAN.
• Its intention is to prevent DUPLICATION OF
  PAYMENTS.

22
Coordination of Benefits (COB)

• When children are covered under both parents
  insurance plans, you apply the BIRTHDAY RULE.
• That is, the plan of the parent whose birthday
  (using both month and day) occurs earlier in the
  year is primary.

23
Coordination of Benefits (COB)

• Regarding children when parents are not together,
  you ALWAYS OBEY THE COURT DECREE.
• When no court decree exists, follow this order
• The plan of the parent with custody is Primary
• The plan of the stepparent with custody is
  Primary
• The plan of the parent who does not have custody
  is Primary
• The plan of the non-custodial parent is Primary

24
Authorization Medical Necessity

• AUTHORIZATION means that, based on the
  information provided, all the requirements are
  satisfied under the benefits health plan for
  medical necessity, and the payer will pay for
  the service.
• MEDICAL NECESSITY describes a health care service
  that a provider, EXCERCISING PRUDENT CLINICAL
  JUDGEMENT, would provide to a covered person for
  the purpose of evaluating, diagnosing, or
  treating an illness, injury, disease or its
  symptoms.
• In other words, the treatment is appropriate and
  necessary.