Medical Insurance

1
Medical Insurance

• Chapter 3
• Basics of Health Insurance

2
Health Insurance

• Contract between policyholder and insurance
  carrier to reimburse for all or a portion of the
  cost of medical treatment
• Purpose to help offset high costs accrued
• Managed Care to control cost and to help those
  unable to afford health ins.

3
Legal Principles

• Ignorance is not a defense
• Legal issues usually fall under civil law
• Insurance is regulated by state laws and not
  federally regulated except for HIPAA and OIG
  federal regulations

4
Insurance Contracts

• Four considerations
• Mentally competent adult not under influence of
  drugs or alcohol
• An offer and an acceptance
• Exchange of value - consideration
• Legal purpose
• Challenged policy
• Incontestable

5
Physician/Patient Contracts

• Begins with accepting the patient and agrees to
  treat
• Implied contract
• Expressed contract
• Written
• Verbal

6
Financial Obligations

• Private patients contract between patient and
  physician
• PPO patient
• Guarantor one who promises to pay the medical
  bills
• Emancipated minor
• Managed care patients
• Employment and Disability examination
• Workers compensation patients

7
Insurance Policy

• Basic health
• Major medical
• Insured, subscriber, member, policyholder,
  recipient
• Dependents

8
Insurance Terms

• Applicant
• Contract
• Renewal Provisions
• Premium
• Grace period
• Deductible
• Coinsurance - copayment

9
Terms continued

• Elimination or Waiting Period
• Claim
• Time limit
• Reimbursement or indemnity

10
Coordination of Benefits

• Patient has more than one insurance policy
• Insurance companies coordinate the reimbursement
• Prevents duplication of payments

11
C of B Rules

• Non-Dependent/Dependent
• The benefits of the plan which covers the person
  as an employee, member, or subscriber are
  determined before those of the plan which covers
  the person as a dependent.

12
C of B

• Dependent Child/Parents Not Separated or Divorced
• The benefits of the plan of the parent whose
  birthday falls earlier in a year are determined
  before those of the plan of the parent whose
  birthday falls later in that year

13
Not Separated cont.

• If both parents have the same birthday, the
  benefits of the plan which covered the parent
  longer are determined before those of the plan
  which covered the other parent for a shorter
  period of time
• The word birthday refers only to month and day
  in a calendar year, not the year in which the
  person was born.

14
C of B

• Dependent Child/Separated or Divorced Parents
• If the specific terms of a court decree state
  that one of the parents is responsible for the
  health care expenses, the benefits of that plan
  are determined first. The plan of the other
  parent shall be the secondary plan.

15
Separated cont.

• If the specific terms of the court decree state
  that the parents shall share joint custody,
  without stating that one of the parents is
  responsible for the health care expenses of the
  child, the plans covering the child shall follow
  the order of benefit determination rules outlined
  for Dependent Child/Parents Not Separated or
  Divorced.

16
Separated cont.

• First, the plan of the parent with custody of the
  child
• Then, the plan of the spouse of the parent with
  the custody of the child and
• Finally, the plan of the parent not having
  custody of the child.

17
More Terms

• Exclusions
• Preexisting conditions
• Waiver or rider

18
Preapproval

• Eligibility
• Precertification
• Preauthorization
• Predetermination

19
Insurance Choices

• Group contract
• Conversion privilege
• Income continuation benefits
• Medical savings account
• Individual contract
• Prepaid Health Plan
• Capitation

20
Methods of Processing

• Manually preparing claims
• In-office electronic filing
• Contracting outside service
• Telecommunications networking system

21
Handling and Processing

• Patient Registration Form
• Insurance Identification Card

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• Patients Signature Requirements
• Assignment
• Participating/nonparticipating
• Encounter Form
• Source document
• Physicians Signature
• Determine Fees
• Ledger Card

24

• Insurance Form
• Providers Signature
• Pending File/Claims Register
• Insurance Payments
• Monthly Statements

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