Commercial Insurance

Transcription

1 covers medical expenses of individuals and groups Types of benefits and policies vary Group vs. Individual coverage Regulated by individual states 2 1

2 Fee-for-Service Types of Coverage High-Risk pools Managed care Association health insurance 3 High Risk Pools High risk pools and the individuals they cover These policies are expensive They have catastrophic limits Verification is important 4 2

3 Automobile Insurance Mandatory in most states Personal Injury Protection (PIP) No fault coverage/medical coverage Comprehensive Collision Property damage Uninsured motorist 5 Automobile Specifics Block 10 on the CMS Policy Limits Verification is necessary 10. IS PATIENT CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous) YES NO b. AUTO ACCIDENT? YES NO c. OTHER ACCIDENT? PLACE (State) Covered Expenses YES NO 6 3

4 Disability Insurance Definition Separation of patient records The importance of signed authorizations What is usually paid When they can be denied The length of disability 7 Liability Insurance Liability Insurance covers losses to an injured party A medical office must handle these claims carefully Liability covers medical bills and other expenses Liability also covers pain and suffering 8 4

5 Subrogation The contractual right of a third-party payer to recover healthcare expenses from a liable party. 9 Commercial Group Plans Aetna Cigna United Health Care Humana

6 Inclusive services Duplicate claims Common Denials Incorrect and/or incomplete patient identifier information Coverage terminated Services non-covered/require prior authorization or pre-certification 11 Payer contract NCCI edits Payer s bundling edits Inclusive Services 12 6

7 Payer contract NCCI edits Payer s bundling edits Inclusive Services Contract example: Urinalysis with office visit If the payer includes in the contract that a urinalysis is included in the office visit, the urinalysis will need to be adjusted. 13 Duplicate Claims Outstanding claims automatically re-filed All open claims should be researched before rebilling 14 7

8 Duplicate Claims Outstanding claims automatically re-filed All open claims should be researched before rebilling Duplicate posting of charges 15 Duplicate Claims Outstanding claims automatically re-filed All open claims should be researched before rebilling Duplicate posting of charges Two physicians with the same charges Surgery (modifier 62) Radiology (modifiers TC and 26) 16 8

9 When To Re-file How long should you wait before a re-file? Make it a practice of your practice to call or access electronically the Insurance program and verify the status of the claim in question Make sure your software is not electronically automatically submitting these claims for you Resubmit only denied charges if information is corrected or additional information is submitted with the claim 17 Common Denials Incorrect and/or Incomplete Patient Identifier Information Verify patient demographic and insurance information at EVERY visit Copy the patient s insurance card so you have the proper information Update on each visit Coverage Terminated 18 9

10 Insurance Card 19 Insurance Card 20 10

11 Insurance Card 21 Insurance Card 22 11

12 Insurance Card 23 Insurance Card 24 12

13 Common Denials Verify coverage Services non-covered Require prior authorization or pre-certification 25 Both In/Out of Network Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis at a Hospital or Alternate Facility include: Lab and radiology/x-ray. Mammography. Benefits under this section include: The facility charge and the charge for supplies and equipment. Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) When these services are performed in a Physicians office, Benefits are described under Physicians Office Services - Sickness and Injury. Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services. CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are described under Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine - Outpatient. PRIOR NOTIFICATION Not required. In Network Lab Testing - Outpatient X-Ray and Other Diagnostic Testing - Outpatient PAYMENT AMOUNT COINSURANCE: 80% Out of Network Lab Testing - Outpatient X-Ray and Other Diagnostic Testing - Outpatient PAYMENT AMOUNT COINSURANCE: 55% 26 13

14 Appeals Each carrier differs Appeal process 27 Aetna Dispute A disagreement regarding a claim or utilization review decision File within 180 days from the date of the initial decision Provide Reason you disagree with the decision Denial letter, EOB statement or overpayment letter and the original claim Appropriate documentation to support the dispute Source:

15 Reconsideration Formal review of a previous claim reimbursement or coding decision, or a claim that requires reprocessing Reconsideration dispute levels: Level 1 Appeal Level 2 Appeal Aetna Source: 29 Cigna Insurance First-Level Appeals All first-level appeals must be submitted in writing within 180 calendar days of the date of the initial payment or denial notice or, if the appeal relates to a payment that was adjusted by CIGNA HealthCare, within 180 calendar days from the date of the last payment adjustment. Second Level appeals require contact with the company for directions 30 15

16 United Health Care Claim Reconsideration Request - This request will be handled as a Claim Reconsideration. A Claim Reconsideration is the first step of the Dispute Resolution Process The reconsideration must be submitted within 180 days. The company has 30 days to review A Formal Appeal is the next step 31 Humana Insurance Humana plans are not readily available on the internet A provider must be registered to use their site The information is extensive The registration is fairly simple The website will walk you through the entire process 32 16

17 CMS 1500 Claims Contract or Web Site Information Block 1, Group Health Plan 33 Commercial Claim Instructions Block 1, the X goes in: Family or individual policy OTHER space Group health plan Group Health Plan Block 2-9 is the same as other insurances Block 10 indicates when the patient s condition is related to employment, automobile accident, or another type of accident. Block and 17 is completed as other insurance claims 34 17

18 Blocks 14, 15, 16, and 18 Liability Coverage Block 14 date for current illness, injury, or pregnancy Block 15 date if patient had same or similar illness Block 16 dates patient is unable to work Block 18 dates of hospitalization 35 Block 19 Block 19 is generally left blank Liability claims may require information Block 19 is reserved for explanations of CPT or HCPCS codes 36 18

19 Block 25, 26, 28, and 29 Blocks 25, 28, and 29 Block 26 is for the patient account number 37 Block 27 Block 27 is accepting assignment It is not necessary to accept assignment If the provider chooses, a NO can be checked here 38 19

20 Commercial Group Health Plans Employers use Group Health plan coverage as a benefit to their employees. There is only one CMS 1500 Form modification 39 Individual Health Coverage Purchased by the individual Premiums are higher Deductibles are higher Co-Insurance amounts are higher Verification is important 40 20

21 REVIEW There are several different types of commercial coverage We have studied the highlights The most important thing to remember is the verification of the coverage 41 The End 42 21