Health Information System

Helpm31990

Chapter08.ppt

Home >Information Systems homework help >Health Information System

CHAPTER

Third-Party Payers

McGraw-Hill

Learning Outcomes

When you finish this chapter, you will be able to:

8.1 Compare the major features of PPO, HMO, and POS health plans.

8.2 Identify the two parts of CDHPs.

8.3 Discuss the organization and regulation of employer- sponsored group health plans and self-insured plans.

8.4 Explain the purpose of Medicare Parts A, B, C, and D.

8.5 Describe the fee structures that are used to set charges.

8-2

McGraw-Hill

Learning Outcomes (Continued)

When you finish this chapter, you will be able to:

8.6 Identify the three methods most payers use to pay physicians.

8.7 Maintain insurance carrier information in the PM/EHR.

8-3

McGraw-Hill

Key Terms

allowed charge
balance billing
Blue Cross and Blue Shield Association (BCBS)
capitation (cap) rate
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
consumer-driven (directed) health plan (CDHP)

8-4

disability compensation programs
discounted fee-for-service
dual-eligible
Employment Retirement Income Security Act of 1974 (ERISA)
Federal Employees Health Benefits (FEHB)
fee schedule
flexible savings account (FSA)

Teaching Notes: There are a lot of key terms, so here are some options to help present them:

Put students into small groups and assign each group a set of terms to define and learn. Then have each group teach their set of terms to the rest of the class.

Assign each student a set number of terms to define as a homework assignment and then discuss the terms together during class.

Ask students whether any of the key terms are familiar to them already; use their responses to launch a discussion of the rest of the terms.

McGraw-Hill

Key Terms (Continued)

group health plan (GHP)
health maintenance organization (HMO)
health reimbursement account (HRA)
health savings account (HSA)
high-deductible health plan (HDHP)
individual health plan (IHP)
Medicaid

8-5

Medicare
Medicare Part A, Hospital Insurance (HI)
Medicare Part B, Supplementary Medical Insurance (SMI)
Medicare Part C, Medicare Advantage
Medicare Part D
Medicare Physician Fee Schedule (MPFS)
Medigap

Teaching Notes: See notes on Slide 4.

McGraw-Hill

Key Terms (Continued)

Medi-Medi beneficiary
Original Medicare Plan
point-of-service (POS) plan
preferred provider organization (PPO)
primary care physician (PCP)
relative value scale (RVS)
resource-based relative value scale (RBRVS)

8-6

self-insured health plans
third-party payer
TRICARE
usual, customary, and reasonable (UCR)
usual fees
workers’ compensation insurance
write off

Teaching Notes: See notes on Slide 4.

McGraw-Hill

8.1 Types of Health Plans

8-7

Third-party payer—private or government organization that insures or pays for health care on behalf of beneficiaries
Preferred provider organization (PPO)—managed care network of health care providers who agree to perform services for plan members at discounted rates
The policyholder pays an annual premium and a yearly deductible.
A PPO may offer either a low deductible with a higher premium or a high deductible with a lower premium.

Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans.

Teaching Notes: Slides 8-7 through 8-10 list the various types of health plans. Consider the following options for covering and discussing the plans:

Draw a table on the board that lists the insurance types along the left side and various pieces of information (annual premium, needs referrals, copayments, etc.) along the top. Use this table to create a compare-contrast grid by checking the pieces of informational that fit each insurance type.

Provide descriptions of each type of insurance and the names of each type; see if students can match each type to its description.

Put students into groups and have each group research one type of insurance. Then have the group “teach” the type to the class.

Cite the advantages and disadvantages of each type of plan, and note what might cause a patient to choose one type over another.

McGraw-Hill

8.1 Types of Health Plans (Continued)

8-8

PPO features (continued):
Members typically pay a copayment at the time of service, and coinsurance may also be charged.
Patients may see out-of-network doctors without a referral or preauthorization; the amount they have to pay will be higher.
Health maintenance organization (HMO)—managed care system in which providers offer health care to members for fixed periodic payments
This type of health plan has the most stringent guidelines and the narrowest choice of providers.

Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans.

Teaching Notes: See notes on Slide 7.

McGraw-Hill

8.1 Types of Health Plans (Continued)

8-9

HMO features (continued):
A Primary care physician (PCP) is a physician in a managed care organization who directs all aspects of a patient’s care; members are assigned to a PCP.
Members must use their HMO’s network except in emergencies or pay a penalty.
HMOs are organized around one of three business models: the staff model, the group or network model, and the independent practice association model.

Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans.

Teaching Notes: See notes on Slide 7.

McGraw-Hill

8.1 Types of Health Plans (Continued)

8-10

Point-of-service (POS) plan—managed care plan that permits patients to receive medial services from nonnetwork providers
A POS plan is a hybrid of HMO and PPO networks.
Members may choose from a primary or secondary network.
This kind of plan charges annual premiums and copayments for office visits.
Indemnity or fee-for-service plans require premium, deductible, and coinsurance payments.

Learning Outcome: 8.1 Compare the major features of PPO, HMO, and POS health plans.

Teaching Notes: See notes on Slide 7.

McGraw-Hill

8.2 Consumer-Driven Health Plans

8-11

Consumer-driven (directed) health plan (CDHP)—medical insurance that combines a high-deductible health plan with one or more tax-preferred savings accounts that the patient directs
High-deductible health plan (HDHP)—health plan that combines high deductible insurance and a funding option to pay for patients’ out-of-pocket expenses up to the deductible
First part of a CDHP
Annual deductible over $1,000

Learning Outcome: 8.2 Identify the two parts of CDHPs.

Teaching Notes: Explain the reasons for a high deductible; discuss what happens when a patient reaches the deductible limit.

McGraw-Hill

8.2 Consumer-Driven Health Plans (Continued)

8-12

The second part of a CDHP involves one of three types of funding options:
Health reimbursement account (HRA)—CDHP funding option where an employer sets aside an annual amount for health care costs
Health savings account (HSA)—CDHP funding option under which funds are set aside to pay for certain health care costs
Flexible savings account (FSA)—CDHP funding option that has employer and employee contributions

Learning Outcome: 8.2 Identify the two parts of CDHPs.

Teaching Notes: Have students debate which of these three funding options is best; encourage them to look deeper than “HRA is best because an employer pays it.”

McGraw-Hill

8.3 Private Insurance Payers and Blue Cross and Blue Shield

8-13

Group health plan (GHP)—plan of an employer or employee organization to provide health care to employees, former employees, and/or their families
Human resource departments manage the health care benefits.
Riders, or options, are often offered for vision and dental services.
During open enrollment periods, employees choose the plans they prefer for the coming benefit period.
This kind of health plan must follow federal and state laws.

Learning Outcome: 8.3 Discuss the organization and regulation of employer-sponsored group health plans and self-insured plans.

Teaching Notes: For slides 8-13 through 8-15, consider the following options for covering and discussing the various types of health plans. (NOTE: CHOSE AN OPTION THAT YOU DID NOT PICK FOR SLIDES 8-7 through 8-10):

Draw a table on the board that lists the insurance types along the left side and various pieces of information (annual premium, needs referrals, copayments, etc.) along the top. Use this table to create a compare-contrast grid by checking the pieces of informational that fit each insurance type.

Provide descriptions of each type of insurance and the names of each type; see if students can match each type to its description.

Put students into groups and have each group research one type of insurance. Then have the group “teach” the type to the class.

Cite the advantages and disadvantages of each type of plan, and note what might cause a patient to choose one type over another.

McGraw-Hill

8.3 Private Insurance Payers and Blue Cross and Blue Shield (Continued)

8-14

Federal Employees Health Benefits (FEHB)—health care program that covers federal employees
Self-insured health plans—health insurance plans paid for directly by the organization, which sets up a fund from which to pay
These do not pay premiums to insurance carriers or managed care organizations.
These set up their own provider networks or lease the use of managed care organizations’ networks.

Learning Outcome: 8.3 Discuss the organization and regulation of employer-sponsored group health plans and self-insured plans.

Teaching Notes: See notes on Slide 13.

McGraw-Hill

8.3 Private Insurance Payers and Blue Cross and Blue Shield (Continued)

8-15

Employee Retirement Income Security Act of 1974 (ERISA)—law providing incentives and protection for companies with employee health and pension plans
The law regulates self-insured health plans.
Individual health plan (IHP)—medical insurance plan purchased by an individual
Blue Cross and Blue Shield Association (BCBS)—licensing agency of Blue Cross and Blue Shield plans

Learning Outcome: 8.3 Discuss the organization and regulation of employer-sponsored group health plans and self-insured plans.

Teaching Notes: See notes on Slide 13.

McGraw-Hill

8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans

8-16

Medicare—federal health insurance program for people sixty-five or older and some people with disabilities
Medicare Part A, Hospital Insurance (HI)—program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care
Medicare Part B, Supplementary Medical Insurance (SMI)—program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies

Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D.

Teaching Notes: For slides 8-16 through 8-20, consider the following options for covering and discussing the various types of health plans. (NOTE: CHOSE AN OPTION THAT YOU DID NOT PICK FOR SLIDES 8-7 through 8-10 and 8-13 through 8-15):

Draw a table on the board that lists the insurance types along the left side and various pieces of information (annual premium, needs referrals, copayments, etc.) along the top. Use this table to create a compare-contrast grid by checking the pieces of informational that fit each insurance type.

Provide descriptions of each type of insurance and the names of each type; see if students can match each type to its description.

Put students into groups and have each group research one type of insurance. Then have the group “teach” the type to the class.

Cite the advantages and disadvantages of each type of plan, and note what might cause a patient to choose one type over another.

McGraw-Hill

8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)

8-17

Original Medicare Plan—Medicare fee-for-service plan
Medigap—plan offered by a private insurance carrier to supplement Medicare coverage
Medicare Part C, Medicare Advantage—managed care health plan under the Medicare program
Medicare Part D—Medicare prescription drug reimbursement plans

Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D.

Teaching Notes: See notes on Slide 16.

McGraw-Hill

8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)

8-18

Medicaid—federal and state assistance program that pays for health care services for people who cannot afford them
Medi-Medi beneficiaries—people eligible for both Medicare and Medicaid
Dual-eligible—Medicare-Medicaid beneficiary
TRICARE—government health program serving dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members

Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D.

Teaching Notes: See notes on Slide 16.

McGraw-Hill

8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)

8-19

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)—health care plan for families of veterans with 100 percent service-related disabilities and the surviving spouses and children of veterans who die from service-related disabilities

Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D.

Teaching Notes: See notes on Slide 16.

McGraw-Hill

8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans (Continued)

8-20

Workers’ compensation insurance—state or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment
Disability compensation programs—programs that provide partial reimbursement for lost income when a disability prevents an individual from working

Learning Outcome: 8.4 Explain the purpose of Medicare Parts A, B, C, and D.

Teaching Notes: See notes on Slide 16. Also, when discussing workers’ compensation insurance, do the following:

Explain that workers’ compensation includes five types of payment:
payment for medical treatments,
payment for temporary disability (to replace lost wages),
permanent disability payments,
compensation for dependents of employees who are fatally injured, and
payments in the form of vocational rehabilitation.

Provide examples of current/recent workers’ compensation suits; have students debate whether workers’ compensation insurance is a help or hindrance. Ask them if they think employees abuse the insurance, and have them explain their reasoning. This could be done as a large or small group, or as an individual assignment.
While this might be a touchy, potentially volatile subject, it is one worth discussing. Tie responses to class lecture and the text information.

McGraw-Hill

8.5 Setting Fees

8-21

Fee schedule—document that specifies the amount the provider bills for services
Usual fees—normal fees charged by a provider
Most payers use one of three methods to set the fees that their plan will pay physicians:
Usual, customary, and reasonable (UCR)—fees set by comparing usual fees, customary fees, and reasonable fees
Relative value scale (RVS)—system of assigning unit values to medical services based on their required skill and time
Resource-based relative value scale (RBRVS)—relative value scale for establishing Medicare charges

Learning Outcome: 8.5 Describe the fee structures that are used to set charges.

Teaching Notes: Explain that billers are the ones that commonly hear questions from patients about fees; it is important for them to know the ins and outs of the payment plans.

Important: Most practices set their fees slightly above those paid by the highest reimbursing plan in which they participate.

McGraw-Hill

8.5 Setting Fees (Continued)

8-22

Medicare Physician Fee Schedule (MPFS)—RBRVS-based allowed fees that are the basis for Medicare reimbursements

Learning Outcome: 8.5 Describe the fee structures that are used to set charges.

Teaching Notes: Ask students which of the three methods for determining payer fees seems to be the most fair? Most logical? Why?

Explain that there are three parts to an RBRVS fee, which are updated every year:

Nationally uniform relative value unit
Geographic adjustment factor
Nationally uniform conversion factor

McGraw-Hill

8.6 Third-Party Payment Methods

8-23

Payers use one of three main methods of paying providers:
Allowed charges
Contracted fee schedules
Capitation
Allowed charge—maximum charge a plan pays for a service or procedure
Balance billing—collecting the difference between a provider’s usual fee and a payer’s lower allowed charge

Learning Outcome: 8.6 Identify the three methods most payers use to pay physicians.

Teaching Notes: Use Table 8.2 in the text to enhance discussion; use the examples on pages 405-406 to illustrate the abstract concepts for students.

McGraw-Hill

8.6 Third-Party Payment Methods (Continued)

8-24

Write off—to deduct an amount from a patient’s account
Discounted fee-for-service—payment schedule for services based on a reduced percentage of usual charges
Capitation (cap) rate—periodic prepayment to a provider for specified services to each plan member

Learning Outcome: 8.6 Identify the three methods most payers use to pay physicians.

Teaching Notes: See notes on Slide 23.

McGraw-Hill

8.7 Maintaining Insurance Information in the PM/EHR

8-25

Setting up insurance carriers correctly in the PM/EHR is essential to getting claims paid in a timely manner.
To maintain insurance carrier information in MCPR:
Access the information by selecting Insurance on the Lists menu.
Select Carriers (to enter, edit, or delete carriers) or Classes (for reporting) on the submenu that appears.
Select the Carriers option; the Insurance Carrier List dialog box is displayed.

Learning Outcome: 8.7 Maintain insurance carrier information in the PM/EHR.

Teaching Notes: Note that insurance carriers for a practice must be set up in MCPR before they can be assigned to patients and/or maintained.; the Insurance Carrier dialog box for each carrier contains all pertinent information.

McGraw-Hill

8.7 Maintaining Insurance Information in the PM/EHR (Continued)

8-26

Maintaining carrier information (continued):
Use the Edit, New, and Delete buttons to change, create, and delete insurance carriers.
Use the Print Grid button to print the information.
Close the dialog box using the Close button.

Learning Outcome: 8.7 Maintain insurance carrier information in the PM/EHR.

Teaching Notes: While walking through the steps required to maintain insurance information, use the screenshots in the text to aid understanding. Before assigning the exercises, ask students if they have any outstanding questions on the process of working with insurance information.

Have students complete Exercises 8.1-8.6.