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Insurance

Insurance. Lori Howard. Claim Premium Deductible Benefits Primary Coverage Secondary Coverage Rider Exclusions. Provider Co-pay EOB UCR HCFA 1500 Itemized Bill UB 92 CPT code. Terms . TYPES OF INSURANCE. Health HMO PPO POS Indemnity. TYPES OF INSURANCE.

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Insurance

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  1. Insurance Lori Howard

  2. Claim Premium Deductible Benefits Primary Coverage Secondary Coverage Rider Exclusions Provider Co-pay EOB UCR HCFA 1500 Itemized Bill UB 92 CPT code Terms

  3. TYPES OF INSURANCE • Health • HMO • PPO • POS • Indemnity

  4. TYPES OF INSURANCE HospitalizationAccidentAthletic Insurance Accidental Self Insurance

  5. TYPES OF INSURANCE • Catastrophic Insurance • NCAA • Benefits start after $50,000 and pay for lifetime • www.ncaa.org

  6. NFSHSAMembership benefitsBenefits start after $25,000 www.nfhs.org

  7. COORDINATE INSURANCE • (Ed Setting) • philosophy of administration • philosophy of physician • be familiar with your policy (exclusions)

  8. know NCAA rules • get to know insurance coordinators at your provider’s offices • Consider buying a CPT code book

  9. COORDINATE INSURANCE • Be organized, have a system • Utilize time management • Get to know CSR at your insurance company

  10. CLAIM PROCESSING (Ed) • get insurance info prior to athletic participation • keep insurance files separate from medical files

  11. Managed Care: find out how many athletes have itcontact each one, speak to a manager, find out if athlete can see team MD, if he accepts UCRCoverage under Athletics Dept. policy

  12. CLAIM PROCESSING (Ed) • Try to have local PC physician assigned • Mark the files of athletes with managed care • Have a follow up system for checking the status of claims

  13. DO NOTS • wait until claim to get primary insurance information • say the institution will pay the claim • take responsibility for filing the primary claims • pre-pay from the athletic budget • wait to file the claim

  14. DO NOTS • assume CPT codes are correct • fail to check claims carefully

  15. IF A CLAIM IS DENIED • find out why • get statement from M.D. saying treatment was necessary • provide evidence from clinical studies • convince M.D. to waive fees above UCR • contact the state insurance commission and challenge denial

  16. INS. BILLING (Clinic) • services are dictated by a physician (must have a script) • paid directly from insurance companies • wait until have authorization from insurance company before initiating treatment

  17. CLAIM PROCESSING (Clinic) • fill out charge slip (super bill) • find out CPT codes • list charges & procedures daily • file claim on HCFA 1500 form • Have PT sign claim (not nec. In GA) • keep copy of pt claim in chart • enter claim into registry in patient chart

  18. CLAIM PROCESSING (Clinic) • mail claim to insurance company • make a note of date submitted • have a follow up system for checking the status • usually takes 4-6 weeks to receive payment • New year = new deductible

  19. PURCHASING INSURANCE • contact agents • get bids

  20. TO SELECT & PURCHASE • monetary limits • exclusions/riders • primary/secondary/HMO’s • deductible • co-payments • who is covered • out of season injury

  21. TO SELECT & PURCHASE • annual premium • how to file claims

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