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

7. Worker’s 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 WASN’T 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 patient’s 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 It’s 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 It’s preferable to speak to a representative for accurate coverage information regarding specific service coverage and if pre-certification/authorization 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 State’s 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 • 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%. • 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. • CO-PAYMENT – A predetermined payment that must be made by the covered beneficiary at the time of service.

20. Verification of Benefits • CARVE OUT – this is where certain benefits are offered by a specialized vendor on a stand-alone, as needed basis. • LIFETIME MAXIMUM – Many payers have a calendar year and lifetime maximum on benefits paid. Once maximum is reached, benefits are exhausted. • VERIFICATION OF PHYSICIAN – This is making sure the attending physician is on the panel for the patient’s 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. • It’s 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.