You should always check the patients insurance card to find out key information about the specific insurance they have. Make a photocopy of both the front and the back of the card. You will use this information when billing, making inquiries, and authorizations. Every medical practice should have available the current provider manuals for every insurance carrier it is contracted with, including its state's Blue Cross/Blue Shield Plans. To discover silent PPOs, always pre-certify procedures, and look at patients' insurance card even if the patients are established. Keep on hand an alphabetic list and profile of all plans with which the practice has a signed contract. Always be aware of preauthorization requirements. If a managed care plan refuses to authorize payment for a recommended treatment, tests, or procedures, have the PCP send a letter to the plan, include medical documentation, such as office visit notes, lab reports, and x-ray reports, to support the insurance claim. When a referral authorization form is received, make a copy of the form for each approved office visit, laboratory test, or series of treatments. Then use the form as a reference to bill for the service. To create a managed care plan reference guide make a grid. Use a sheet of paper, and list each plan with the billing address vertically in a column to the left. Then list significant date horizontally across the top. Suggested titles for column categories are as follows: eligibility telephone numbers, copayment amounts, preauthorization requirements, restrictions on tests frequently ordered, participating laboratories, participating hospitals, and the contract's time limit for promised payment. Referring to this grid can provide specifics at a glance about each plan's coverage and copayment amounts. Keep this information in a three ring binder. A good procedure is to include this information on each patient's data sheet when benefits are verified.
KEY POINTS:
·
Providers must be contracted with Blue
Cross/Blue Shield to receive payment as a member physician. Patients may have a
traditional fee-for-service or one of many types of managed care plans. Plan benefits
and coverage, as well as deductibles and copayments, vary.
·
Managed care plans are prepayment health care
programs in which a specified set of health benefits are provided in exchange
for a yearly fee or fixed periodic payments to the provider of service.
Patients join the plan and pay monthly medical insurance premiums individually
or though their employer. Patients pay a small copayment and sometimes a
deductible for medical services.
·
Primary care physicians (PCPs) act as gatekeepers
who control patient access to specialists and diagnostic testing services.
·
Health maintenance organizations (HMOs) have
models, such as prepaid group practice model, staff model, network HMO, and
direct contract model.
·
The Patient Protection and Affordable Care Act
(the Affordable Care Act), and H.R. 4872, the Health Care Reconciliation Act)
have provisions which include the following: forbids insurers form canceling
insurance coverage (rescission), eliminates preexisting condition exclusions,
ends lifetime limits on benefits, gives tax credits to small businesses that
offer coverage, provides temporary insurance until 2014 for people who have
been denied because of their health status, allows young people to remain on
their parents’ insurance until age 26, requires insurers to use a high
percentage of premiums for benefits instead of profits or overhead, makes some
preventive measures free, and almost everyone is required to be insured or they
will pay a fine.
·
Types of managed care plans are the exclusive
provider organization (EPO), foundation for medical care (FMC), independent (or
individual) practice association (IPA), preferred provider organization (PPO),
silent PPO, physician provider group (PPG), point-of-service (POS) plan,
triple-option health plan, provider-sponsored organization (PSO), and religious
fraternal benefit society (RFBS).
·
Managed care plans, such as employee benefit
plans (EBPs) purchased by employers, must comply with the federal regulations
of Employee Retirement Income Security Act (ERISA) and do not fall under state
laws.
·
The Quality Improvement Organization (QIO)
program (formerly the peer review organization) evaluates cases to determine
appropriateness, medical necessity, and quality care.
·
Utilization review (UR) is a process bases on
established criteria for evaluating and controlling the medical necessity of
services and providers’ use of medical care resources to curb expenditures.
·
Some managed care plans may require prior
approval for certain medical services or referral of a patient to a specialist.
Four types of referrals are formal
referral, direct referral, verbal referral, and self-referral.
·
If a contract has a stop-loss limit, it means
that the provider can begin asking the patient to pay the fee for the service
when the patient’s services are more than a specific amount.
·
A managed care plan that has a withhold
provision may retain a percentage of the monthly capitation payment or a
percentage of the allowable charges to physicians until the end of the year to
cover operating expenses.
*find links to resources on The Internet Resource tab.
