Training and Development Program

By Idalmis Fernandez and James Gonzalez

UHealth Patient

Access Center

Insurance FundamentalsModule 1 and 2

Learning Objective Define health insurance terminology

and concepts Describe the most common types of

managed care products and programs Understand health insurance

documents, forms and publications Identify and resolve common health

insurance problems that impact clinical practice

Health BIBLE

CONTRACT SUMMARYFinding the Contract Summary Online:Log on to UMMG website: www.umdoctors.com Click on “Employee Intranet” - top grey-menu bar Pop-up login window username and password (enter UM sign-in Outlook email domain name and password)  Click on “Healthplan Contract Summary”

The Contract Summary has information about …

UMMG ContractsEffective datesUChart Registration CoverageContract limitationsAuthorization PoliciesType of managed care productLevel of care participationPrimaryRoutine SpecialtyTertiary

Telephone numbersContracted hospitals and labsSpecialty Networks participation

Insurance Terms INSURANCE TERMS Insurance: Is protection against a loss. In health insurance, an insurer guarantees to pay a sum

of money to health professionals or facilities for prevention or treatment of a health problem.   Health Insurance Payors - A company licensed to sell health insurance (i.e. AvMed, BCBS,

Cigna, Humana, etc…)   Health Insurance Plan - A defined program of insurance with specific benefits, specific costs

and specific rules (i.e. AvMed H.MO., BCBS P.P.O., Cigna E.P.O., Humana Open access, etc…)   Indemnity Plans - A health care plan that allows members to see virtually any doctor that they

choose and to receive coverage for services without any authorization. Popular, prior to the widespread introduction of Managed Care Plans

  Managed Care Plans - A health care payment system that attempts to manage utilization and

reduce healthcare costs (HMO/PPO/POS/EPO)   Individual Insurance or Self-insured – An individual who is not part of an employee group or

organization that purchases individual insurance coverage   Group Insurance – An organization or company that is contracted with an insurance

company to provide coverage for employees or organization members. (e.g. University of Miami group plan)

UChart’sVisual Analysis

Health Plan Comparison Product HMO EPO PPO POS Indemnity

Type Health Maintenance OrganizationExclusive Provider

OrganizationPreferred Provider

OrganizationPoint of Service Indemnity

   

   

 

Gatekeeper HMO  A health plan in which the patient receives medical services that are delivered by a Primary Care Physician (PCP)   PCP selection required No Out-of Network benefits or

coverage (exception only in case of emergency)

PCP referrals are required to see specialists

Health plan authorization is required for most medical services

Co-payments for doctor’s visits

  

A health plan that functions like a PPO, in which patients must visit a physician in their Network, but do NOT have coverage for out-of-network services

  No PCP

required Self-refer or

direct access to specialists

No Out-of Network benefits

Co-payments and Co-insurance

 

A plan that contracts with a limited network of physicians and facilities to provide services to patients at a discounted rate    No PCP

required Self-refer or

direct access to specialists

Out-of Network benefits

Deductible, Co-payments and Co-insurance

 

A health plan works like an HMO with an out-of-network or “PPO” option.

When an In-Network physician is selected:

Works like an HMO (PCP, Referral, etc…)

In-Network benefits applied

When an Out-of-Network physician is selected:

Works like a PPO

Out-of-Network benefits applied

 

Traditional Plan A plan that allows members to see virtually any doctor that they choose to receive coverage for services without authorization Fee-for-

Service type plan

NO PCP requirement

Not restricted to network of physicians

NO Authorization required

 HMO OPEN ACCESS Allows direct access or self-referral (“referral free”) to specialist For some HMO Open Access plans a PCP selection may be required but no referral is needed to see Specialist.

POS Open Access - direct access or self-referral (“referral free”) to specialist for in-network and out-of-network coverage.   

MedicareMEDICAREMedicare is a Federal entitlement program, authorized by Congress to provide medical benefits to individuals who are over 65, who meet certain criteria. Federal workers and anyone eligible for Social Security benefits are automatically enrolled in Medicare Part A. Enrollment in Part B is voluntary and requires a monthly premium.

The following are eligible for Medicare services:

• People age 65 or older• Some people under age 65 with disabilities • People with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring

dialysis or a kidney transplant• Afflicted spouses and afflicted dependent children of workers who pay Social Security

Benefits.• Retired federal employees enrolled in the CSRS (Civil Service Retirement system) and their

spouses over 65.

The Center for Medicare and Medicaid Services (CMS) is the federal agency responsible for managing the Medicare program.

For additional information on Medicare visit www.medicare.gov or www.ssa.gov

Code  IdentificationA Primary claimant (wage earner)

B Aged wife, age 62 or overB1 Aged husband, age 62 or over

B2 Young wife, with a child in her care

B3 Aged wife, age 62 or over, second claimant

B5 Young wife, with a child in her care, second claimant

B6 Divorced wife, age 62 or over

BY Young husband, with a child in his care

C1-C9 Child - Includes minor, student or disabled child

D Aged Widow, age 60 or overD1 Aged widower, age 60 or over

D2 Aged widow (2nd claimant)

D3 Aged widower (2nd claimant)

D6 Surviving Divorced Wife,  age 60 or over

E Widowed MotherE1 Surviving Divorced MotherE4 Widowed FatherE5 Surviving Divorced FatherF1 Parent (Father)F2 Parent (Mother)F3 StepfatherF4 StepmotherF5 Adopting FatherF6 Adopting Mother

HA Disabled claimant (wage earner)

HB Aged wife of disabled claimant, age 62 or over

M Uninsured – Premium Health Insurance Benefits (Part A)

M1 Uninsured - Qualified for but refused Health Insurance Benefits (Part A)

T Uninsured - Entitled to HIB (Part A) under deemed or renal provisions; or Fully insured who have elected entitlement only to HIB

TA Medicare Qualified Government Employment (MQGE)

TB MQGE aged spouseW Disabled Widow

W1 Disabled WidowerW6 Disabled Surviving Divorced Wife

The Social Security number followed by one of these codes is often referred to as a claim number.  We assign these codes once you apply for benefits.  These letter codes may appear on correspondence you receive from Social Security or on your Medicare card.  They will never appear on a Social Security card.For example, if the wage earner applying for benefits and your number is 123-45-6789, then your claim number is 123-45-6789A. This number will also be used as your Medicare claim number, once you are eligible for Medicare. 

MedicareMedicare Part A Medicare Part B

Medicare Supplemental Plan (Medigap)

Medicare Advantage (Medicare Replacement Plans)

Inpatient hospital

Skilled Nursing Facility

Hospice care Home health

care Blood

transfusions 

Enrollment is automatic for those who turn 65 and have worked the required amount of time paying into Social Security or Railroad Retirement.    

   

 

HOSPITAL Inpatient

Outpatient hospital

Physician services Diagnostic Tests Durable Medical

Equipment

Ambulance services

 

Enrollment is voluntary and requires a monthly premium payment.

*Annual deductible $163 *Reimburses 80% of covered services  *Patient responsible for deductible and 20% co-insurance   

   

 

PHYSICIANS Outpatient

An insurance plan that covers the patient’s Medicare deductible and 20% co-insurance obligations

Policies may be purchased:

Individually

May be paid through an employer-sponsored program, for retirees of a company

All supplemental plans cover the following core services:  Part B - 20% co-

insurance Hospital co-

insurance from day 61-90

Additional hospital days after the reserve days

 Examples of 2nd payors are: Mail Handlers Insurance, BCBS , AARP

  

SECONDARY PAYOR

Advantage Plans include:

Health Maintenance Organization (HMO) Preferred Provider Organization Plans (PPO) Private Fee-for-Service Plans (PFFS)  Offers wider range of benefits.  Offer prescription drug benefits  Patients with an Advantage Plan do not need a supplemental plan 

 

 

 

 

 

 

 

 

 

MANAGED CARE

MEDICARE IMPORTANT: For Medicare beneficiaries who continue to work after age 65 and maintain coverage under an employer health plan, if the employer group has more than 20 members, the group plan is primary for the employee and spouse and Medicare is the secondary payer.

MedicaidMEDICAID The Medicaid program provides health coverage to low-income families and to some elderly and disabled individuals.

Medicaid Basic Eligibility

Aid to Families and Dependent Children

(AFDC)

Supplemental Security Income (SSI)

Pregnant Women and Children

Medicare Beneficiaries

Children and adults who meet Medicaid

(AFDC) eligibility criteria

Provides payments to low income, elderly, blind and disabled

individuals

Provides coverage to: *Pregnant Women *Children up to age 6 - eligible if family income is below 133% of poverty line *Children age 6-11 - family income is

below 100% poverty line*Children age 12-18 - family income is

below AFDC levels

Supplemental to Medicare Part B. For low income

Medicare beneficiaries

Managed Care 

Definition 

Product Names

MediPass MediPass is a statewide provider network run by Florida Medicaid. Form of managed care designed to: Ensure access to Primary Care Reduce inappropriate utilization Control program costsPrimary Care Providers are responsible for providing or arranging for the recipient's primary care and for referring the recipient for other medically necessary services (e.g. Specialty Care).

N/A

Medicaid HMOs Under this program, Florida contracts with HMOs to provide prepaid services to Medicaid recipients. There are currently 14 HMOs providing Medicaid services throughout Florida.

 

Provider Service Network (PSN) 

A Provider Service Network (PSN) is an integrated health care delivery system owned and operated by Florida physician groups.

  

 

Children’s Medical Services Network(CMSN)(NOT AN INSURANCE PLAN) 

The principal health insurance provider for children with special health care need (CSHCN) due to long term chronic physical, behavioral or emotional conditions Medicaid (Title 19) eligible CSHCN up to age 20 Florida KidCare (Title 21) eligible CSHCN up to age 19 Safety Net – eligible CSHCN who do not qualify for

Medicaid or KidCare

Children’s Medical Services (CMSN) Network

Medicaid Managed Care Eligible recipients may choose to receive health services through, Medicaid Provider Access System (MediPass), Medicaid HMOs, Provider Service Network (PSN) or the Children's Medical Service Network (CMSN)

KidCare Program

Through Florida KidCare, the state of Florida offers health insurance for children from birth through age 18, even if one or both parents are working. It includes four different parts. When you apply for the insurance, Florida KidCare will check which part your child may qualify for based on age and family income.

MEDIKIDS: children ages 1 through 4.HEALTHY KIDS: children ages 5 through 18.CHILDREN’S MEDICAL SERVICES NETWORK: children birth through 18 who have special health care needs.MEDICAID: children birth through 18. A child who has other health insurance may still qualify for Medicaid.

Healthcare Acronyms•CMS - Centers for Medicare and Medicaid Services • JCAHO - Joint Commission on Accreditation of Healthcare Organizations•OSHA -

Occupational Safety and Health Administration•SNF - Skilled

Nursing Facility•PHT - Public Health Trust•SCHIP - State Children's Health

Insurance Program•WIC - Women's,

Infants, and Children

Program at the US Dept of Agriculture•HIPPA - Health Insurance Portability and Accountability Act•CDC - Center for

Disease Control and Prevention•VA - Veterans Affairs

VETERANS ADMINISTRATION & TRICARE•Veterans Administration Health Care System – The VA system operates hospitals, outpatient clinics and nursing homes, nationwide. The program is intended to provide comprehensive health care to those veterans with severe service-related disabilities. For other veterans, the program is intended to provide care for service-connected disabilities and to act as a safety net for veterans with limited access to health care. The VA administers a health benefits program that covers services defined by the individual veteran's benefit eligibility.

For additional information, visit the VA System website at http://www.va.gov/health_benefits/ •TRICARE Military (Civilian Health and Medical Programs of the Uniformed Services) This program of health care delivery provides insurance coverage for active duty military personnel, their dependents and military retirees. The TRICARE program is managed by the military in partnership with civilian contractors. (i.e. Humana)

The program provides two options: 1. TRICARE Prime: managed-care option, similar to a civilian HMO plan.

2. TRICARE Standard (PP0): a fee-for-service option, offering comprehensive health care coverage, for those not enrolled in TRICARE Prime. Standard offers the greater flexibility in choosing a provider, but it will also involve greater out-of-pocket expenses (annual deductible, co-payments and co-nsurance) for the patient.

TRICARE Extra: can be used by any TRICARE eligible beneficiary, who is not active duty, and not enrolled in Prime. Extra is essentially a supplemental plan for an for TRICARE Standard members who want to save on out-of- pocket expenses by making an appointment with a TRICARE Prime network provider.

Several of these programs require the services of a primary care case manager. For more details visit the TRICARE website at - http://www.tricare.osd.mil/

CASE SCENARIODirections: In groups, discuss and then present how you would handle the following scenarios: 1. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Patient has CarePlus (non-contracted HMO). What should the receptionist tell the patient? 2. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Care PPO (non- contracted PPO). What should the receptionist tell the patient?3. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Patient has Mutual of Omaha Indemnity plan. What should the receptionist tell the patient?4. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After asking for demographic information, you ask the patient for insurance coverage. Patient has Care POS, (non-contracted POS) and is authorized to see UM physician as in-network. What should the receptionist tell the patient?

Levels of Medical Care

PRIMARY CARE (PCP) - total health of the patient (e.g. Internal Medicine, Family Medicine, Pediatrics, OB/GYN)  SECONDARY CARE (SPECIALTY) - routine specialty care (e.g. Dermatology, Cardiology, Surgery, Ortho/Rehab etc…)   TERTIARY CARE - is complex medical treatment rarely available in the community, outside of academic medical centers (i.e. Specialist referrals to Specialist, transplants, revisions).

SINGLE CASE NEGOTIATIONS (SCN)The University of Miami conducts a SCN when the patient has a non-contracted HMO and needs specific care that is not commonly found in the community. WE DO NOT DO SINGLE CASE NEGOTIATIONS FOR: •Non-contracted PPO - members have out of network benefits •Indemnity plans •Self pay patients

If the patient needs a SCN do not give them an appointment, have them call their HMO health plan representative who will call our nurse case manager to coordinate the authorization. If the service is approved the patient will call back to schedule an appointment with an authorization number.

UMMG case management notified of

need for Single case

Notification from insurance company?

Letter of Agreement is generated

Letter is signed?

Via telephone calls, faxes or email from:

· PCPs· Specialists· Insurance Company· Hospital Admissions· UMMG Departments· Physician Referral Office - PRO· BPEI appointments

YES

NO

YESCreate case in UChart System

Appropriate departments are

notified

• Always accept all contracted plans, non-contracted PPOs and indemnity plans

• Always notify Health Plan Relations of problems, issues and changes with any of the insurance plans (#243-7141)

• Always notify UMMG Credentialing office (#243-7688) of changes, additions and deletions to faculty practice

• Always notify UMMG Business Dev. (#243-5273) of problems with online services (i.e. Medifax, Availity, jhs-domc.org, unitedhealthcareonline, etc…)

 

• Always verify member eligibility and plan benefits

• Always check to see if referral or authorization is required for the service

• Always collect member co-payment or deductible

• Always send consult report back to referring physician

• Always use the Contract Summary as a reference tool

• Always treat patients with respect and courtesy

 

Best Practices

On-line ActivityDirections: Answer the following questions using the Contract Summary online. 1. AvMed•At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this health plan? 2. BCBS – Health Options •At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this health plan? 3. Cigna•At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this health plan? 4. Humana•At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this health plan?

5. JHS Division of Managed Care (JMH Health Plan)•At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this health plan? 6. Aetna•At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this health plan? 7. Neighborhood Health Partnership - NHP•At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this healthplan? 8. Vista Health Plan of South Florida•At what LEVEL OF CARE do we accept patients?•List the UChart Registration Coverage•List one CONTRACT LIMITATION. •List one AUTHORIZATION POLICY.•What Specialty Networks contract for this healthplan?

Module 2 UCHART

Scheduling Registration Work Flow

Video Demonstration

http://www.youtube.com/watch?v=oypYhRyiCg8

Private Link

UChart Sched/Reg Flow

Universal Registration

Appointment Entry Screen

Specific Appointment Registration

Difference between Hospital Visits and Non Hospital.

The Difference between

Hospitals ABLEH BPEI(UM Physician's)UMHC UM Physician'sSCCC UM Physician'sJMH UM Physician's

Guarantors Who is the Guarantor for Medical

Bills ?

Who the guarantor is for medical bills depends on a couple things. An adult that obtains medical care is responsible for their own medical bills, so they are the guarantor. If a child is taken for medical care then there are a couple things that can determine who is guarantor. The parent who takes the child for care normally signs a paper that states they are responsible for any expenses. Of course, if there are court orders stating a certain parent is responsible for all medical expenses, then it can be enforced.

Guarantor Summary Screen Example of Multiple Accounts

Guarantors Coverage & Add Add’l Coverage Info for Specific Account

Coverage Summary Example with multiple Guarantors

Reg-Appointment Screen

Universal

Specific Appt registration

POS-22 and POS-11Hospital Accounts vs. Visit Accounts

Universal Checklist

Reg-Appt Specific CheckList

UChart Coverage Field

THE END!