HC Practicum Midterm Material
Government Benefit Programs
Medicare
Worker’s Comp
MEDICARE
Federal benefit program
Administered by HCFA
Local payors contracted
chiropractors may be:
participating provider
non-participating
Benefits have two parts:
Part A
Hospital and related benefits
Chiropractors receive no reimbursements
Part B
Outpatient benefits
Chiropractors may receive reimbursement
MEDICARE
Part B - Outpatient benefits
Calendar year deductible
80% of APPROVED charges
MEDICARE
CHIROPRACTORS
CMT only approved procedure
Must have current x-ray
Medicare Supplement policies may reimburse other
charges
Non par providers collect @ time of service
Must file HCFA-1500
Use MUS release form for non CMT services
WORKERS COMPENSATION
State Law to effect:
Social Contract between employer and employee
State Appeals process
Benefits are “ABSOLUTE”
Employer Liability Insurance
WORKERS’ COMPENSATION
All medically necessary expenses
Must have employer authorization to treat
Can not charge/collect from patient
72 hour notification (courtesy)
Loss of wages
Four types of disability
2 temporary
2 permanent
Whole man rule 400 weeks
SERVICE PROVIDERS
Provide services against prepayment
“Membership dues”
Dr. contracted with Provider
Marketing strategy:
“No Claims Paperwork”
BLUE CROSS AND BLUE SHIELD
Local not-for-profit Corporations
75 in the United States
services only in area
Hospital or Doctors services
Control of care provided (standards)
Consolidating/Merging
BLUE CROSS
Started in the 1920s
Hospital services
Negotiated claims settlement
Difficult to co-ordinate benefits
BLUE SHIELD
Started in 1900s
Doctors services
Usual, Customary and Reasonable reimbursement
standard in FFS
UCR
USUAL: What does this provider usually charge for
the service?
CUSTOMARY: What do other providers in the area
charge for the service?
REASONABLE: Considering the co-morbidity
factors is the surcharge reasonable
BLUE MAJOR
Loss of members due to Comprehensive Major
Medical
Created National Blues (1978)
jointly owned by all BCBS companies
provide “out of area” coverages
provide other coverages:
dental, vision, pharmacy
BCBS in the 90s
Compete with Commercial Carriers
Own PPO networks
Own HMOs and IPAs
Consolidating/Merging
Going “for profit”
Providing TPA services
Medicare, other government plans, self-insured
employers
MANAGED CARE ORGANIZATIONS
HMO (Health Maintenance Organization)
Started in the late 1920s
Also called closed panel HMO
Minor effect until HMO Act 1973
Mandated to employers
Financial support for startups
MANAGED CARE ORGANIZATIONS
PPO (Preferred Provider Organization)
Insurance industry reaction to HMOs
Quick growth due to marketing knowledge
IPA (Individual Practice Organization)
Also called open HMO
Physician reaction to HMO and PPO
Low marketing savvy/penetration
High bankruptcies, purchase by HMO & PPO
MANAGED CARE ORGANIZATIONS
POS (Place of Service)
Combination of one or more of above and
commercial insurance policy
Provides insured/patient choice of in- or out-ofnetwork providers
Provides out-of-area coverage
MANAGED CARE ORGANIZATIONS
Almost all Managed Care Organizations have:
office visit co-pay
utilization review
pre- or concurrent review
MANAGED CARE ORGANIZATIONS
Provider compensation
Fee for Services
Case Basis
Capitation
MANAGED CARE ORGANIZATIONS
Providers are reviewed for:
Performance
clinical judgement and results
Quality
based on patient and peer satisfaction
Value to the network
economic and financial results
MANAGED CARE ORGANIZATIONS
Overall judgement about the provider is based on
the Value Matrix: MCO wants “Best Practices”
providers
MANAGED CARE ORGANIZATIONS
TREMENDOUS GROWTH
St. Louis statistics:
less then 20% in 1990
40% in 1993
Estimated 65% in 1996
Many areas in California, Oregon and Arizona
almost 95%
CREDENTIALLING
WHAT IS IT?
Assessment and validation of the qualifications of
the providers
WHY IS IT?
Quality assurance from the plan’s point of view:
quality providers give quality care and services at
economic value
CREDENTIALLING
WHY ELSE IS IT?
Meets the guidelines/requirements of the customer
(employers) or guarantor (US government)
HOW OFTEN?
Annually or bi-annually
CREDENTIALLING
LICENSING CHECK (verified with State)
GRADUATION CONFIRMATION (CCE)
MALPRACTICE INSURANCE
GOVERNMENT BENEFIT PROGRAMS AND
OTHER PROVIDER SANCTIONS
WORK HISTORY (5 yrs and CV)
SITE VISIT
PERFORMANCE REVIEW (recredentialing)
CREDENTIALING
ONE MCO’S STATEMENT:
Clinically we want the chiropractor who has the
skill in gathering information, demonstrates
effectiveness in using diagnostic methods, has
competence in diagnosis, exhibits good judgement
and skill in implementing treatment and competence
in providing continuing care, is effective in
patient-physician relationships and accepts
responsibilities of a physician
(American Chiropractic Network, Inc.)
COMMERCIAL INSURANCE
Including a review of all payors
Insurance Policies
Policies are a Legal Contract:
Must be an agreement (offer and acceptance)
Must have legal purpose
Must have competent parties
Must have equitable compensation
Burden on the “more knowledgeable” party
Insurance Policies
How are they sold?
Group
Association
Individual
What do they cover?
First Dollar coverages
Major Medical coverages
First Dollar Policies
Cover expenses without a deductible
Have low maximum benefits
Four types
Hospital Room and Board
Surgical Schedule
Miscellaneous Medical Expenses
Hospital Expense Policies
Major Medical Policies
High Annual or Occurrence Deductible
Coinsurance
Stop Loss
High Lifetime Benefit
Benefit Period
Major Medical Policies(continued)
Two Types:
Traditional Major Medical
as describe on previous slide
Comprehensive Major Medical
Imposes the major medical benefits “on top of” the
Hospital Expense benefits
Combines first dollar and “catastrophic” benefits
Creates a “corridor” deductible
Chiropractors and Insurance policies
Policy must include Chiropractor in the definition of
physician
Must provide out patient Dr. Office coverages:
Miscellaneous Medical expense
Hospital expense
Major Medical
Comprehensive Major Medical
Review the third party payors
Government Benefit Programs
Medicare, Medicaid, Worker’s Comp
Service Providers (BC BS)
Commercial Carriers
First Dollar and Major Medical
Managed Care Organizations
HMO, PPO, IPA, POS
DISCUSSION
I also announced the mid-term would be taken at the
end of the session on February 24. The mid-term
(now that I have written it) consists of 33 question
worth 40 points. There are 5 short answer questions,
the rest is matching or multple choice. The material
on the test is everything we covered during the
sessions and the assigned reading in the text book
including the CPT and ICD manuals which you
were supposed to review and understand on your
own
To help you a little bit in preparing for the exam,
specifically with regard to the "self study" of the
manuals:
You must know the complete titles of the manuals
and the purposes for which the codes are to be used.
You must be able to recognize the format of each
code and the significance of it structure. For
instance:
the first two digits of the CPT code indicate what
section the code comes from,
the fourth and fifth digits of the ICD code (the
specificity) indicates either the system or the body
location of the diagnosis,
the modifiers of the CPT code serve specific
functions.
You do NOT need to memorize any individual
codes.
I am looking for global understanding of the coding
systems at this time, the details will come over the
next few weeks in using the manuals.