insurance lori howard. terms n claim n premium n deductible n benefits n primary coverage n...

InsuranceInsurance

Lori HowardLori Howard

TermsTerms

ClaimClaim PremiumPremium DeductibleDeductible BenefitsBenefits Primary CoveragePrimary Coverage Secondary CoverageSecondary Coverage RiderRider ExclusionsExclusions

ProviderProvider Co-payCo-pay EOBEOB UCRUCR HCFA 1500HCFA 1500 Itemized BillItemized Bill UB 92UB 92 CPT codeCPT code

TYPES OF INSURANCETYPES OF INSURANCE

HealthHealth

»HMOHMO

»PPOPPO

»POSPOS

»IndemnityIndemnity

TYPES OF INSURANCETYPES OF INSURANCE

HospitalizationHospitalizationAccidentAccidentAthletic InsuranceAthletic Insurance

AccidentalAccidentalSelf Self

InsuranceInsurance

TYPES OF INSURANCETYPES OF INSURANCE

Catastrophic InsuranceCatastrophic Insurance

–NCAANCAA

»Benefits start after $50,000 and Benefits start after $50,000 and pay for lifetimepay for lifetime

»www.ncaa.orgwww.ncaa.org

NFSHSANFSHSAMembership benefitsMembership benefitsBenefits start after $25,000 Benefits start after $25,000 www.nfhs.orgwww.nfhs.org

COORDINATE INSURANCECOORDINATE INSURANCE

(Ed Setting)(Ed Setting)

–philosophy of administrationphilosophy of administration

–philosophy of physicianphilosophy of physician

–be familiar with your policy be familiar with your policy (exclusions)(exclusions)

–know NCAA rulesknow NCAA rules

–get to know insurance get to know insurance coordinators at your provider’s coordinators at your provider’s officesoffices

–Consider buying a CPT code Consider buying a CPT code bookbook

COORDINATE INSURANCECOORDINATE INSURANCE

–Be organized, have a systemBe organized, have a system

–Utilize time managementUtilize time management

–Get to know CSR at your Get to know CSR at your insurance companyinsurance company

CLAIM PROCESSING (Ed)CLAIM PROCESSING (Ed)

get insurance info prior to athletic get insurance info prior to athletic participationparticipation

keep insurance files separate from keep insurance files separate from medical filesmedical files

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

CLAIM PROCESSING (Ed)CLAIM PROCESSING (Ed)

–Try to have local PC physician Try to have local PC physician assignedassigned

–Mark the files of athletes with Mark the files of athletes with managed caremanaged care

–Have a follow up system for Have a follow up system for checking the status of claimschecking the status of claims

DO NOTSDO NOTS

wait until claim to get primary wait until claim to get primary insurance informationinsurance information

say the institution will pay the claimsay the institution will pay the claim take responsibility for filing the take responsibility for filing the

primary claimsprimary claims pre-pay from the athletic budgetpre-pay from the athletic budget wait to file the claimwait to file the claim

DO NOTSDO NOTS

assume CPT codes are correct assume CPT codes are correct fail to check claims carefullyfail to check claims carefully

IF A CLAIM IS DENIEDIF A CLAIM IS DENIED

find out whyfind out why get statement from M.D. saying get statement from M.D. saying

treatment was necessarytreatment was necessary provide evidence from clinical studiesprovide evidence from clinical studies convince M.D. to waive fees above UCRconvince M.D. to waive fees above UCR contact the state insurance commission contact the state insurance commission

and challenge denialand challenge denial

INS. BILLING (Clinic)INS. BILLING (Clinic)

services are dictated by a physician services are dictated by a physician (must have a script)(must have a script)

paid directly from insurance companiespaid directly from insurance companies wait until have authorization from wait until have authorization from

insurance company before initiating insurance company before initiating treatmenttreatment

CLAIM PROCESSING (Clinic)CLAIM PROCESSING (Clinic)

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

CLAIM PROCESSING (Clinic)CLAIM PROCESSING (Clinic)

mail claim to insurance companymail claim to insurance company make a note of date submittedmake a note of date submitted have a follow up system for checking have a follow up system for checking

the statusthe status usually takes 4-6 weeks to receive usually takes 4-6 weeks to receive

paymentpayment New year = new deductibleNew year = new deductible

PURCHASING INSURANCE PURCHASING INSURANCE

contact agentscontact agents get bidsget bids

TO SELECT & PURCHASETO SELECT & PURCHASE

monetary limitsmonetary limits exclusions/ridersexclusions/riders primary/secondary/HMO’sprimary/secondary/HMO’s deductibledeductible co-paymentsco-payments who is coveredwho is covered out of season injuryout of season injury

TO SELECT & PURCHASETO SELECT & PURCHASE

annual premiumannual premium how to file claimshow to file claims