payor plan soup jackie ruley edt6000 january 18, 2010
TRANSCRIPT
Payor Plan Soup
Jackie Ruley
EDT6000
January 18, 2010
• Distinguish among the major types of plans, including HMO, PPO, EPO, and indemnity.
• Interpret the information provided on a patient’s insurance card.
• Select the correct payor plan.
Instructions• Click on the links in each session to advance.
Course Objectives and Instructions
START
Let’s get Started
CLICK HERE
CLICK HERE
Click PPO
What’s on a card?
Blue Cross/Blue ShieldDooble, Noodle Account NumberID Number 89676NOD129876
THE NOODLE COMPANYCOPAY: PCP SPEC ER
$10 $10 $40CUSTOMER SERVICE: (302) 437-0021
PPO
CLICK CROSS
Payor
Plan
What’s on a card?
CIGNA HMODUMPLINGS INC Group Number 123987ID Number: DUM89676
Dumpling, AppleCOPAY: PCP SPEC ER
$10 $25 $00CUSTOMER SERVICE: 1-800-437-0021
HMO
CLICK HMO
What’s on a card?
THE HERSHEY COMPANY
POSID W789 5324 GRP: 80734-768-72664
01 Mint, Cool 03 Mint, Curley02 Mint, Pop 04 Mint, ChocolateCOPAY: PCP SPEC ER
$20 $20 $00CUSTOMER SERVICE: 1 (800) 435-7266
AETNA
CLICK POS
Plan Type: PPO Plans
• Preferred Provider Organization
• Part of a “network”
• If a network provider is used, an adjustment or discount is taken
• If a out of network provider is used, out-of-pocket cost is higher
CLICK ORGANIZATION
• The entity that pays the claim
• Examples:– Aetna– Blue Cross– Cigna– Medicaid– Unision
What is a Payor?
1. CLICK Aetna – Review - CLICK “X” to close website
2. CLICK Cigna – Review - CLICK “X” to close website
CLICK HERE TO CONTINUE
What is a Plan?
The product line offered by the Payor
Plan Type: PPO Plans
Preferred Provider Organization
CLICK PPO
Plan Type: HMO
Health Maintenance Organization
CLICK HMO
The patient’s insurer, which consists of a payor and a plan.
Click on payor
Coverage Definition
Plan Type: POS
• Point Of Service• Treated as an HMO plan, but also has
out-of-network benefits• Patients have a Primary Care Physician (PCP)
or “gatekeeper” who manages their healthcare• Patients are typically subject to a deductible and
out-of-pocket costs if PCP does not authorize visit
• Authorizations are required for maximum benefits
CLICK HMO
Plan Type: HMO
• Health Maintenance Organization
• Also known as “managed care” plans
• Patients have a Primary Care Physician (PCP) or “gatekeeper” who manages their healthcare
• Co-Payment due at time of service
• Referrals and authorizations are required
CLICK GATEKEEPER
Plan Types: EPO
Exclusive Provider Organization
CLICK EPO
Plan Types: EPO
• Exclusive Provider Organization
• Some plans are treated as HMO and require authorization
• Other plans are treated as PPO and do not require authorization, but have no out-of-network benefits
• Very important that information is verified before patient is seen
CLICK HERE
Which Plan requires a Primary Care Provider
THP OA HMO
Every Payor needs a Plan?
CLICK PLAN
Let’s Review
• COB is for Coordination of Benefits, not a Plan Type, try again.
RUL POS COB EOB
CLICK HERE
Select the Plan Type
Blue Cross/Blue ShieldBean, Kidney Account NumberID Number 89676SNI129876
SNICKER VALLEY SCHOOL DISTRICTCOPAY: PCP SPEC ER
$15 $25 $40CUSTOMER SERVICE: (800) 437-0021
EPO
CLICK EPO
Let’s Review
• What is a Plan Type?
A. A Model
B. A Product Line
C. A TV Show
Let’s Review
• What is a Plan Type?
C. A TV Show – Sorry Try Again
CLICK HERE
Let’s Review
• What is a Plan Type?
B. A Product Line – Correct
Every payor has multiple product lines.
CLICK PLAN TYPE
Let’s Review
• What is a Plan Type?
A. A Model – WRONG
Try Again
CLICK TRY AGAIN
Let’s Review
• Select a Plan Type.
RUL POS COB EOB
Let’s Review
• EOB is an explanation of benefits. Select again.
RUL POS COB EOB
CLICK HERE
Which Plan requires a Primary Care Provider
THP – IS TOTAL HEALTH PLUS
SORRY
CLICK HERE
Which Plan requires a Primary Care Provider
OA - IS OPEN ACCESS
TRY AGAIN
CLICK HERE
Which Plan requires a Primary Care Provider
CONGRATULATIONS – YOU ARE CORRECT!
HMO requires that you select a Primary Care Provider to be your “gatekeeper”
CLICK HERE
Theend
CLICK THE END
Jackie Ruley
EDT 6000
January 18, 2010
Let’s Review
• Sorry Wrong Answer – TRY AGAIN
RUL POS COB EOB
CLICK HERE
Let’s Review
• Select a Plan Type.
RUL POS COB EOB
Yes, a POS is a Point of Service Plan.
It is treated as an HMO plan, but also has out-of-network benefits.
CLICK HERE
CLICK POS