CHAA Study Guide 2017

Point of Service collection
Collecting the patient’s portion of the bill at the time the service is rendered

Financial Pre-Determination
Method through which the provider identifies the actual payment sources and assists the patient in determining expected reimbursement, their out of pocket expenses, and alternative funding sources

Emergency Medical Treatment and Active Labor Act (EMTALA, 1986)
Federal law enacted by the CMS to protect patients against discrimination based on economic status and mandates patients are screened and stabilized when seeking emergency care or are in active labor

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Nation’s oldest and largest standards-setting and healthcare accrediting body that works to improve quality of healthcare by initiating performance improvement services; Independent, not-for-profit

Board of Commissioners
Joint Commission’s governing body that provides policy leadership and oversight

Standards for Hospital Accreditation (Rewritten 1970)
Published by TJC; Represent optimal achievable levels of quality, instead of minimum essential levels of quality, and registered nurses, administrators, and physicians conducted accreditation surveys

Social Security Act (Amended 1972)
Required that the Secretary of the U.S. Department of Health and Human Services (DHHS) validate and evaluate Joint Commission findings; The Joint Commission then changed its name to JCAHO in 1987

Accreditation Manual for Hospitals (1993)
Reorganization around important patient care and organization functions shifting the focus from standards that measure capability to perform those that look at its actual performance

Office of Inspector General (OIG)
Offers a voluntary compliance program under a designated compliance officer that helps to improve quality of care, reduce fraud, reduce waste and abuse, and reduce cost of healthcare to federal, state, and private health insurers

Health Insurance Portability and Accountability Act of 1996 (HIPAA)
1) Protects patient’s private information (PHI)
2) Encourages electronic transactions
3 Requires safeguards to protect the security and confidentiality of PHI
4) Portability
5) Funds combats of fraud and abuse

Portability in HIPPA
Once a person has insurance coverage, when they change health plans (ex. change jobs) the previous coverage may be used to reduce or eliminate any pre-existing condition exclusions that might apply under the new plan

The Privacy Rule
Permits certain incidental uses and disclosures which occur as a by-product of permissible disclosures, as long as reasonable safeguards were applied and the minimum necessary standard was implemented by the heath care entity

Minimum necessary policies
Policies based on job duties that limit how much PHI is used, disclosed, and requested for certain purposes

Information Services
1) Integrated support for all departments with entire health organizations
2) Identify patients or records uniquely
3) Automated functions in the financial, clinical, and administrative areas
4) Obtain reimbursement for services rendered
5) Easier access to clinical/administrative data
6) Save time by automating tasks

2 common ways data is transmitted:
1) Batch processing
2) Interfaces

Batch processing
Many transactions are stored and sent on a pre-scheduled or demand basis

Software takes data from one system and sends it to another frequently reformatting it tore acceptable to the system

Integrated Healthcare Networks (evolved from traditional independent hospitals)

Master Patient Index (MPI)
1) Uniquely identifies the health system’s entire population
2) Stores key identifying data on each patient

Clinical Data Repository (CDR)
Provides ready access to information from a variety of sources within a healthcare delivery network

Clinical Data Repository (CDR)
Clinical data from ancillary services will be integrated into a single, long term record for the patient; may provide the ability to trend analysis

U.S. Uninsured Help Line
Helps the 6.8 million uninsured Californians get coverage

Partnership for Prescription Assistance
National program to help patients in need get access to prescription medicines

Health insurance
Coverage for medical expenses a patient could incur as a result of illness or injury

Policyholder (Subscriber)
Person who contracts with the insurance company for healthcare coverage

Policyholder for BlueCross, Commercial, and PPO
Policyholder person whose name appears on the insurance card

Policyholder for HMOs
Each insured person has his/her own card; patient must be asked
Policyholder = 00 or 01
Spouses = 01 or 02
Dependents = 03, 04, etc.

Policyholder for Tricare (formerly Champus/Champva)
Policyholder sponsor or active/retired military personnel

Policyholder for Medicare/Medicaid
Policyholder ALWAYS the patient

Policyholder for Workers’ Compensation
Policyholder is usually the employer

Health Maintenance Organization (HMOs)

Centers for Medicare and Medicaid Services (CMS)
Federal agency within the U.S. Dept. of Health and Human Services (DHS) responsible for administering the largest federal health programs; Works with Health Resources and Services Administration to run CHIPs

Business Centers within CMS
1) Center for Beneficiary Choices
2) Center for Medicare Management
3) Center for Medicaid and State Operations

Children’s Health Insurance Program (CHIP)
Program for uninsured children in the U.S.

CMS’ Mission
To assure health security for its beneficiaries

CMS’ Vision
To lead the Nation’s healthcare system toward improved health for all

Health Care Quality Improvement Initiative
CMS initiative emphasizing systematic assessment of patterns of care and outcomes for beneficiaries

Partners with other quality-focused organizations (PROs and ERSD Network Organizations) engaging in national projects aimed at improving the processes and outcomes of care for beneficiaries

Peer Review Organization (PROs)
1) Program administered by CMS that monitors and improves utilization and quality of care for Medicare beneficiaries
2) Consists of 53 Quality Improvement Organizations responsible for each U.S. state, territory, and the District of Columbia

PRO Mission
To ensure:
1) Quality
2) Effectiveness
3) Efficiency
4) Economy of health care services

PRO Functions
1) Conduct Cooperative Quality Improvement Projects (examination and improvement)
2) Provide Beneficiary Protection and Education (mandatory case review and outreach activities)

Leads the health care industry in the use of electronic technology for all phases of claims processing, reducing administrative costs

Medicare Transaction System
Requirement under HIPAA that should bring greater efficiency to the processing and payment of claims, and better service info needs of consumers and providers

Relative Value Resource Based System (RVRBS)
1) Replaced payment system based on historic patterns
2) National fee schedule based on the work and overhead costs associated with each medical service

Prospective Payment System
1) Reduced growth rate of Medicare outlays for hospital IP services
2) DRG system that allows hospitals to operate more efficiently, controlling costs without reducing quality of care

Diagnosis Related Group (DRG) System
Pays hospitals a fixed amount per patient based on diagnosis; Prospective Payment System

Ambulatory Payment Groups (APGs); Ambulatory Payment Classification System (APCs)
CMS outpatient payment system that covers episodes of care for a particular medical diagnosis; excludes Behavioral Health

Social Security Act (Title XVIII)
Public or private entities and agencies may participate in the administration of the Medicare program under agreements or contracts entered into with CMS

Medicare Contractors
Fiscal intermediaries and carriers

Fiscal Intermediaries
Medicare contractors that perform bill processing and pay benefits for Medicare Part A

Medicare contractors that perform claims processing and benefit payment functions for Part B

Intermediaries and Carriers
Perform program integrity activities or payment safeguard activities such as:
1) Medical review of claims to determine medical necessity and appropriate level of care
2) Deterring and detecting Medicare fraud
3) Auditing provider cost reports and ensuring Medicare pay the right amount when a beneficiary has other health insurance

Medicare Program Safeguard Contractors
Under HIPAA, they will perform some/all of the activities already performed by Intermediaries and Carriers such as:
1) Review of provider activities
2) Cost report audits
3) Medicare secondary payer determinations
4) Provider and beneficiary education regarding program integrity
5) Developing and updating a list of durable medical equipment that is frequently unnecessarily utilized

Medicare Eligibility Requirements
1) People aged 65+
2) People of any age with End Stage Renal Disease
3) Certain disabled people under 65

Features of Medicare
Most features are universally applied, but some variation exists from state to state for Medigap and Managed Care offerings

Medicare Claim Numbers
Patient’s or spouse’s social security number with a letter/number prefix/suffix

Medicare Card
Identifies if a patient has Medicare Part A and/or B and when the benefits became effective

Letter Code
Tells how the patient acquired their Medicare benefits

A (prefix)
Primary wage earner
Retired railroad employee
Entitled to benefits through spouse
Disabled widow
Disabled widower

Original Medicare Plan
1) Traditional fee-for-service arrangement
2) Available everywhere in U.S.
3) Beneficiaries automatically eligible after 65th bday
4) Beneficiaries must apply 3 months before 65th bday

Parts of Medicare
Part A – Hospital Insurance
Part B – Medical Insurance
Part C – Medicare Advantage Plan
Part D – Prescription Drug Coverage

Medicare Part A
Hospital insurance:
1) IP hospital services
2) Skilled nursing facility services (SNF)
3) Home health services
4) Hospice care

Medicare Part B
Medical insurance:
1) Doctor services
2) OP hospital services
3) ER visits and ambulance transportation
3) Diagnostic tests
4) Lab services
5) Some preventative care (mammography, Pap smear screening)
6) OP therapy
7) Durable medical equipment and supplies
8) Home health services that Part A doesn’t cover

Medicare Part C
Medicare Advantage Plan; private insurance companies offering plans (mostly to seniors) such as HMOs and PPOs

Medicare Part D
1) Medicare Prescription Drug Coverage
2) Helps lower prescription drug costs
2) Offers up to $3,600 for people with limited income to help pay for drug coverage

Medicare Carriers and Fiscal Intermediaries
Private insurance organizations that handle claims and interpret reimbursement regulations under the Original Medicare Plan

Handle medical insurance (Part B) claims

Fiscal Intermediaries
Handle all hospital insurance (Part A) claims

Medicare Covered Services
Medicare (Part A) Hospital Insurance helps pay for necessary medical care and services in Medicare-certified hospitals, SNF, home health agencies, and hospices

Inpatient Hospital Care
Medicare Part A helps pay for up to 90 days of IP care in each benefit period

Medicare (A) Inpatient Hospital Care Covered Services
1) Semi-private room
2) Meals
3) General nursing services
4) Operating and recovery room costs
5) Intensive care
6) Drugs
7) Lab tests
8) X-rays
9) All other necessary medical services/supplies

Medicare’s 3 Day (72 Hr) Rule
1) Requires pre-admission testing and diagnostic services provided to a beneficiary by the admitting hospital within 3 days prior to admission are included in the IP payment
2) Not to be billed as separate OP charges unless no Part A coverage
3) Includes ER visits, but NOT ambulance services

Benefit Period
1) Begins on first day of services in hospital or SNF
2) Ends 60 days after discharge if 60 days haven’t been interrupted by skilled care elsewhere
3) No limit to number of periods
4) Beneficiary must pay IP hospital deductible for each period

Life Time Reserve Days (LRD)
1) Medicare will pay for an additional 60 days of hospitalization when beneficiary is an IP for greater than 90 days
2) Only used once in a lifetime
3) For each day, Medicare pays all covered charges except for the daily co-insurance

Important Message from Medicare (IMM)
Given to all IP Medicare beneficiaries, explains:
1) Rights as hospital patients (care and follow-up)
2) Advises what to do if patient feels he/she is being discharged too early and provides contact information for PRO
3) Hospitals CANNOT force patients to leave during case review

Skilled Nursing Facility Care (SNF)
1) If medically necessary, Part A helps pay for up to 100 days in each benefit period
2) Medicare pays all approved charges for the first 20 days
3) Patients pay a co-insurance amount for days 21-100

SNF Covered Services
1) Semi-private rooms
2) Meals
3) Skilled nursing services
4) Rehabilitation services
5) Drugs
6) Medical supplies

Home Health Care
1) If medically necessary, Medicare pays the full approved cost including part-time or intermittent skilled nursing services prescribed by a physician for treatment or rehab of homebound patients
2) Patients only pay 20% coinsurance charge for medical equipment (wheelchair, walker)

Hospice Care
1) Not covered by a Senior Medicare HMOs
2) Assists with care for terminally ill beneficiaries
3) No deductibles
4) Beneficiaries pay limited costs for drugs and IP respite care

Medicare Part B
1) Pays 80% of approved charges for most covered services
2) Beneficiaries responsible for paying a $100 deductible per calendar year and remaining 20% of the Medicare approved charge
3) Limited additional charges

Limited Additional Charges
1) Part B stipulation where patients pay 15% over Medicare’s approved amount if their physician does not accept assignment
2) Only applies to certain services and does NOT apply to supplies or equipment

Yearly Medicare Enrollment Review
1) November 15 – December 31
2) Medicare beneficiaries can enroll in a drug plan, review their health care and drug coverage, and make changes

Except for limited cases in Canada and Mexico, does not pay for coverage outside the U.S.

Medicare Part A (non-covered)
Does NOT pay for:
1) Convenience items
2) Private rooms unless medically necessary
3) Nursing home care except SNF for rehabilitation
4) Custodial services (daily living activities)

Medicare Part B (non-covered)
Does NOT pay for:
1) Most prescription drugs
2) Routine physical exams or services not related to injury or illness
3) Dental care or dentures
4) Cosmetic surgery
5) Routine foot care
6) Hearing aids
7) Eye exams or glasses

Advance Beneficiary Notice (ABN)
1) Should be given to a Medicare beneficiary if Medicare may not consider services medically necessary and there’s a chance Medicare won’t pay
2) If not signed before service, patient can’t be held responsible for bill

Fiscal Intermediaries
Use software that compares the diagnosis (ICD9 code) to the service (CPT code) to determine medical necessity

Medicare as Secondary Payer (MSP)
1) Another insurance is primary and Medicare is secondary
2) Other insurance (excluding Medigap) that must pay before Medicare
3) Questionnaire should be completed on all Medicare patients each time a service is rendered

Medicare as Secondary Payer requirements
1) Patient is 65+ with group health insurance through they or their spouse’s current employer with 20+ employees
2) Patient is under 65 and disabled, and they or any family member is covered by group health insurance through a current employer with 100+ employees
3) Patient has Medicare due to permanent kidney failure (ESRD)
4) Patient has illness/injury covered under workers’ compensation, the federal black lung program, no-fault insurance, or liability insurance

Retirement Date Before Medicare Entitlement
Entitlement date used as the retirement date

Retirement Date Post Medicare Part A Entitlement
If it has been at least 5 years since retirement, enter a date of 5 years back from the date of service as the retirement date

ICD9 Codes
Diagnosis codes

CPT Codes
Current Procedural Terminology codes used for coding procedures

Recurring visits
1) One account is created and the patient has several visits for the same service and all charges are entered into the one account (Ex. physical therapy)
2) Verify patient’s MSP info every 90 days

Diagnostic Related Grouping (DRG) rate
1) Avoids excessive IP stays
2) Medicare pays fixed amounts to hospitals according to the patient’s diagnosis, regardless of charges or length of stay
3) Determines base payments hospitals will receive comprised of a standardized amount

Medicare pays higher amount based upon DRG if hospital services many low-income patients or is an approved teaching hospital

Medicare Payment
Based on coded diagnoses and procedures and rarely influenced by total charges

Ambulatory Payment Classifications (APCs)
1) Medicare payments of professional services and most hospital outpatient services
2) Tied to CPT codes
3) Payment rate established for each
4) Calculated based on the national average cost (operating and capital) of the hospital

Ambulatory Payment Classifications
1) Amount the patient is responsible for will vary until the amount can be set at a standard 20% of the payment
2) Gradually phasing of payment to prevent patients from being hit with large co-pays
3) Medicare placed a cap on the max amount a patient is responsible for
4) Patient liability will not exceed the IP deductible amount for each OP service

Fee Schedule
How Medicare pays for outpatient services like Lab and Physical Therapy

Supplemental Insurance
Types of private health insurance that pay some or all of healthcare costs not covered by Medicare
1) Employee coverage
2) Retiree coverage
3) Medigap coverage

1) Medicare supplemental insurance
2) Private insurance designed to help pay Medicare cost-sharing amounts such as Medicare’s co-insurance, deductibles, and uncovered services
3) Must follow federal and state laws
4) Must be 1 of 10 standardized policies to make comparison easy
5) Unnecessary for patients covered by Medicaid or in Medicare Managed Care plans
6) Illegal for insurance companies to sell plans to these beneficiaries

Medicare SELECT
1) Type of Medicare supplemental health insurance sold by insurance companies and HMOs
2) Similar to standard Medigap insurance
3) Each insurer has specific hospitals, and sometimes doctors, they are required to use in order to be eligible.
4) Lower policy premiums than Medigap due to specificity

Medicare Beneficiary Noties (MBN)
1) Monthly statement that clearly lists claims info
2) Replaces Explanation of Your Medicare Part B Benefits (EOMB), the Medicare Benefits Notice (Part A), and benefit denial letters

Medicare+Choice Plan
Provides care under contract to Medicare
1) Medicare managed care plans like HMOs
2) Medicare Private Fee-for-Service plans

Medicare+Choice plan
1) Medicare pays a set amount of money for your care every month to these private health plans
2) In return, the plan manages the Medicare coverage for its members

Medicare+Choice Plan members
1) Still in the Medicare program
2) Must have Medicare Part A and B, and continue to pay Part B premium
3) Still gets regular Medicare-covered services and may be able to get extra benefits like prescription drugs or additional hospital days
4) May get benefits like coordination of care or reduced out-of-pocked expenses

Private Fee-for-Service
The private company (not Medicare) decides how much it pays and the patient pays for outlined services

Private Fee-for-Service stipulations
1) Patients can go to any Dr. or hospital that accepts the terms of the plan’s payment
2) Provides coverage to people with Medicare who join this plan
3) Private company pays a fee for each Dr. visit/service, patient may also have a copay
4) “Pre-notification” requirement
5) Patients may pay more if the plan lets Drs, hospitals, and other providers bill more than the plan pays; may be a limit; patients must pay difference

Pre-Notification Requirement
Requires patient notify insurance carrier about any “elective” IP hospital admissions

Alternative healthcare choices offered by Medicare
**Dependent upon where the beneficiary lives
**Beneficiaries still in the Medicare program
** Must provide basic Medicare covered services
Medicare Managed Care Plans
Preferred Provider Organizations (PPO)
Provider Sponsored Organizations (PSO)
Private Fee-for-Service Plans
Medicare Medical Savings Account Plans

Eligibility Requirements for Alternative Medicare Health Plans
1) Have both Part A and Part B
2) Continue to pay the monthly Part B premium
3) Live in the plan’s service area (counties where plan is offered)
4) Not have End Stage Renal Disease (ESRD)

Medicare HMO Plans
Follow MSP rules for auto accidents, work-related accidents, and the working aged
Ex. If a patient with this plan has services related to an auto accident, the auto insurance MUST be billed primary

1) Established by federal legislation in 1965 to provide basic health care coverage for certain low-income people
2) Funded and administered through state-federal partnership
3) States have a wide-degree of flexibility to design their program
3) Secondary to Medicare

State Authorities for Medicaid
1) Establish eligibility standards
2) Determine what benefits and services to cover
3) Set payment rates

Medicaid Qualifications
1) Certain low-income families with children
2) Aged, disabled, or blind people on Supplemental Security Income
3) Certain low-income pregnant women and children
4) Certain persons with catastrophic medical expenses who would not otherwise qualify

Basic Services Covered by Medicaid
All states must cover:
1) IP and OP hospital services
2) Lab and X-ray
3) Skilled nursing and home health
4) Dr. services
5) Family planning
6) Periodic health check-ups, diagnosis, and treatment for children

Apply at local welfare or social service offices; many states may allow applying at alternate locations

Traditional Medicaid
1) Participant’s financial status evaluated on a regular basis
2) Each Medicaid recipient will have his/her own recipient ID number

Traditional Medicaid Card
1) In many states, new card is issued each month
2) Eligible dates appear on card
3) Issued to the head of the family
4) Lists names and recipient ID numbers

HMO Medicaid
1) Contracts and billing requirements determined by the State
2) Healthcare organizations contract with this organization to provide services to Medicaid recipients
3) Claims are submitted directly to and paid by organization, which is then reimbursed by Medicaid

Workers Compensation
Services resulting of a work related accident/injury that are paid for by the patient’s employer or the employer’s workers compensation insurance company

Workers Compensation
1) Employer must authorize services
2) No card

Billing Requirements for Workers Compensation
1) Claim number
2) Name of person authorizing services
3) Patient’s social security number

Key Information for Workers Compensation
1) Time and date of injury
2) Type of injury
3) Name of employer and contact person
4) Immediate supervisor
5) Employee insurance info (in case injury deemed not work related)
6) Enter patient classification type as “Workers Compensation” and who should receive the bill

Auto Insurance
1) Coverage for injuries resulting from an auto accident
2) Primacy between Auto and Health insurance determined by state regulations
3) Usually primary for all victims of an auto accident
4) Obtain claim number, billing address, and adjuster’s name/phone number
5) Verify benefits

Auto Insurance = Primary
1) Patient has no health insurance
2) Medicare or Medicaid as primary and services result from an auto accident

Liability Coverage
1) For injuries that are the result of negligence of another party
2) Healthcare facilities have their own policies
3) MSP questionnaire identifies liability for Medicare patients
4) Medicare will pay if coverage is denied and decision does not change in the future
5) No insurance card

Commercial Insurance
1) Insurance monitored by state insurance commissions that does to require a specific contract with a provider organization to reimburse for patient services
2) Patients not required to select a PCP or go to a specific provider

Commercial Insurances
Workers Compensation, Blue Cross, Auto, PPO, HMO
NOT: Medicare, Medicaid, Federal, State or County Programs

Commercial Insurance Cards
1) ID number
2) Group number
3) May or may not be an effective date
4) Policyholder’s social security number may be required for billing

Preferred Provider Organizations (PPOs)
1) Contracts between employers, doctors, and hospitals where the doctors and hospitals agree to provide discounted services for a volume of members in return
2) Members are not required to select a PCP but must use a participating provider for full coverage

Participating Providers
Doctors/hospitals participating in PPOs

PPO Cards
1) Many different cards
2) ID number
3) Effective date
4) Co-pay amounts for ER/UC and office visits
5) May or may not have a group number

Health Maintenance Organizations (HMO)
Insurance plans that strive to control healthcare costs by requiring members to receive services as designated facilities; members must select a PCP; contracts with specific providers/facilities

Overseen by the Department of Defense in cooperation with regional civilian contractors; secondary payer to coverage from another health plan (HMO/PPO); primary if other coverage is Medicaid or Indian Health Service

Tricare Prime
Tricare similar to HMO; active duty service members automatically enrolled

Civilian Health Medical Program for the Veterans Administration; for families of veterans with 100% service connected disability and the surviving spouse or children of a veteran who dies from a service connected disability; eligibility determined by Department of Veterans Affairs

Tricare Extra
Tricare PPO that saves money for patients

Tricare Standard
Tricare Fee-for-Service option, same as former CHAMPUS; shares the cost of most medical services from civilian providers even beneficiaries cannot get care from a military hospital/clinic

Tricare for Life
Tricare expanded medical coverage for Medicare-eligible beneficiaries; must have Medicare Part B; patient received all benefits under Original Medicare Plan; Medicare pays first

Military Treatment Facilities (MTFs)
Primary source of healthcare for active duty service members

Common Working File
Verification system linked to Medicare

Carve Out
Decision to desperately purchase a service which is typically part of an HMO plan

Coordination of Benefits (COB)
Determining the order in which benefits are paid and the amounts that are payable when a patient is covered by multiple health plans

National Association of Insurance Commissioners (NAIC)
Standardized the coordination of benefit rules

Birthday Rule
Determines which parents plan will be primary when dependents are on both parents’ health plan; the plan of the parent whose birthday occurs earlier in the year is primary

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