Curriculum to Accompany

Medical Assisting:

Administrative and Clinical Competencies,

6th Edition

Course:

Health Care Coverage


Curriculum to Accompany Medical Assisting: Administrative and Clinical Competencies, 6th Edition

Course: Health Care Coverage

Contents

Part A: Fundamentals of Managed Care

Part B: Health Care Plans

Part C: Preparing Claims


Curriculum to Accompany Medical Assisting: Administrative and Clinical Competencies, 6th Edition

Course: Health Care Coverage

Course Overview

In the big picture of health care coverage, one will find many unique and individual facets that compose this picture. In today’s world, insurance coverage may be through a managed care provider, a preferred provider organization, and/or traditional plans through commercial carriers. Everyone likes to have choices when it comes down to health care coverage whether it is employers, employees, carriers, and/or consumers. This module addresses health care coverage with the most efficient and effective ways to obtain maximal reimbursement.

Resource List

Textbook: Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-6633-8. Chapter 9.

Student CD-ROM: CD-ROM that accompanies Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition. This CD-ROM contains StudyWARE, The Critical Thinking Challenge, and an Audio Library.

Workbook: Workbook to accompany Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-3267-0. Chapter 9.

Instructor’s Materials: Instructor’s Resource Manual to accompany Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-3268-9.

Instructor’s CD-ROM: Electronic Classroom Manager to accompany Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-3269-2.

DVD: Thomson Delmar Learning’s Critical Thinking for Medical Assistants DVD Series. Program 5: Insurance and Coding. Series ISBN 1-4018-3857-X.

DVD: Thomson Delmar Learning’s Skills and Procedures for Medical Assistants DVD Series. Program 3: Modern Reimbursement Procedures. Series ISBN 1-4018-3868-5.

The Internet: It is strongly recommended that faculty and learners alike have a working knowledge of the Internet.

Equipment List

  1. Multimedia projector
  2. Computer with Internet access
  3. Multimedia equipment
  4. AAMA credentialing information
  5. AMT credentialing information
  6. DVD player

CAAHEP content

III.C.1.f(3) Insurance, procedural and diagnostic coding

ABHES content

VI.B.1.b(7)(c) Insurance (including HMOs, PPOs, co-pays, CPT coding, etc.)

CAAHEP competencies

III.C.1.a(3)(a) Apply managed care policies and procedures

III.C.1.a(3)(b) Apply third party guidelines

III.C.1.a(3)(c) Perform procedural coding

III.C.1.a(3)(d) Perform diagnostic coding

III.C.1.a(3)(e) Complete insurance claim forms

ABHES competencies

VI.B.1.a(3)(t) Apply managed care policies and procedures

VI.B.1.a(3)(v) Perform diagnostic coding

VI.B.1.a(3)(w) Complete insurance claim forms

VI.B.1.a(3)(x) Use a physician’s fee schedule

Learning Activities

(HW) Terminology Notebook. Assign chapter for reading and have students define key terms and retain in a key term notebook for future reference.

(ICD) Have the students to discuss the differences between HMO, PPO, group, and individual coverage.

(ICA) Show a DVD clip—“Introduction to insurance and coding” from Program 5: Insurance and Coding (Critical Thinking series).

(ICA) Provide 2-3 scenarios for students to apply and understand the birthday rule.

(ICA) Provide examples of different co-payment amounts (80-20, 60-40, 70-30); have the students to calculate the various balances due from the patient.

(ICA) Drill the students on the various terms in Table 9-1 to ensure understanding of them.

(HW) Activity. Complete Activity 2 on page 269 of the text.

(HW) Chapter 9, Unit 1 Workbook Assignment Sheet.

(ICA) Show a DVD clip—“Insurance and HIPAA” from Program 5: Insurance and Coding (Critical Thinking series).

(ICA) Show a DVD clip—“Explanation of benefits (EOB)” from Program 3: Modern Reimbursement Procedures (Skills and Procedures series).

(ICA) Obtain copies of EOBs (black out the names) for students to review.

(ICA) Create 2-3 scenarios that have an annual deductible amount due from 80-20, 70-30, and 60-40 plans. Have the students to calculate the balance due from the patient including the deductible.

(ICD) Ask the students how many of them or their families have been required to pre-certify and/or pre-authorize to receive medical services.

(ICD) Contrast the various HMO models.

(ICD) If IPAs are common in your area, give the students practice names to see how many of them knew of their status.

(ICA) Involve the students in a pro/con discussion for the gatekeeper (PCP). Talk about the ethical implications involved with the gatekeeper.

(ICA) Poll the students to see how many of them are aware of CDHPs. If unaware, initiate a discussion of which account each of them would prefer to cover their expenses and their rationale for their preference.

(HW) Discuss the four major types of state benefits for workers’ compensation claims.

(HW) Ask the students to identify the differences in Medicare and Medicaid coverage.

(HW) Have the students to identify what individuals are eligible for TRICARE coverage.

(HW) Chapter 9, Unit 2 Workbook Assignment Sheet.

(ICD) Ask the students to tell you the difference(s) in ICD and CPT coding.

(ICD) Have the students to point out vital portions of the CMS1500 claim form and why the information is so important.

(ICA) Provide for student review properly completed CMS1500 forms as a reference point (use fictitious names or black out the names).

(ICA) Show a DVD clip—“Coding and processing insurance claims” from Program 3: Modern Reimbursement Procedures (Skills and Procedures series).

(ICA) Show a DVD clip—“CPT codes” from Program 3: Modern Reimbursement Procedures (Skills and Procedures series).

(ICA) Show a DVD clip—“ICD-9-CM codes” from Program 3: Modern Reimbursement Procedures (Skills and Procedures series).

(ICA) Have the students to identify common errors in insurance claim submissions.

(ICA) Contrast the difference in accepting assignment and participating physicians.

(ICA) Show a DVD clip—“Checking for coding errors” from Program 5: Insurance and Coding (Critical Thinking series).

(ICA) Show a DVD clip—“Claims and codes” from Program 5: Insurance and Coding (Critical Thinking series).

(ICA) Complete Procedure 9-1; retain copy of the encounter form as work product and attach to the performance objective checklist.

(ICA) Complete Procedure 9-2; retain copy of the completed CMS1500 claim form as work product and attach to the performance objective checklist.

(ICA) Access the MOSS student CD to complete and print an insurance claim form from a case study. (This could be used as documentation of the completed CMS1500 for Procedure 9-2.)

(HW) Chapter 9, Unit 3 Workbook Assignment Sheet.

(HW) The Critical Thinking Challenge, pages 267-268.

(HW) The StudyWare Challenge, Chapter 9. Have students take the Quiz in “Quiz Mode” and either email their scores to the instructor, or print the scores to turn in.

(ICA) Following review of the chapter and homework assignments, give a quiz on this chapter that includes the content and competencies listed for CAAHEP and ABHES.

Part A: Fundamentals of Managed Care

Learning Objectives

Cognitive

  1. Define the key terms presented in the unit.
  2. Describe the changes in health care coverage in the last 20 years and the reasons for the changes.
  3. Explain the purpose of HMO’s.
  4. Explain the concept of managed care.
  5. Distinguish the two major classes of health insurance.
  6. Explain the reason for keeping patient insurance information confidential.
  7. List the different types of health insurance discussed in the unit.
  8. Explain the birthday rule.

Initial Questions and Activities

å  Have the students to discuss the differences between HMO, PPO, group, and individual coverage

Key Concepts / References & Activities / Slides
Health maintenance organizations (HMOs) / Page 237 / 3-7
Insurance terms / Table 9-1, Pages 238-239
The birthday rule / Page 240 / 8-9
The insurance paper trail / Pages 240-241

(ICA) In-Class Activities

  1. Show a DVD clip—“Introduction to insurance and coding” from Program 5: Insurance and Coding (Critical Thinking series).
  2. Provide 2-3 scenarios for students to apply and understand the birthday rule
  3. Drill the students on the various terms in Table 9-1 to ensure understanding of them.

(ICD) In-Class Discussion

  1. What is the primary purpose of HMOs?

They serve to help contain health care costs; examples include promoting wellness; encouraging routine physical, examinations, and vaccinations; and, requesting that patients see providers as soon as possible when health problems arise.

  1. What is the birthday rule?

The rule deals with dependent children when both parents have equal health care coverage. The parent with the birthday occurring first in the calendar year has primary coverage for the dependents. If both parents have the same birthday, the one with the longest running plan is the primary. In cases of divorce, the parent with custody of the minor children is primary. However, if a court orders a specific parent as responsible for providing coverage, the rule is void.

(HW) Homework Assignments

1.  Terminology Notebook. Assign unit for reading and have students define key terms and retain in a key term notebook for future reference.

2.  Activity. Complete Activity 2 on page 269 of the text.

3.  Chapter 9, Unit 1 Workbook Assignment Sheet.

Presentation Tools

Note to Instructors: If you change Objectives or Assignments, don’t forget to change the slides accordingly.

Chapter 9, Slides 1-2 / Introduce the course and unit.
Slide 3-7 / Health maintenance organizations (HMOs).
Slide 5 / Include the concept that managed care plans encourage preventative medicine by paying for annual physical examinations, well-baby and well-woman check ups, and vaccinations.
Slides 8-9 / The birthday rule.
Slide 10 / Have students answer the checkpoint questions on the slide to review the content in the unit.

Part B: Health Care Plans

Learning Objectives

Cognitive

  1. Define the key terms in the unit.
  2. Identify the original purpose of an indemnity-type insurance plan.
  3. Identify the health care philosophy of an HMO.
  4. Name the types of HMOs and explain their differences.
  5. Explain how a PPO differs from an HMO.
  6. List five federal health care plans.
  7. Name the three centers that were established by the changes in 2001.

Initial Questions and Activities

å  Ask the students how many of them or their families have been required to pre-certify and/or pre-authorize to receive medical services

å  Contrast the various HMO models.

å  If IPAs are common in your area, give the students practice names to see how many of them knew of their status.

Key Concepts / References & Activities / Slides
Commercial health insurance / Pages 242-243 / 12
Types of HMOs / Page 243 / 13-14
Consumer-driven health plans (CDHPs) / Page 244
Workers’ compensation / Page 245 / 15
Medicaid coverage / Page 245 / 15
Medicare coverage / Pages 247-250 / 15
TRICARE (CHAMPUS) / Page 250 / 16

(ICA) In-Class Activities

  1. Show a DVD clip—“Insurance and HIPAA” from Program 5: Insurance and Coding (Critical Thinking series).
  2. Show a DVD clip—“Explanation of benefits (EOB)” from Program 3: Modern Reimbursement Procedures (Skills and Procedures series).
  3. Obtain copies of EOBs (black out the names) for students to review.
  4. Create 2-3 scenarios that have an annual deductible amount due from 80-20, 70-30, and 60-40 plans. Have the students to calculate the balance due from the patient including the deductible.
  5. Involve the students in a pro/con discussion for the gatekeeper (PCP). Talk about the ethical implications involved with the gatekeeper.
  6. Poll the students to see how many of them are aware of CDHPs. If unaware, initiate a discussion of which account each of them would prefer to cover their expenses and their rationale for their preference.

(ICD) In-Class Discussion

  1. Describe the differences between pre-certification, pre-authorization, and pre-determination.

For pre-certification, the carrier is consulted to see if the patient is covered for a proposed treatment. For pre-authorization, the carrier is consulted to determine if the service if covered and medically necessary. In pre-determination, the carrier informs the provider how much will be paid for the proposed treatment.

  1. When did the federal government create consumer-driven health plans?

2003.

  1. True or False? The patient is always billed in cases of work-related claims.

False; the patient should never be billed for such claims unless the treatment was unauthorized or considered excessive by the workers’ compensation commission.

  1. How often are Medicaid cards issued to eligible recipients?

The cards are issued on a monthly basis, one of the reasons that it is so important to verify current coverage by requesting the card when registering for an appointment.

  1. Which agency is responsible for administering Medicare?

The Social Security Administration.

  1. Name one stipulation of HIPAA directly relevant to Medicare claims.

Effective 10/1/05, all providers are required to submit Medicare claims electronically.

  1. Which carrier was established to help dependents of active military service personnel and their dependents?

TRICARE (CHAMPUS)

(HW) Homework Assignments

  1. Terminology Notebook. Assign unit for reading and have students define key terms and retain in a key term notebook for future reference.
  2. Assign students to write a 1-2 page paper on one of the following topics:

·  Discuss four major types of state benefits for workers’ compensation claims

·  Identify the differences in Medicare and Medicaid coverage.

·  Identify what individuals are eligible for TRICARE coverage.

  1. Chapter 9, Unit 2 Workbook Assignment Sheet.

Presentation Tools

Note to Instructors: If you change Objectives or Assignments, don’t forget to change the slides accordingly.

Chapter 9, Slides 11 / Introduce the unit.
Slide 12 / Indemnity-type insurance plans.
Slides 13-14 / Health maintenance organizations.
Discuss why PPOs are beneficial for the physician that enrolls to provide such services.
Slides 15-16 / Federal health care plans.
Tell students when an injured worker must file a claim for work-related injuries for eligibility of workers’ compensation coverage.
Slide 17 / Centers established in 2001: The Center for Medicaid & Medicare Service (CMS), the Center for Beneficiary Choices, and the Center for Medicaid and State Operations
Slide 18 / Have students answer the checkpoint questions on the slide to review the content in the unit.

Part C: Preparing Claims