HIM 1061 - Intro to Medical Insurance

1. Describe the claims process.
2. Apply basic insurance information common to all insurance carriers.
   1. Become familiar with managed care contracts between physicians and insurance carriers that may affect insurance reimbursement.
   2. Explain the benefits.
3. Transfer simple, moderate, and complex case histories onto insurance forms.
   1. Practice with case studies similar to situations to be encountered.
   2. Submit complete, accurate information.
4. Define benefits and eligibility of federally-funded medical health care.
   1. Classify people who are eligible for Medicaid assistance.
   2. Determine eligibility, pre-authorization, filing deadlines, and third-party liability of Medicaid patients.
   3. Demonstrate knowledge of Medicare coverage:  Hospital Insurance (Part A) and Medical Insurance (Part B).
   4. Determine when Medicare is the primary payer and when it is the secondary payer.
   5. Explain who is eligible for TRICARE and CHAMPVA and how to verify eligibility.
   6. Explain the filing procedures of Blue Cross and Blue Shield.
   7. Discuss the categories of eligibility for Social Security disability programs and workers’ compensation.
   8.  Discuss the differences in hospital claims processing.
5. Develop a plan to collect payment when problems arise with provider/subscriber.
   1. Discuss the advantages and disadvantages of internal billing and external billing.
   2. Write a series of collection letters.
   3. Develop techniques to explain insurance problems to patients.
6. Apply legal considerations when completing medical insurance forms.
   1.   Avoid potentially fraudulent situations.
   2. Practice medical records confidentiality and retention policies.
   3. Explain the importance of a “Release of Medical Information” statement.
7.  Apply specific problem-solving techniques when insurances companies deny a claim.
   1. Describe how to deal with delinquent payment.
   2. Explain rebilling.
   3. Explain appeals for incorrect payment/rejection.
   4. Describe claims review.
8. Identify the types of private health plans available in today’s market
   1. Be able to name the basic benefits provided in an indemnity plan
   2. Know the difference between coinsurance and co-payment
   3. Identify the types of managed care plans and how they are structured:

                        i.          Health Maintenance Organizations

                        ii.         Point of Service HMOs

                        iii.        Preferred Provider Organizations

                        iv.        Consumer Driven Health Plans