HEALTH INSURANCE OVERVIEW

Most healthcare practices in the United States accept responsibility for filing

health insurance claims, and some third-party payers (e.g., Blue Cross/Blue

Shield) and government programs (e.g., Medicare) require providers to file

claims. A health insurance claim is the documentation submitted to a third-party

payer or government program requesting reimbursement for healthcare services

provided.

 In the past few years, many practices have increased the number

of employees assigned to some aspect of claims processing. This increase is a

result of more patients having some form of health insurance, many of whom

require preauthorization (prior approval) for treatment by specialists and documentation

of post-treatment reports.

 If preauthorization requirements are not

met, payment of the claim is denied. If the insurance plan has a hold harmless

clause (patient is not responsible for paying what the insurance plan denies) in

the contract, the healthcare provider cannot collect the fees from the patient. In

addition, patients referred to non-participating providers (e.g., a physician who

does not participate in a particular healthcare plan) incur significantly higher

out-of-pocket costs than anticipated. Competitive insurance companies are

fine-tuning procedures to reduce administrative costs and overall expenditures.

This cost-reduction campaign forces closer scrutiny of the entire claims process,

which in turn increases the time and effort medical practices must devote to

billing and filing claims according to the insurance policy filing requirements.

Poor attention to claims requirements will result in lower reimbursement rates

to the practices and increased expenses.

A number of managed care contracts are signed by healthcare providers.

A healthcare provider is a physician or other healthcare practitioner (e.g., physician’s

assistant). Each new provider-managed care contract increases the

practice’s patient base, the number of claims requirements and reimbursement

regulations, the time the office staff must devote to fulfilling contract requirements,

and the complexity of referring patients for specialty care. Each insurance

plan has its own authorization requirements, billing deadlines, claims

requirements, and list of participating providers or networks. If a healthcare

provider has signed 10 participating contracts, there are 10 different sets of

requirements to follow and 10 different panels of participating healthcare providers

from which referrals can be made.

Rules associated with health insurance processing (especially government

programs) change frequently; to remain up-to-date, insurance specialists

should be sure they are on mailing lists to receive newsletters from third-party

payers. It is also important to remain current regarding news released from the

Centers for Medicare and Medicaid Services (CMS) which is the administrative agency

within the federal Department of Health and Human Services (DHHS). The

Secretary of the DHHS is often reported by the news media as having announced

the implementation of new regulations.

The increased hiring of insurance specialists is a direct result of employers’

attempts to reduce the cost of providing employee health insurance coverage.

Employers renegotiate benefits with existing plans or change third-party payers

altogether. The employees often receive retroactive notice of these contract

changes and, in some cases, once notified may have to wait several weeks before

new health benefit booklets and new insurance identification cards are issued.

These changes in employer-sponsored plans have made it necessary for the

healthcare provider’s staff to check on patients’ current eligibility and benefit

status at each office visit