Group and individual policies provide medical insurance coverage. The policy defines the payments that are required, such as premiums, coinsurance, and copayments. It also describes the services that are covered and those that are not. In addition to medical insurance, two other policy types are important for medical insurance specialists: disability insurance that covers loss of income due to a person’s inability to work and workers’ compensation that provides benefits for job-related claims.
An indemnity health plan reimburses beneficiaries according to the contract’s schedule of benefits in exchange for payment of a specified premium, deductibles, and coinsurance. Patients with indemnity plans receive care from the providers of their choice. Managed care plans, in contrast, contract with both beneficiaries and providers to control the delivery and cost of health care services. In exchange for lower premiums and other cost reductions, plan members agree to a reduced choice of health care providers and tighter regulation of access to services.
Fee-for-service reimbursement is a retroactive payment method in which payment is made after services are provided. In capitation, a fixed prospective payment is made for services to be provided during a specified period of time.
An HMO locks patients into receiving services from providers with whom it has contracts; sometimes a primary care physician coordinates care and makes required referrals to specialists. A POS offers more flexibility to choose providers, but at an increased cost to the patient. A PPO offers patients lower fees in exchange for receiving services from plan providers but does not usually require care coordination or referrals.
A consumer-driven health plan combines a high-deductible, low-premium PPO with a pretax savings account to cover out-of-pocket medical expenses up to the deductible point.
Private payers of health benefits are either insurance companies or self-insured employers. Most private health insurance is employersponsored. Government-sponsored health care programs include Medicare, Medicaid, TRICARE, and CHAMPVA.
The ten steps in the medical billing process are: (1) preregister patients, (2) establish financial responsibility for the visit, (3) check in patients, (4) check out patients, (5) review coding compliance, (6) check billing compliance, (7) prepare and transmit claims, (8) monitor payer adjudication, (9) generate patient statements, and (10) follow up patient payments and handle collections.
Medical insurance specialists must know medical terminology, anatomy, physiology, and medical coding, have communication and information technology skills, pay attention to detail, be flexible and honest, and be able to work as team members.
Medical insurance specialists work in a variety of environments ranging from small to very large medical practices and for insurance companies, government-sponsored programs, and billing services.
Ethical conduct in medical practices means being honest and truthful and acting with integrity. Professional etiquette sets standards for good manners in dealing with others.
