Health Insurance Profiles
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Jan 9, 2024
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Health Insurance Profiles
Katie McCandless
Government Payors
Government payors are U.S. government funded health insurance plans.
Examples of government payors are Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
These programs help support certain populations and economic statuses.
Qualifications for Government Payors
Medicare covers people 65 or older, and some younger people with disabilities.
Medicaid varies by state, but their main qualifications are, pregnant women and children with low income, people with disabilities, seniors, parents, or caregivers with low income, and children in foster care.
CHIP covers children in families that make too much money to qualify for Medicaid. In some states, CHIP also covers pregnant women.
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Billing Government Payors
When it comes to billing government payors Medicare should always be billed first.
Medicare pays first when you’re a dual eligible and you get Medicare covered services.
Medicaid pays last, after Medicare and any other health insurance you have.
If you don’t have combined plans, then your provider will just bill the insurance you have.
How Government Payors are Billed
Medicare will set a value for everything they cover. Once the provider decides if the accept the Medicare assignment, they will send a bill to Medicare that identifies the services rendered to the patient. After that the patient will receive their share of the bill if there is any.
The same process is used for Medicaid and CHIP.
SPECIAL CONSIDERATIONS AND CHALLENGES FOR GOVERNMENT PAYORS
There are some challenges or considerations you may need to look at before enrolling into these plans
For example, people enrolled in Medicare can experience unnecessary hospitalizations, and those hospital stays can be costly, easily running into the thousands. This can increase prices across the board for patients.
Medicaid patients experience increased barriers to care, compared to privately insured patients. More providers are willing to accept more private insured patients, than Medicaid patients.
Providers willing to accept CHIP have also declined in the recent years just like Medicaid.
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Commercial Insurance
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Commercial health insurance is health insurance provided by private issuers—as opposed to government-sponsored health insurance, which is provided by federal agencies.
Common types of commercial health insurance include HMOs, PPOs (preferred provider organizations) , POS (point-of-service) plans, Medicare Advantage plans, Medicare supplemental plans, dental plans, vision plans, HRAs (health reimbursement accounts) , and LTC (long term care) plans.
Qualifications for Commercial Insurance
Plan offerings are regulated and overseen by each state. Most commercial insurance is provided as group-sponsored insurance, offered by an employer.
The specific details of a commercial insurance plan can vary widely and are determined by the company that offers the plan. State regulatory and legislative bodies also dictate certain aspects of what the plans are required to offer and how they must operate.
The qualifications vary depending on the plan.
Billing Commercial Insurance
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Costs and billing all depends on which plan the patient enrolls in and what policy they have, and whether they use a group plan, individual plan, or private plan.
However, there are laws that mandate how and when insurers must pay invoices and reimburse providers and patients, as well as the amount of funds the insurer must keep in reserve to have sufficient capital to pay out benefits.
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How Commercial Insurance is Billed
Commercial insurance bills are based off CPT codes.
A medical biller and coder will code all services and treatment provided to you and send a claim to your insurance. The insurance will then review these codes and pay your bill. You may receive your portion of the bill if you haven’t already paid it by then.
Considerations and Challenges for Commercial Insurance
Certain commercial insurers that serve the individual and group markets are erecting unnecessary barriers to care that have a human cost. This includes improper use of utilization management programs, inappropriate denial of medically necessary covered services, overly restrictive medical necessity criteria that are not transparent to patients or providers, unnecessary and unreasonable documentation requirements, and mid-contract changes to patients’ coverage
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WORKERS’ COMPENSATION
Workers' compensation is designed to protect employees and employers from the negative consequences associated with a work-related accident.
Insurers don’t typically offer different types of workers’ compensation policies. The state fund workers’ comp plan or workers’ comp plan you can get from an insurance company are generally standard in the industry.
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Qualifications for Workers’ Comp.
Employees may be eligible for workers' compensation if they suffer an accident or injury while working. Illnesses that occur, as a result, of exposure in the work environment may also be covered by the employer's policy.
Each state has different laws on Workers’ Compensation.
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Billing Workers’ Comp.
Billing for workers’ compensation claims can differ from state to state, sometimes making it problematic. Knowing your state’s regulations, which are established by your state commission, will keep your practice in compliance. However, there is general nationwide billing information for workers’ compensation claims that does help keep billing somewhat uniform.
Workers’ compensation insurance will have no deductible or copayment, and all providers must accept the compensation payment as payment in full. Balance billing of patient is prohibited.
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How Workers’ Comp is Billed
The employee must report injury within 30 days of accident.
Once the patient comes in for a work-related injury, the office/hospital will call the employer for confirmation, and obtain all information needed for their claim. They will then send it to the employee’s Workers’ Comp. plan. These types of claims should not be submitted to the health insurance plan, but directly to the Workers’ Comp. plan.
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Considerations and Challenges for Workers’ Comp.
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Some challenges identified with Worker’s Comp. are, medical price inflation, increasingly complex claims, health care provider and service shortages, new workplace safety challenges, and insurance industry labor shortage.
References
Children’s Health Insurance Program (CHIP) eligibility requirements
. (n.d.). HealthCare.gov. https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/
Medicaid | Medicare
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%20you,other%20health%20insurance%20you%20have.
Hsiang, W., Lukasiewicz, A. M., Gentry, M., Kim, C., Leslie, M., Pelker, R. R., Forman, H. P., & Wiznia, D. H. (2019). Medicaid patients have greater difficulty scheduling health care appointments compared with private insurance patients: A Meta-Analysis.
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Racine, A. D., Long, T. F., Helm, M., Hudak, M. L., Shenkin, B. N., Snider, I. G., White, P. H., Droge, M., & Harbaugh, N. “. (2014). Children’s Health Insurance Program (CHIP): accomplishments, challenges, and policy recommendations.
Pediatrics
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Green, L. (2023). Commercial health insurance: Definition, types, and examples.
Investopedia
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Guides: Health care Reimbursement: Commercial insurance
. (n.d.). https://guides.library.jhu.edu/heath-care-reimbursement/insurance
Addressing commercial Health plan challenges to ensure fair coverage for patients and providers | AHA
. (2022, November 1). American Hospital Association. https://www.aha.org/guidesreports/2022-11-01-
addressing-commercial-health-plan-challenges-ensure-fair-coverage-patients-and-providers#:~:text=This%20includes%20improper%20use%20of,mid%2Dcontract%20changes%20to%20patients’
Types of Workers’ Compensation Insurance Policies | The Hartford
. (n.d.). The Hartford. https://www.thehartford.com/workers-compensation/types-of-workers-compensation-insurance
Aapc, A. (2010, March 24).
Workers' compensation billing - AAPC Knowledge Center
. AAPC Knowledge Center. https://www.aapc.com/blog/5121-workers-compensation-billing/