Health Insurance Programs - Essay Example

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From the paper "Health Insurance Programs" it is clear that CHAMPVA and TRICARE have similarities in their customer base. They use the same federal strategies and have similar rules. For Tricare eligibility, one must be retired military and enrolled in DEERS. …
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Health Insurance Programs
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Extract of sample "Health Insurance Programs"

CHAMPVA is a Civilian Medical Program of the Veterans Affairs department. It is the government's health insurance program for veterans with 100% service-related disabilities and their families. Members must be: the spouse or child of a veteran totally disabled; the child or spouse of a veteran who passed on from a Veterans affair connected disability, was at the time of death, completely disabled due to service; the surviving child and spouse of a military member whose demise was while on duty.
For CHAMPVA one cannot be retired military, and there is no DEERS enrollment (Moisoi 2010). TRICARE has no disability criteria for eligibility while CHAMPVA veterans must be fully disabled, or died while on duty. Tricare members do not receive medical services by veteran affairs doctors while CHAMPVA veterans and dependents can receive medical care through veteran affairs medical facilities.
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Managed care models provide quality medical services within a budget to an enrolled population. An example is the Staff Model, where physicians are salaried employees of a Health Maintenance Organization. Medical services are only open to HMO members. The physicians adopt the principles of managed care and the system tries to reinforce high quality and cost-effective care with administrative supports.
Procedures for implementing insurance plans include Supervisor training that increases awareness of behavior problems and open channels of communication between staff and managers and Employee orientation that educates employees to understand their benefits and assists them in taking the first step toward benefit utilization.
Utilization Review is the process of appraising the medical requirement and employment of resources for care. The principles enhance good ethical conduct, the confidentiality of information and data. They ensure that members maintain a level of competency through continuing education.
In the managed care referral process medical groups provide training for clinical area staff for new contracts or major changes in current contracts including the development of managed care basics and referral awareness courses for all staff. Departments are informed of new contract agreements and their contents and receive provider manuals prior to contract effective dates. The group provides referral information updates for all clinical areas on a regular basis and develops ways to reduce steps required for scheduling staff in the referral process. When scheduling patients, staff verifies that the referral requirements are met for each patients insurer.
To process an insurance claim, the adjuster looks at the guidelines and applies them to claim. Filing an insurance claim electronically automatically edits all claims against its constantly updated list of state and commercial claims (Moisoi 2010). Unlike manual filling that needs more than your medical billing system to get your claims reports, electronic filing receives verification of accepted and rejected claims directly into your accounts.
Guidelines for third-party claims are: For outpatient treatment preauthorized for payment, there are explicit limits on disclosures to payers of information related to mental health treatment; for outpatient treatment that requires authorization for payment, clinical information disclosed to payers for preauthorization purposes will be used only by them to perform the review.
Medicaid fee schedule reimburses providers the lesser of the billed amount or the maximum allowable fee. Medicare schedule valuing totals are adjusted to reflect the distinction in practice costs from area to area.
RBRVs is work units used to determine the value of various physicians labor.
DRG is a method that classifies hospital patients based on diagnosis consisting of distinct groupings. Read More
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