The medical assistant's role
A medical assistant can be involved in many different tasks related to health insurance. Being familiar with the technology and forms that are used will make you more efficient at your job.
Health insurance identification card
A patient enrolled in a health insurance plan will be issued a health insurance identification (ID) card that supplies the following information:
- Health insurance company
- Health plan type
- Subscriber identification number
- Copay amounts
- Health plan name
- Subscriber’s name and covered dependents
- Policy group number
- Health plan contact phone numbers
The medical assistant must be able to identify all of the information provided on the health insurance identification card. To ensure that the person with the insurance card is actually the person named on the card, the medical assistant should also ask to see a photo ID. This information needs to be entered into the practice management software for accurate billing. The medical assistant will also be responsible for scanning an image of the health insurance identification card. Both sides of the card should be scanned because there is important information, usually instructions for preauthorization, on the backside of the card.
Verifying eligibility
Verification of eligibility is the process of confirming health insurance coverage for the patient. When you are scheduling an appointment, health insurance information should be collected (unless it is an emergency situation). If the healthcare facility is not part of the patient’s network of providers, the individual should be informed of this. The patient can then decide whether to schedule an appointment. The medical assistant should also verify the effective date, or date the insurance coverage began, and confirm that the patient will be covered on the date the medical services are provided. The medical assistant should make it a practice to review each insurer’s online insurance web portal, which can verify insurance eligibility, benefits, and exclusions, prior to the patient’s appointment. If the online insurance web portal is not available, the medical assistant should contact the provider services desk; the phone number should be listed on the patient’s health insurance ID card.
In the recent past, the medical assistant would have to call the health insurance company to verify eligibility for every patient. Each call to the health insurance company’s automated system would take at least 5 minutes, and unless the medical assistant spoke to a member services agent, which would take even more time, access to all of the patient’s benefit information would not be available. Today, most privately sponsored health insurance plans offer online insurance provider portals, which allow for quick and easy verification of eligibility. The healthcare facility will have to apply for access to the online web portal. Once it has been approved, a patient’s benefits can be looked up in their entirety in seconds instead of minutes. Information on a patient’s benefit plan can be uploaded to the** electronic health record (EHR) **quickly; this process reduces the use of paper in the healthcare facility.
Other types of insurance
When you work in a healthcare facility, the most common type of insurance you will see is health insurance. However, there are other types of insurance that can require the involvement of a healthcare provider. These other types of insurance are discussed next.
Workers’ compensation
Workers’ compensation is an insurance plan for individuals injured on the job or become ill due to job-related circumstances. An example of a job-related illness would be mesothelioma caused by inhaling asbestos. The insurance plan covers the following:
- Medical care and rehabilitation benefits
- Weekly income replacement benefits
- Death benefits to dependents
The provider accepts the workers’ compensation reimbursements as payment in full and does not bill the patient. Time limitations are set for the prompt reporting of workers’ compensation cases. The employee is obligated to promptly notify the employer. The employer must then notify the insurance company and refer the employee to a healthcare provider.
All 50 states have passed workers’ compensation laws to protect workers against the loss of wages and the cost of medical care resulting from an occupational accident or disease, as long as the employee was not proven negligent. State laws differ regarding employees who are included and the benefits provided by workers’ compensation insurance. Federal and state legislatures require employers to maintain workers’ compensation coverage to meet minimum standards, covering most employees for work-related illnesses and injuries. The purpose of workers’ compensation laws is to provide prompt medical care to an injured or ill worker so that the person may be restored to health and return to full earning capacity in as short a time as possible.
Disability insurance
Disability insurance is a type of insurance that replaces income if the patient has a disability that is not work related. The disability means that the employee is unable to perform standard work functions or duties. It could involve either short-term or long-term disability benefits. Both provide 40% to 70% of the individual’s pre disability income. Many employers offer a disability policy to their employees. Generally, the employee pays the monthly premium. These policies can also be purchased by an individual.
Short-term disability means that a person is unable to work for 9 to 52 weeks. Long-term disability policies pick up when short-term benefits are exhausted. Long-term disability coverage will pay out until the patient returns to work or for the number of years specified in the policy. Some policies will pay out until the patient reaches the age of 65 and then is eligible for Social Security benefits. There may be a waiting period before benefits can be paid. Sick time can be used for the waiting period days.
Weekly or monthly cash benefits are provided to employed policyholders who become unable to work due to an accident or illness. The accident or illness must not be related to work because that would be covered under workers’ compensation. Payments are made directly to the insured and are intended to replace lost income resulting from an illness or other disability. Disability payments are not intended for payment of specific medical bills, and a disability insurance policy should not be confused with a regular health insurance plan.
The medical office may be involved in the examination of the patient to determine the level of disability and when the disability ends. There are forms that a healthcare provider must complete and then submit to the insurance carrier. Prompt attention to the completion of these forms is important, as these patients are waiting for the benefits to pay their bills and buy groceries.
Liability insurance
Life insurance provides payment of a specified amount, upon the insured’s death, either to a designated beneficiary or to the insured’s estate. Annuity life insurance policies provide monthly cash benefits if the policyholder becomes permanently and totally disabled. Sometimes the proceeds from life insurance are used to meet the expenses of the insured person’s last illness.
The healthcare facility may be required to complete physical examination forms when a patient is applying for life insurance. If there is an annuity policy, the healthcare provider may have to determine if there is a permanent disability and submit documentation.
Long-term care insurance
Long-term care insurance is a relatively new type of insurance that covers a broad range of maintenance and health services for chronically ill, disabled, or developmentally delayed individuals. Medical services may be provided on an inpatient basis (e.g., at a rehabilitation facility, nursing home, or mental hospital), on an outpatient basis, or at home.
Liability insurance
Liability insurance covers losses to a third party caused by the insured. There are many types of liability insurance, including automobile, business, and homeowners’ policies. Liability policies often include benefits for the following:
- Medical expenses resulting from traumatic injuries
- Lost wages
- Sometimes pain and suffering
All liability insurance policies are payable to victims injured by the insured person’s home or car, without regard to the insured person’s actual legal liability for the accident.
The Affordable Care Act
In the early 2000s, it became clear that a large number of Americans lacked basic health insurance. Pre-existing conditions made it difficult for Americans who did not work full time or were self-employed to obtain health insurance. In addition, the health insurance market was discriminating against young adults 18 years or older, who may not have been qualified to receive health benefits because they could not find full-time employment.
In 2010, the Patient Protection and Affordable Care Act, known as the Affordable Care Act (also Obamacare), was enacted. It increased the quality, availability, and affordability of private and public health insurance for more than 44 million uninsured Americans. The legislation included new qualifying regulations, taxes, mandates, and subsidies. The federal mandate not only has opened opportunities for more Americans to obtain affordable health insurance but also works to reduce overall healthcare spending in the long run.
The following are other patient protections and provisions under the Affordable Care Act:
- Insurance companies are prohibited from dropping patient health coverage if the individual gets sick or makes an unintentional mistake on the health insurance application.
- Pre-existing conditions and gender discrimination were eliminated, so patients cannot be charged more based on their health status or gender.
- Young adults can remain on their parent’s or guardian’s insurance policy until age 26.
- Health insurance marketplaces were created, where low- to middle-income Americans can compare plans and lower their costs on healthcare coverage.
- States expanded Medicaid coverage to 15.9 million Americans to include those who qualify for cost assistance through the marketplace.
- Individuals seeking health insurance can apply only during the open enrollment period, which is established by each state.
With more Americans having health insurance, the number of office visits to providers across the country is expected to increase. Thus, efficient health insurance management policies should be instituted to meet the new demand for services.