Medicare is the biggest government payer practitioners will deal with, but it’s by no means the only one. Government-operated health insurance encompasses many other programs and in this second of a two-part series, Nitin Chhoda addresses other government-sponsored insurance plans.
Healthcare insurance programs operated by the government provide coverage for veterans, low-income adults and injured workers.
Managed by the federal government, some programs are administered at the state level.
All have very specific regulations and can require pre-authorizations, referrals, and proof of medical necessity before they approve reimbursements.
Medicaid
Next to Medicare, Medicaid is one of the best known healthcare insurance programs in the U.S. Designed to provide the poor and low-income individuals with basic health services, it’s administered at the local level. Each state has considerable leeway in the manner in which it administers the program, determines individual eligibility, and what services are provided.
Funding cuts to Medicaid at the federal level has resulted in many states limiting coverage to the most basic levels for adults. The program also provides limited healthcare coverage for those who require nursing home care. Children in the program receive dental and vision services, along with healthcare. Medicaid patients are entitled to surgical procedures, inpatient hospital treatment, and prenatal care.
It’s extremely difficult to verify a patient’s Medicaid eligibility, what portion of the bill the client may be responsible for, and what services are covered until the actual reimbursement claim is submitted. Medicaid maintains a stringent fee schedule, regardless of actual costs.
Tricare
Funded by the U.S. Department of Defense, Tricare is the healthcare plan that serves active military personnel and their dependents. Tricare encompasses three levels of care – Standard, Prime and Life. Tricare Standard is for active duty, retired and reserve retirees, and their family members. It operates similar to a PPO. Recipients are required to pay a deductible and copay, but can see any civilian healthcare provider.
Tricare Prime resembles an HMO and serves the same segment of the military as the Standard. Patients have more restrictions and must only utilize network providers. Tricare for Life is a supplement plan for former Tricare members that are eligible for Medicare. The plan pays according to a fee schedule similar to Medicare.
CHAMPUS VA
The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) serves VA patients and those not eligible for Tricare, along with spouses and dependents of military personnel who were disabled in the line of duty. Surviving spouses and dependents of veterans killed due to military-related injuries are also eligible.
CHAMPUS healthcare plans are usually secondary payers. When it’s the primary payer, the plan functions much like an HMO. It’s imperative that coverage is verified prior to the client’s visit to ascertain if a referral or pre-authorization is required before treatment is provided.
Workers’ Compensation
Administered by the U.S. Department of Labor, Workers’ Compensation is available for workers injured while on the job or who develop an occupation-related disease. Practitioners must enroll in the healthcare program and obtain a DOL number.
Workers’ Comp claims always require pre-authorization, but that doesn’t guarantee payment for services.
Before treating a client, verify pertinent information about the disease or injury with the employer. A diagnosis code must be approved by the Workers’ Comp carrier and the medical provider must prove medical necessity.
Clinicians should obtain a pre-authorization for every procedure. Workers’ Compensation claims are paid according to a healthcare pre-determined fee schedule, and funds deposited through electronic fund transfer.
Patients covered by government-operated healthcare programs can add significantly to the revenues of any practice, but clinicians should exercise caution especially with their medical billing and make sure to verify every aspect of the client’s coverage prior to treatment.
Government healthcare plans have numerous rules, regulations and filing requirements and if they’re not followed to the letter, reimbursements won’t be forthcoming.
