medicaid and workers compensation€¦ · web viewdecember 12, 2016 final portfolio karen stevens...

MEDICAID AND WORKERS COMPENSATION

KAREN STEVENSMAAT235- LUKIC

December 12, 2016Final portfolio

Medicaid and Workers Compensation 1

Table of Contents

Executive summaryOverview of Medicaid and Workers Compensation…………………………………………………………2-3

TerminologyCommon language associated with Medicaid and Workers Compensation……………………4-6

ReportDetailed descriptions of Medicaid and Workers Compensation……………………………………..7-14

ConclusionReport and research inferences……………………………………………………………………………………14

ReferencesA list of sources utilized for presentation completion…………………………………………………15


Executive Summary

MEDICAID

Medicaid is a widely-recognized health insurance company. It was enacted under the

same statue as Medicare in 1965 (Mitchell, Baumrucker, Herz, 2015, 1). This program is

intended for low income people who have few resources to provide medical care (Valerius,

Bayes, Newby, Blochowiak, 2017, 17). 72% of those enrolled are covered a by managed care

(Mitchell, Baumrucker, Herz, 2015, 12). Most commonly resembling a HMO plan (not always

and at state discretion). This tells us it generally operates within a network of medical

professionals. Funding is jointly participated by Federal and State governments. Broad

expectations are implemented Federally while; each state elaborates their own program. As

medical professionals, we should know the criterion, benefits, and covered services will vary in

each state. Coverage will need to be verified each visit. Federally expectations must be met to

receive funding on this level (Valerius, Bayes, Newby, Blochowiak, 2017, 17). All states choose

to participate in Medicaid voluntarily. Although not mandated Federally, in 2014 this program

represented 15% of the U.S. health care spending, supplying insurance coverage to

approximately 65 million people. The cost was a substantial $498 billion (Mitchell, Baumrucker,

Herz, 2015, 1). The sheer numbers involved, means a biller / medical professional will feasibly

experience Medicaid.

The prevalence of Medicaid, impacts many people and consumes substantial funds;

which is why it was chosen as an addressed topic. It will likely be encountered, so a basic

comprehension is beneficial. Due to the fact, each state has its’ own program and conditions of it

may change- elevates the need to be cognizant of this health care entity. Further, throughout

independent research, I am noticing a grave lack of basic health insurance competency among

consumers. By researching Medicaid, I can use this cognition to educate consumers (and staff)

associated with this facility. Thus, customer service will satisfy, gaining a positive reputation for

myself and company.


WORKER’S COMPENSATION

Unlike Medicaid, worker’s compensation has no explicit Federal directives, but does

associate with Department of Labor (Szymendera, 2016, 21). Each state has enacted an

independent version and overtime, has progressed to what we recognize today as worker’s

compensation. States dictate if managed care participation is required. However, many are

leaning on the benefits (like getting employees back to work) and cost control of these plans. It is

purchased by employers with more than 3 employees to cover work-related injuries and illnesses

(Valerius, Bayes, Newby, Blochowiak, 2017, 396). Employers may have a choice of state

Workers Compensation insurance, private insurance, or self -insurance to cover workers.

Previously, it was sometimes referred to as the ‘grand bargain’ as it benefits employers and

employees alike. The bargain: employees prevent out of pocket, work related medical costs and

gain a percentage of lost wages (within state expectations). While, employers are adverting

lawsuits (Szymendera, 2016, 1). Today, proper worker’s compensation course of actions is more

clearly defined. Comprehending the process will streamline the reimbursement processes

correlating to a work-related injury/ illness. Also, as a medical worker provisions are equally

important. Such as, those utilizing worker’s compensation forfeit protection under the HIPAA

privacy rule. Meaning, employers have access to case pertinent documentation without requiring

patient consent.

The afore mentioned statement is a great example of why I chose to discuss worker’s

compensation. Most of us, have or will be covered under this insurance at some point.

Employment in the medical field means we will also likely encounter it. It is essential to

understand the rights and processes for those involved and the differences working with this

insurance. As well as, ensuring we all conduct acts in accordance with statues and job requisites.

A prime example of ‘knowledge is power’.


TERMINOLOGY

Abbreviations are displayed followed by common insurance language. The terms are

specific and not inclusive of those utilized by Medicaid and Worker’s Compensation.

ACA- Affordable Care Act

CHIP- Children’s Health Insurance Program (s-state)

CMS- Center for Medicare & Medicaid Services

DOB- Date of Birth

DOS- Date of Service

DX- Diagnosis

EOC- Episode of Care

ER- Emergency room

FMAP- Federal Medical Assistance Percentage

HMO- Health Maintenance Organization

NonPAR- nonparticipating

OSHA- Occupational Safety and Health Administration

OV- Office Visit

OWCP- Office of Workers Compensation Programs

PAR- participating

PT- patient


SMI- Supplementary Medical Insurance

SSN- Social security number

TPA- Third-party claims administer

TPO- Treatment, Payment, and healthcare Operations

Affordable care act- health insurance reform, meant to improve coverage and benefits (expanded Medicaid)

Benefits- services that are covered and compensated; advantages

Carrier- health plan, insurance company, payer

Cash benefits- money paid to insured for lost wages


Categorically needy- criteria that are met for eligibility

Center for Medicare & Medicaid services- division of government responsible for Medicare, Medicaid, and other health programs that operate within HHS

Claim- a formal request for reimbursement

Co-insurance- percentage of charges owed by patient for services, the other portion is paid by carrier

Co-payment- numeration due by patient at the time of service to provider, required and defined by insurance company

Cost sharing- division of financial responsibility

Covered services- supported procedures and services that are defined by the insurance company

Deductible- yearly monetary value that must be paid by the insured before a health insurance plan can go into effect

Disability benefits- assistance (monetary) provided by insurance company to those temporarily, permanently, partially, or fully disabled

Dual eligible- Medicare and Medicaid beneficiary

Eligibility- meeting stipulated requirements; qualifying for

Employer cost- value the employer is responsible for

Enrollee- person receiving health insurance

Federal medical assistance percentage- factor that determines federal financial participation

Fee-for-service- payment method based on provider’s charge for their (specific) service

Funding- a supply of resources used to sustain objectives

Legislation- laws mandating conduct

Managed care- cost effective system responsible for managing finances and health care services

Medical benefits- services and procedures that are covered and compensated by insurance

Out-of-pocket- the money paid at the expense of the patient

Payer-health plan, carrier, insurance company

Premiums- money the insured pay to the carrier for a health care policy

Provider payments- money dispersed by insurance company


In order to function lucratively and offer superior service, we need to discuss Medicaid

and Workers Compensation regulations. Medicaid can be arduous to comprehend because states

administer their own principles under Federal guidelines. Federal expectations are required by all

states, to receive funding. Workers compensation functions under different pretenses. Although it

varies from state to state like Medicaid, purposes and processes are more clear. This program

lacks gravity of federal oversight that Medicaid exhibits. We will examine Federal regulations

and any state specific information will pertain to our state of employment, New York.

Medicaid can be represented as fee for service or managed care. A fee for service

enrollee can seek treatment from any provider, as long as they accept Medicaid insurance. Over

half of plans work within managed care networks. Meaning, enrollees are bound to choose from

network physicians and abide by referral criteria. Managed care can be mandatory or voluntary,

supporting state dictations. Participants are provided a member card with an access number, used

on claims. As professionals, we need to authenticate eligibility (with these cards) before each

visit. Deductibles, coinsurance, copayments, and exemptions exist (Valerius, Bayes, Newby,

Blochowiak, 2014, 363-364). Monetary plan contributions vary by state, some noting required

payments on enrollee card. Federally, there is a maximum out-of-pocket cap; so, fees cannot

exceed this set value (CMS, n.d.).

Federally, claim submissions for Medicaid have advanced over recent years. For

example, filings use procedure and diagnosis codes. Procedure codes are obtained from HCPCS

and diagnosis codes are retrieved from ICD-10-CM code sets. Using the codes properly will

create a code link; telling the payer medical necessity requirements have been met (vary to some

extent between states). This needs to happen for a claim submission to be successful. Medicaid

should always be the last payer to be billed (OASAS, 2016, 6,9). Pay close attention if the


enrollee is dual eligible. Clean claims usually receive payment within thirty days. Unless, the

practice is converting to electronic submission. A paper filing, clean claim can assume reparation

inside forty-five days. A provider is allocated ninety days; after a denial, to dispute the claim

(WellCare, 2016, 84-86). Contracts between Medicaid and physicians with the Department of

Health and Human Services (D.O.H.H.S) often declare, Medicaid payments are to be accepted as

‘paid in full’. Any financial discord are entered as a tax write off (Valerius, Bayes, Newby,

Blochowiak, 2014, 363).

NY claims also use HCPCS and ICD-10-CM code sets in an 837-electronic format.

Practices in the process of converting, use CMS-1500 forms. NY billers should know particular

billing regulations may apply. For instance, Medicaid will pay for 100% of a primary surgery;

50% for a secondary surgery; and 25% for additional procedures. New York filings are

submitted to managed care providers by out-of-network assistance, no later than fifteen months

from the date of service (DOS). In- network claims are given 120 days for submission. If this

insurance is used as a second payer, there is a ninety-day cutoff. Tax ID numbers, NPI numbers,

preauthorization numbers are expected to be provided, when applicable (WellCare, 2016, 82,91).

Thus far, we can see that varying state requirements feature Medicaid complexity.

The benefits, attributes, and standard costs of Medicaid also differ from state to state;

operating under Federal instruction. As previously stated, the Federal government imposes a

maximum out-of-pocket cost. While, states determine deductibles, copays, and exemptions. The

maximum out-of-pocket costs are determined by the Federal Poverty level and are reviewed

annually. So, we all need to maintain current literacy of Medicaid out-of-pocket fees. In 2013,

deductibles climaxed at $2.65: managed care copays $4: institute care $75: nonemergency $8:


referred prescriptions $4: and non-referred drugs $8. The Federal government dictates out-of-

pocket fees are not to exceed five percent of the enrollee income (CMS, n.d.).

Federal law offers two primary benefit packages that are elaborated by individual states.

These packages represent services covered. The traditional benefit package is required to cover

inpatient hospital visits, labs, nursing homes, and x-rays. This provision operates under state

wide rules. Alternative benefits, on the other hand, do not conduct within state wide rules. This

plan covers family planning and emergency/nonemergency transportation services (Mitchell,

Baumrucker, Herz, 2015, 7). When seeking increased benefit and cost cognition, we would

explore state specific standards.

While each state may have different Medicaid administers (NY- Department of Health

[DOH]); the financial security, funding, and future have more certainty than other aspects of

Medicaid. This government sponsored health care program benefits those who are categorically

needy. It is funded jointly between state and federal government, as long as, a state meets federal

requirements (Valerius, Bayes, Newby, Blochowiak, 2014, 17). The Federal government cost

share is dispersed annually and it is resolved using FMAP (federal medical assistance

percentage) calculations. Up to sixty percent of a state’s obligation can be accessed through local

government (Mitchell, Baumrucker, Herz, 2015, 11,13). Understanding funding is just as

important as comprehending security of these plans.

The Medicaid program is designed to contest fraud, abuse, and waste. For example,

claims are investigated ensuring code linkage and medical necessity. Over or mispayments are

recovered from responsible providers. Enrollment eligibility are reviewed every six months

(Mitchell, Baumrucker, Herz, 2015, 21). The federal government projects laws on a federal level.

While, states regulate insurance companies, record keeping, and liscensing. Basically, there is


immense supervision regarding Medicaid. The benefit, Medicaid will be around long into the

future. This program is also equipped to adapt to change with growing health care systems in this

country- proving Medicaid is durable.

These changes occur when legislation demands it. Probably the most dramatic impact

came to Medicaid with the passing of the Affordable Care Act (ACA). The goal was to create

consistency among Medicaid, Medicare, and CHIP. As well as, increase access to health care.

For example, eligibility was expanded to people under sixty-five who represent 133% of the

Federal Poverty level (Mitchell, Baumrucker, Herz, 2015, 21). Medicaid can now be obtained

through DSS (Department of Social Services) with proof of assets. Applicants can now appeal a

denial (Valerius, Bayes, Newby, Blochowiak, 2014, 352). Further, services cannot lawfully be

withheld due to inability to pay because the target group is categorically needy (CMS, n.d.). So,

did the ACA achieve goals that were set in place? Not necessarily. In 2012, the Supreme Court

determined the Federal government could not revoke their portion of funding solely because a

state opts out of Medicaid expansion. On January 1, 2014, the maturation became state optional;

of which, many have embraced. The impact of the ACA on Medicaid is relevant. New ACA

annual health insurance fees increase Medicaid output because Medicaid MCO rates elevate

(Mitchell, Baumrucker, Herz, 2015, 21-22). Medicaid is designed to handle legislative alterations

and has stood strong after the ACA enacted. New regulations and legislations will likely occur in

the future. The strength of this program rests on joint government participation. Although costs

may be affected, the solidarity of this program will continue to aid those eligible. Without a

doubt, Medicaid has a will stand the test of time.

Workers compensation is a whole different entity than Medicaid. In fact, it varies from

most health insurance plans; operating under different standards and with specific purpose. Each


state lists covered services, but reserves the right to deny claims. A claim could be refused for

example, if appropriate/provided safety equipment was not being used at the time of injury

(Valerius, Bayes, Newby, Blochowiak, 2014, 398). All parties involved have important roles for

successful acquisition of reimbursement. To follow claim expectations, an employer is required

to report injuries to the state Workers Compensation board and insurance within state assigned

time frames. The employer (human resources) then directs the worker to a network physician for

medical services. Other expectations are state specific. For instance, NY has a record retention

requisite. Data for one calendar year (from point of injury), is kept in original form for a

minimum of three years (Workers compensation board, 2016). Although an employer may

voluntarily follow the case, the extent of mandatory involvement ends here. A physician treats,

determines scope (if any) of disability, and monitors a progression back to work. The insurance

is responsible for assigning claim numbers (used to ID claims) and defining case eligibility. The

results will either be ‘admission of liability’ or ‘notice of contest’, to which the worker is

informed. Claim checks covering medical expenses are sent directly to the provider. While, lost

wage benefits are allocated to the employee without tax deduction; until criteria have been met

and termination of compensation is appropriate (Valerius, Bayes, Newby, Blochowiak, 2014,

400). As billers, we need to recognize consistent reimbursement standards associated with

Workers Compensation.

First, a patient will not have out-of-pocket fees and should not be charged for a visit

(Szymendera, 2016, 19). Also, private insurances are not billed for Workers Compensation

related services. The claim will be denied because most payers do not restitute such

circumstances. Unlike Medicaid, Workers Compensation claims (most states) are filed manually


using CMS 1500 forms. Copies of office notes (documentation and treatment) accompany the

form to the insurance. The reason manually submission is preferred, is vast handling occurs.

States dictate and implement benefits, attributes, and costs to consumer. One common

denominator in states that offer Workers Compensation, they cover employee medically

necessary expenses and a percentage of lost wages (Valerius, Bayes, Newby, Blochowiak, 2014,

396). Although it is understood a patient pays no out-of-pocket expenses; in 2013, Worker

Compensation cost employers a staggering $88.5 billion. A portion of this is benefit payments.

Benefits differ from state to state, but likely include cash benefits. Cash benefits are not

considered income, which is why lost wage reparation is not subject to tax deduction

(Szymendera, 2016, 14,19). Benefits use a deductible provision. It is not a traditional deductible.

Instead, this means cash benefits are held for the first seven days from date of injury; unless,

injury exceeds fourteen days. To which, a retro of the first seven days occurs (Valerius, Bayes,

Newby, Blochowiak, 2014, 397).

Other benefits may include disability, survivor, and burial. In most states, disability

privileges have minimum and maximum coverage capacity. For example, partial disability has a

cap and is based on a percentage of predisability wages (Szymendera, 2016, 14). Some cover

rehabilitation services. In the event death occurs to the worker, survivor benefits are allocated

monthly to family/dependents. Burial benefits are a one-time sum paid regardless if dependents

exist. Costs and benefits vary from state. Billers should familiarize regulations in their state of

employment.

It is important to understand Workers Compensation funding, security, and future. We

are going to examine oversight. This program is administered by the OWCP, which is a division


of the department of labor (Valerius, Bayes, Newby, Blochowiak, 2014, 395). Further, human

resources have justifiable handling. After injury, employees are assigned an adjuster. Much of

case monitoring is maintained by the adjuster, who specializes in care coordination including,

but not limited to; authorizing treatments, sending compensation investigators (to ensure

employee follows case plan), and supervising all case pertinent progress. The goal of an adjuster

is to protect a payers’ integrity and encourage a back to work transition. Providers will likely

encounter oversight participants.

Workers compensation is fully paid by an employer who may engage three funding

options. First, an employer can obtain state funded Workers Compensation. In this situation,

copays and premiums are directed to a central state fund, from which claims are paid. Another

option is a private plan. An employer works with a payer to gain access and benefits of network

providers. Usually network providers work with a common aspiration to get the injured back to

work as soon as medically possible. Some states allow a third, alternate funding option; self-

insurance. This means an employer sets up a personal fund from which claims are paid. Most

states allowing the third option, require preauthorization and later, proof to the Workers

Compensation board (Valerius, Bayes, Newby, Blochowiak, 2014, 396). This program differs in

how health care is provided. The chosen funding defines who has the most control over the case,

the employee or employer (Szymendera, 2016, 12). While security and funding appear sturdy,

the future of Workers Compensation is unknown, at best. Partially because of insufficient

Federal oversight. Unlike most other insurances, how much an employer pays out may affect

hiring wages. Often, lower starting wages offset an employer’s monetary output for insurance.

This program is vulnerable to legislative changes.


Statues for this program have progressed over time. The 1970, Occupational Safety and

Health Act made the work environment safer for employees. For example, requiring material

data sheets for chemicals and making available safety equipment. Other expectations about

benefits exist. In fact, 39/50 states allow lifetime benefits to be paid; while, the other eleven cap

benefits by age, duration, or predetermined monetary amount (Szymendera, 2016, 12,16-17).

Benefits were among new legislation aspirations by President Obama.

President Obama wanted to change how benefits are allocated for disability. His

suggestion, convert from service of benefits to a lump sum. He also advocated halting disability

payments at retiring age because recipients would become eligible for social security. Whatever

Obama’s intent, these entities were not submitted in the 2017 budget request. This was not the

first-time changes to this program were adverted due to Federal budget restraints. In 2015, there

was a prompting for increased federal oversight of Workers Compensation (Szymendera, 2016,

15, 25). This would give long-term stability to the program. However, this attempt for

modification fell short of budget abilities.

Despite the type of insurance, billers need to be cognizant of factors involving pertinent

operations. Understanding reimbursement regulations and financial aspects are critical for

participation in a successful revenue cycle. From this, we identify societal impacts. It attributes

to professionalism and allows us to provide a higher degree of care. Comprehending past

legislation and its’ affects permits anticipation for future statues that could impact the

functionality of a program. We need to become life-long learners because of the constant

changes to the health care system. The changes offer new occupational opportunities and develop

a sense of job security. Knowledge and informational literacy help prepare us to effectively

operate a practice. It also contributes to the financial security of a business. We can all use this


data to have productive client interactions, victorious claim submission, and achieve lucrative

reimbursement with increased integrity and compliance.

REFERENCES:

CMS (n.d). Cost sharing out of pocket costs: Medicaid. Retrieved from

https://www.medicaid.gov/medicaid/cost-sharing/out-of-pocket-costs/index/list of

benefits/reimbursement

Mitchell, A., Baumrucker, E., Herz, E. (2015). Medicaid overview. Congressional research

service. Retrieved from Ebsco host database.

OASAS (2016). General Medicaid billing information. Retrieved from

https://www.oasas.ny.gov/admin/hcf/reimburs.cfm

Szymendera, S. (2016). Worker’s compensation overview and issues. Congressional research

service. Retrieved from Ebsco host database.

Valerius, J., Bayes, N., Newby, C., Blochowiak, A. (2014). Medical insurance: a revenue cycle

process approach (7). McGraw Hill; New York: NY.

WellCare (2016). Medicaid provider manual- NY. Retrieved from

https://www.Medicaid.NYS.gov

Workers Compensation Board (2016). Laws, regulations, and decisions. Retrieved from

http://www.wcb.gov/content/main/wclaws/recentlyadopted/part3

http://www.wcb.gov/content/main/wclaws/recentlyadopted/part3

https://www.Medicaid.NYS.gov/

https://www.oasas.ny.gov/admin/hcf/reimburs.cfm

https://www.medicaid.gov/medicaid/cost-sharing/out-of-pocket-costs/index/list

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