Kootenai | Kootenai Health | Issue 3, 2017

What Do TheyMean? Know these common insurance terms: Premium. The amount that must be paid for health insurance. The individual and/or an employer usually pays the premium monthly. Co-pay. A fixed amount (for example, $20) paid by an enrollee for a covered health care service, usually paid when the individual receives the service. Deductible. The amount an enrollee owes for health care services before the health plan be- gins to pay. For example, if an individual’s deductible is $1,000, the health plan won’t pay anything until he or she has paid $1,000 out-of-pocket for covered health care services. The deductible may not apply to all services. Co-insurance. The percentage of costs of a covered health care service the patient is responsible for paying (20 percent, for example) after meeting the plan deductible. Take action If you have a question or an outstanding bill you’d like to take care of, visit KH.org/pay-my-bill , or call (208) 625-6199 . 8 9 11 12 14 13 Patient statements. After the account has been accurately settled with the insurance company, a patient statement is created, stating an amount owed, and mailed to the patient. There are a series of four statements and phone calls made to the patient to obtain payment. At this point in the process, it is the patient’s responsibility to contact the hospital or clinic billing department to make a payment on the account. The full amount owed does not have to be paid immediately, but it is important to talk with someone about your plan to make payments. If the patient does not follow up with the billing department within 120 days, then the account balance is sent to a debt collection agency. Payment denials and follow-up. If the insurance company denies a claim, the account representatives provide supporting documentation or update account informa- tion and appeal the payment denial. Payment posting. Once insurance pays on the account, the payments are electronically sent to the hospital or clinic billing department for reconciliation. Account follow-up and collections. Within 20 days of the claim’s submission to insurance, the account representa- tives in the billing department review accounts to ensure the claim is processed in a timely manner. Claims submission/ billing. After the service is provided, charges are applied to the account and the appropriate codes are assigned, the claim is sent electronically to insurance payers. The average time for payers to reimburse on an account is 55 days. Coding. Certified coders review all physician documentation and translate the written diagnosis, condition and procedure into a billing code. Coding has many regulatory re- quirements, and codes can only be assigned based on physician documentation. Charges. As the patient receives care, charges are applied to the patient account. Physician/clinical documentation. The physician enters information in the patient’s health record, documenting the care provided, the patient’s outcome and the plan of care going forward. Clinical care provided to patient. The patient receives the service or procedure requested. KH . ORG 17