MEDI 101- MEDICAL
INSURANCE AND CODING
INTRODUCTION TO
HEALTH INSURANCE
Topic Outline
A. What is Health Insurance
B. Major Developments in Health Insurance
C. Health Insurance Coverage Statistics
D. Medical Documentation
E. Electronic Health Record (HER)
14 March 2024 Page 2
Objectives
1. Define key terms
2. State the difference between medical care and
healthcare
3. Discuss the significant events in healthcare
reimbursement
4. Identify and explain the impact of significant events
in the history of healthcare reimbursement
5. Interpret health insurance coverage statistics
14 March 2024 Page 3
What is Health Insurance?
It is a contract between a policyholder and a
third-party payer or government program to
reimburse the policyholder for all or a
portion of the cost of medically necessary
treatment or preventive care provided by
healthcare professionals.
14 March 2024 Page 4
Insurance Terminology
•Third-party-payer: Insurance Company
• Coordination of Benefits: Clause in an insurance policy
a. Birthday Rule
b. Gender Rule
14 March 2024 Page 5
Medical Insurance Coverage
•Basic- Hospitalization, lab test, surgery, and x-rays
•Medical- outpatient ( Pathology, x-ray, and diagnostic lab fees)
•Hospital- inpatient (Room allowance-Semi-private room) (Operating
room charges, x-ray, laboratory work, drugs,)
•Surgical- Physician’s fee for surgery and anesthesia
•Major Medical- extensive injuries from an accident or prolonged
illness.
• Disability-Inability to work as a result of an illness or injury which
maybe work or may be work related.
•Dental Insurance-
•Vision Care- eye exams and prescription of glasses
14 March 2024 Page 6
Glossary of Health Insurance Terms
1. Group health insurance- Traditional Healthcare coverage
subsidized by employers and other organizations.
2. Individual health insurance – Private health insurance policy
purchased by individuals or families who do not have access
to group health insurance coverage.
3. Public health insurance- Federal and state government
health programs available to eligible individuals.
Ex. Medicare, Medicaid, TRICARE
4. Single-payer plan- Centralized healthcare system adopted by
some Western nations and funded by taxes
14 March 2024 Page 7
Continuation…
5.Socialized Medicine- a type of a single-payer system in which
the government owns and operates healthcare facilities and
providers receive salaries.
6.Universal health insurance- The goal of providing every
individual with access to health coverage, regardless of the
system implemented to achieve that goal.
14 March 2024 Page 8
MAJOR DEVELOPMENTS IN HEALTH INSURANCE
14 March 2024 Page 9
Continuation…
14 March 2024 Page 10
Health Insurance Coverage Statistics
14 March 2024 Page 11
Medical Documentation
Patient Record (Medical Record) – documents healthcare services
provided to a patient, and healthcare providers are responsible for
documenting and authenticating legible, complete, and timely
entries according to federal regulations and accreditation standards.
The record includes:
1. Patient Demographics
2. Documentation to:
a. Diagnoses
b. Treatment
c. Result of the treatment
14 March 2024 Page 12
A. The Primary purposes of the record:
a. Provide continuity of Care
B. Secondary Purposes:
a. Evaluating the quality of patient care
b. Providing data for use in clinical research, epidemiology
studies, education, public policy making, facilities planning, and
healthcare statistics.
c. Providing Information to third-party payers for
reimbursement.
d. Serving the medico-legal interests of the patient,
facility, and providers of care.
14 March 2024 Page 13
Medical Necessity
- The patient’s diagnosis must also justify diagnostic and /or
therapeutic procedures or services provided.
“ If it wasn’t documented, it wasn’t done”
- a patient record serves as medico-legal document and a
business record
14 March 2024 Page 14
DOCUMENTATION METHOD
Problem-oriented Record (POR)
-is systematic method of documentation that consists of four
components:
1. Database
2. Problem list
3. Initial Plan
4. Progress notes
14 March 2024 Page 15
Database
1. Chief Complaint
2. Present conditions and diagnoses
3. Social data
4. Past, Personal, Medical, and Social History
5. Review of Systems
6. Physical Examination
7. Baseline Laboratory data
14 March 2024 Page 16
Progress Notes
SOAP Format
Subjective- How the patient feels ex. Headache
Objective- lab or x-ray result
Assessment- Evaluation of the provider
Plan- Therapeutic or educational plan
14 March 2024 Page 17
Electronic Health Record
Is a more global concept that includes the collection of patient
information documented by a number of providers at different
facilities regarding one patient.
14 March 2024 Page 18
Electronic Medical Record
has a more narrow focus because it is the patient record
created for a single medical practice using a computer,
keyboard, a mouse, optical pen device and other related
device.
14 March 2024 Page 19
Total Practice Management Software
Is used to generate the EMR, automating the following medical
practice functions:
1. Registering patients
2. Scheduling appointments
3. Generating insurance claims and patient statements
4. Processing payments from patient and third-party payers
14 March 2024 Page 20
14 March 2024 Page 21
14 March 2024 Page 22
END
14 March 2024 Page 23
