Sources of Payment

Video Transcription

[MUSIC PLAYING] $5,000,001, $5,000,0002, $5,000,0003-- man, I am killing it in this private practice thing. This is awesome. Wow. Oh, hey.

So this lesson will cover sources of payment. The general topics discussed include who pays, how payments will be collected, and where payments go. Here are the specific topics that we'll cover in this lesson-- who pays, EAP, private insurance, primary and secondary insurances, Medicaid, TRICARE, other plans, clients self-pays. Where's that $20? I'm missing one.

Several different payment providers exist. The list is not exhaustive, and other types of plans also pay for medical services, but the list does cover the most common means for payment. They include-- EAPs; Medicaid; Medicare; military programs, such as TRICARE or Military OneSource; HMOs, or Health Maintenance Organizations; PPOs, or Preferred Provider Organizations; self-funded plans; or the actual client being self-referred. Keep in mind that some individuals have both primary and secondary insurances which need to be considered.

EAPs are programs that are provided by employers as a benefit of employment. Employees can either refer themselves or be mandated by an employer-- typically, for a limited number of sessions. It's helpful for the counselor to be on the insurance of the current employee so that when the EAP sessions are over and counseling is not complete, the counselor can then bill the employee's private insurance if sessions need to continue.

Private insurance is typically held by individuals who elect to pay for insurance through their employment. There are several different types of private insurance plans, including-- HMOs, PPOs, and ASOs. The difference between HMO plans and PPO plans are that HMO plans typically require referrals, whereas PPOs do not. Additionally, on an HMO plan, the client must see the providers that are within the network. The providers must have agreed to a set of quality standards to a lower rate for services in order to be reimbursed for sessions. And providers may require PCP, or Primary Care Provider, to authorize any additional care.

Clients with PPO plans can see any of the doctors in network without a referral and do not need a PCP, or Primary Care Provider, to guide their treatment. Self-funded plans are also known as ASOs, or Administrative Services Only plans. These plans are fully funded by an employer who is responsible for paying all costs affiliated with client care.

There are two types of private insurance a client can have, primary and secondary. Primary insurance belongs to the individual or subscriber who has secured the insurance, but other individuals, such as spouses and children, may be on the plan if the subscriber has elected for a family based plan.

Secondary insurances are typically utilized by family members. When someone in the same household as the primary the insured also holds his or her own insurance, that individual may have primary insurance or their own, as well as secondary insurance, such as their spouses. This can happen when the primary insurance holder's company requires any family member who is offered insurance by their employer to also pay for their own insurance.

When this happens, the household member becomes the primary for his or her own insurance. And the other household member becomes primary on their insurance. If a family plan is elected by either person, then the spouse has secondary insurance under their spouse's plan.

So back to the money. Payment can be made in different ways. It can be made in full by a primary insurance or in part by secondary paying the rest or not at all with secondary insurers paying a portion or all of the bill. Now go back and re-watch that about five times, and you might start to get an idea of what this is about.

Medicaid and Medicare are state- and federally funded payers. Medicaid plans are specific plans offered by a private insurer. Many states have private insurance companies managing Medicaid programs. These programs are state specific, and it will be important to check your own state for rules and regulations. Currently in some states, you can be paneled on Medicaid panels but cannot be paneled on Medicare panels.

The military has two programs for their service personnel. Military OneSource is an EAP model, whereby TRICARE is military members' private insurance. These plans pay different rates. Other types of plans exist, but what is most important is that you decide which plans you want to be paneled on. It's common during a credentialing phase to become paneled on all open or eligible panels at that time.

Last but not least, the client may need to pay for services out of pocket. This holds true for copays, deductibles, co-insurances, as well as self-payments. So here's what we covered in this lesson-- who pays, EAP, private insurance, primary and secondary insurances, Medicaid, TRICARE, other plans, clients self-pays.

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