P. 1
Healthcare Domain Course Material

Healthcare Domain Course Material

|Views: 205|Likes:
Published by senthilj82

More info:

Published by: senthilj82 on Aug 22, 2011
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as DOC, PDF, TXT or read online from Scribd
See more
See less

12/17/2012

pdf

text

original

Sections

  • 1.5References
  • 2Healthcare Overview
  • 2.1Unit Objectives
  • 2.2Genesis Of Healthcare
  • 2.3How the industry Works?
  • 2.4Healthcare pillars
  • 2.4.6External Agents
  • 2.5Healthcare workflow
  • 2.7Review Questions
  • 2.8References
  • 3Members
  • 3.1Unit Objective
  • 3.2.1Insurance Business: An Overview
  • 3.3Individual and Group Insurance in detail
  • 3.3.1Individual Insurance
  • 3.3.2How to get individual insurance?
  • 3.3.3Group Insurance
  • 3.3.4Company Paid Groups
  • 3.3.5Affinity Groups
  • 3.3.6Self Insured Group
  • 3.4Member’s enrollment
  • 3.4.1What is Enrollment?
  • 3.4.2How is enrollment carried out?
  • 3.4.3Output of enrollment process
  • 3.4.4Enrollment: Overall Picture
  • 3.5Member’s and Dependent’s eligibility
  • 3.5.1Eligibility
  • 3.5.2Eligibility Process
  • 3.5.3How a member should approach right provider?
  • 3.5.4Eligibility Data Transfer
  • 3.5.5Eligible Dependents
  • 3.6Member Services
  • 3.6.1Means of services
  • 3.7Premium Collection
  • 3.8Member Group Maintenance
  • 3.8.1What are Groups?
  • 3.8.2Groups Formation
  • 3.8.3Groups Maintenance
  • 3.9Disability Benefits
  • 3.9.1Member’s concern
  • 4Provider
  • 4.1Provider types
  • 4.2Provider Participation
  • 4.3Provider Contract
  • 4.3.1 Provider Contract Process
  • 4.3.2 Credentialing Criteria
  • 4.3.3 Verification of Provider Credentialing Information
  • 4.3.4 Types of Contracts
  • 4.3.5 Provider Reimbursement
  • 4.5Provider Referral
  • 4.5.1 Referrals processing
  • 4.5.2 Referral types
  • 4.6Provider Network
  • 4.6.1 Quality Provider Networks
  • 4.6.4 Network Hospital Standards
  • 4.7Provider maintenance
  • 4.7.1 some common information of Providers
  • 4.9Review Questions
  • 4.10References
  • 5Sales
  • 5.1Unit Objectives
  • 5.3.1Calculation for Brokers
  • 5.4Quote Creation
  • 5.4.1What is a quote?
  • 5.4.2The Process Of Quote Creation
  • 5.5Actuaries
  • 5.7Insurance Payer’s Sales Department
  • 5.7.1External Agents that deal with Sales Department of Insurance Payers
  • 5.8Review Questions
  • 6Benefits
  • 6.1Unit Objectives
  • 6.3Indemnity Plans
  • 6.4Managed Care Plans
  • 6.4.1Health Maintenance Organization (HMO)
  • 6.4.2Preferred Provider Organization (PPO)
  • 6.4.3Point Of Service (POS)
  • 6.4.4Exclusive Provider Organization (EPO)
  • 6.5Which plan is the best?
  • 6.6.3Pharmacy Plans
  • 6.6.4Medicare Plans
  • 6.6.7Long Term Care
  • 6.6.8Disability Income Insurance
  • 6.6.9Catastrophic Coverage Plans
  • 6.6.10 Exercise
  • 6.8Laws and Legislations
  • 6.8.1Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
  • 6.8.2Health Insurance Portability and Accountability Act (HIPAA)
  • 6.9Review Questions
  • 6.10References
  • 7Claims
  • 7.1Claim generation and submission to Providers
  • 7.1.1Claims Intake Process
  • 7.1.2Claims Intake : Diagrammatic
  • 7.2Claim Adjudication Process
  • 7.2.1Claim Preparation and determining eligibility
  • 7.2.2Determine payment
  • 7.2.4Claim adjudication outputs
  • 7.3Claim Payments
  • 7.3.1Provider Payments
  • 7.3.2Member Re-imbursement
  • 7.4Claim Adjustments
  • 7.4.1Refund Adjustment
  • 7.4.2Minus Debit Adjustment
  • 7.4.3Manual Check Adjustment
  • 7.4.4Void Adjustment
  • 7.4.5Stop Adjustment
  • 7.5Government reporting
  • 7.6Explanation of Benefits (EOB)
  • 7.7.17.7.1What are Accumulators?
  • 7.7.27.7.2Function/Purpose of Accumulators
  • 7.7.3What is accumulated?
  • 7.8Overall Claims system diagram :
  • 7.9Review Questions
  • 8External Agents
  • 8.1Unit Objectives
  • 8.3Government Agencies
  • 8.3.1Centers for Medicare & Medicaid Services (CMS)
  • 8.3.2DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHSS)
  • 8.3.3Centers for Disease Control and Prevention (CDC)
  • 8.3.4Agency for Health Care Research and Quality (AHRQ)
  • 8.3.6Health Resources and Services Administration (HRSA)
  • 8.4Government Acts and Regulations
  • 8.5Clearing Houses
  • 8.5.1Benefits Of A Clearinghouse
  • 8.5.2Clearinghouse versus Direct Filing
  • 8.5.3Clearinghouse Income
  • 8.6Third Party Administrators
  • 8.7Specialized Adjudication Engines/Companies Adjudicator
  • 8.9Accreditation Agencies
  • 8.9.1The Accreditation Process
  • 8.10Drug Manufacturers
  • 8.11Review Questions
  • 8.12References
  • 9Summary
  • 9.1Unit Objectives
  • 9.2.1The Beginning: Member wants to purchase insurance
  • 9.2.2Getting a provider
  • 9.2.3An Enrolled member wants to seek medical services
  • 9.2.4 Member has filed a claim
  • 9.2.5Effect of external agencies
  • 9.3Review Questions
  • 9.4References
  • 10Appendices
  • 10.1Appendix A: Total E-Business Services Forecast for Healthcare
  • 10.2Appendix B: The world Healthcare market and Healthcare IT spending
  • (Source: Gartner Research, Inc)
  • 10.3Appendix C: The Cash Flux of the US Healthcare Industry
  • 10.4Appendix C: Sample Quote Sheet
  • 11Glossary

Healthcare Market Overview ___________________________________________________________________

Table of Contents

1 Healthcare Market Overview......................................................................5 1.1 Introduction............................................................................................5 1.2 What is an HMO?.....................................................................................5 1.3 The Industry Outlook................................................................................5 1.3.1 Trends in Healthcare – Provider Space....................................................6 1.3.2 Trends in Healthcare – Payer Space........................................................7 1.4 Key Players.............................................................................................7 1.5 References..............................................................................................8 2 Healthcare Overview..................................................................................9 2.1 Unit Objectives .......................................................................................9 2.2 Genesis Of Healthcare .............................................................................9 2.3 How the industry Works?........................................................................10 2.4 Healthcare pillars...................................................................................12 2.4.1 Members...........................................................................................12 2.4.2 Providers...........................................................................................12 2.4.3 Benefits.............................................................................................13 2.4.4 Claims..............................................................................................14 2.4.5 Sales................................................................................................15 2.4.6 External Agents..................................................................................15 2.5 Healthcare workflow...............................................................................16 2.6 Summary..............................................................................................17 2.7 Review Questions...................................................................................18 2.8 References............................................................................................18 3 Members..................................................................................................21 3.1 Unit Objective........................................................................................21 3.2 Introduction..........................................................................................21 3.2.1 Insurance Business: An Overview.........................................................21 3.3 Individual and Group Insurance in detail...................................................23 3.3.1 Individual Insurance...........................................................................23 3.3.2 How to get individual insurance? .........................................................23 3.3.3 Group Insurance................................................................................25 3.3.4 Company Paid Groups.........................................................................26 3.3.5 Affinity Groups...................................................................................27 3.3.6 Self Insured Group.............................................................................27 3.3.7 Self-Employed Members......................................................................28 3.3.8 Exercise............................................................................................29 3.4 Member’s enrollment..............................................................................30 3.4.1 What is Enrollment?............................................................................30 3.4.2 How is enrollment carried out?.............................................................30 3.4.3 Output of enrollment process...............................................................31 3.4.4 Enrollment: Overall Picture..................................................................32 3.4.5 Exercise............................................................................................32 3.5 Member’s and Dependent’s eligibility........................................................33 3.5.1 Eligibility...........................................................................................33 3.5.2 Eligibility Process................................................................................33 3.5.3 How a member should approach right provider?.....................................34 3.5.4 Eligibility Data Transfer.......................................................................35 3.5.5 Eligible Dependents............................................................................35 3.5.6 Exercise............................................................................................35 3.6 Member Services....................................................................................37 3.6.1 Means of services...............................................................................37 __________________________________________________________________________________ 65736839.doc Ver. 1.0 Page 1 of 132

Healthcare Market Overview ___________________________________________________________________ 3.6.2 Services provided by the insurer..........................................................37 3.7 Premium Collection.................................................................................39 3.8 Member Group Maintenance....................................................................39 3.8.1 What are Groups?...............................................................................39 3.8.2 Groups Formation...............................................................................40 3.8.3 Groups Maintenance...........................................................................40 3.9 Disability Benefits...................................................................................41 3.9.1 Member’s concern .............................................................................41 3.9.2 Exercise ...........................................................................................41 4 Provider...................................................................................................44 4.1 Provider types.......................................................................................44 4.2 Provider Participation..............................................................................45 4.3 Provider Contract...................................................................................45 4.3.1 Provider Contract Process...................................................................45 4.3.2 Credentialing Criteria.........................................................................45 4.3.3 Verification of Provider Credentialing Information..................................46 4.3.4 Types of Contracts.............................................................................46 4.3.5 Provider Reimbursement....................................................................46 4.4 Exercise................................................................................................47 4.5 Provider Referral....................................................................................47 4.5.1 Referrals processing...........................................................................47 4.5.2 Referral types...................................................................................48 4.6 Provider Network...................................................................................48 4.6.1 Quality Provider Networks..................................................................48 4.6.2 Network Adequacy.............................................................................49 4.6.3 Rental networks................................................................................49 4.6.4 Network Hospital Standards................................................................49 4.7 Provider maintenance.............................................................................49 4.7.1 some common information of Providers ...............................................49 4.8 Exercise................................................................................................50 4.9 Review Questions...................................................................................51 4.10 References..........................................................................................51 5 Sales........................................................................................................53 5.1 Unit Objectives......................................................................................53 5.2 Introduction..........................................................................................53 5.3 Brokers.................................................................................................53 5.3.1 Calculation for Brokers........................................................................53 5.4 Quote Creation......................................................................................54 5.4.1 What is a quote?................................................................................54 5.4.2 The Process Of Quote Creation.............................................................54 5.5 Actuaries...............................................................................................58 5.6 Underwriters..........................................................................................59 5.7 Insurance Payer’s Sales Department.........................................................60 5.7.1 External Agents that deal with Sales Department of Insurance Payers.......61 5.8 Review Questions...................................................................................62 6 Benefits....................................................................................................64 6.1 Unit Objectives .....................................................................................64 6.2 Introduction ........................................................................................64 6.3 Indemnity Plans.....................................................................................64 6.4 Managed Care Plans...............................................................................65 6.4.1 Health Maintenance Organization (HMO)...............................................66 6.4.2 Preferred Provider Organization (PPO) ..................................................68 6.4.3 Point Of Service (POS).......................................................................69 __________________________________________________________________________________ 65736839.doc Ver. 1.0 Page 2 of 132

Healthcare Market Overview ___________________________________________________________________ 6.4.4 Exclusive Provider Organization (EPO)...................................................71 6.5 Which plan is the best?...........................................................................71 6.5.1 Exercise............................................................................................72 6.6 Other Plans...........................................................................................73 6.6.1 Vision Plans.......................................................................................73 6.6.2 Dental Plans......................................................................................73 6.6.3 Pharmacy Plans..................................................................................74 6.6.4 Medicare Plans...................................................................................75 6.6.5 Medigap............................................................................................75 6.6.6 Medicaid............................................................................................76 6.6.7 Long Term Care.................................................................................76 6.6.8 Disability Income Insurance.................................................................76 6.6.9 Catastrophic Coverage Plans................................................................76 6.6.10 Exercise........................................................................................77 6.7 Individual Insurance and Group Insurance.................................................77 6.8 Laws and Legislations.............................................................................78 6.8.1 Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)...........78 6.8.2 Health Insurance Portability and Accountability Act (HIPAA).....................78 6.9 Review Questions...................................................................................79 6.10 References..........................................................................................79 7 Claims......................................................................................................81 7.1 Claim generation and submission to Providers...........................................81 7.1.1 Claims Intake Process.........................................................................81 7.1.2 Claims Intake : Diagrammatic..............................................................82 7.2 Claim Adjudication Process......................................................................83 7.2.1 Claim Preparation and determining eligibility..........................................83 7.2.2 Determine payment ...........................................................................86 7.2.3 Update Claim.....................................................................................88 7.2.4 Claim adjudication outputs..................................................................88 7.3 Claim Payments.....................................................................................91 7.3.1 Provider Payments..............................................................................91 7.3.2 Member Re-imbursement....................................................................92 7.4 Claim Adjustments.................................................................................92 7.4.1 Refund Adjustment ............................................................................93 7.4.2 Minus Debit Adjustment .....................................................................93 7.4.3 Manual Check Adjustment ..................................................................93 7.4.4 Void Adjustment.................................................................................93 7.4.5 Stop Adjustment................................................................................93 7.5 Government reporting............................................................................94 7.6 Explanation of Benefits (EOB)..................................................................95 7.7 Accumulators.........................................................................................95 7.7.1 7.7.1 What are Accumulators?.............................................................95 7.7.2 7.7.2 Function/Purpose of Accumulators................................................96 7.7.3 What is accumulated?.........................................................................96 7.7.4 Types of Accumulator..........................................................................96 7.8 Overall Claims system diagram :..............................................................97 7.9 Review Questions...................................................................................97 7.10 References..........................................................................................98 8 External Agents......................................................................................100 8.1 Unit Objectives ....................................................................................100 8.2 Introduction .......................................................................................100 8.3 Government Agencies...........................................................................100 8.3.1 Centers for Medicare & Medicaid Services (CMS)...................................100 __________________________________________________________________________________ 65736839.doc Ver. 1.0 Page 3 of 132

...105 8...........106 8................................................................1 HIPAA.......................................103 8...........1 Appendix A: Total E-Business Services Forecast for Healthcare.............................2.......125 10 Appendices......................................................3 Review Questions......................................125 9.......9 Accreditation Agencies.............................5 National Information Center on Health Services Research and Health Care Technology (NICHSR)........................4.....................................................................................................................................................................4 Member has filed a claim.........................123 9.........................................................................................................................................................................................................................................................................................2...... 1............4 Appendix C: Sample Quote Sheet..123 9.........5...........117 8.......................129 11 Glossary..............................................124 9.....5 Effect of external agencies..3.............5.....................3.........124 9.......................4 References..115 8...........................4 Exercise.......115 8....................10 Drug Manufacturers...................3..................................................1 Unit Objectives ..................................3......................1 The Accreditation Process..........2 Getting a provider...7 Exercise............................2 Appendix B: The world Healthcare market and Healthcare IT spending..............6 Third Party Administrators......2.....125 9...............................127 10.............5..............127 10................1 The Beginning: Member wants to purchase insurance........................113 8...........9.......................................................................114 8.....123 9.....5 Clearing Houses........................................................................128 (Source: Gartner Research.....124 9.......................102 8........................................................6 Health Resources and Services Administration (HRSA).4..113 8...................................2 DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHSS)........................................................125 9.............................8 General Agents........................127 10............3 Centers for Disease Control and Prevention (CDC)............................3 Exercise..1 Benefits Of A Clearinghouse...5...........................................4..........102 8..............................3 Clearinghouse Income...........................................................3.............................................doc Ver................116 8..............3...........................................................4 Government Acts and Regulations...................................................... Inc)..........................................................................................121 8..........120 8...............Healthcare Market Overview ___________________________________________________________________ 8.....................121 9 Summary..................2..............................103 ELECTRONIC HEALTH TRANSACTIONS STANDARDS ..........................128 10.........................................7 Specialized Adjudication Engines/Companies.............117 8.....101 8....103 8...........11 Review Questions....2 Clearinghouse versus Direct Filing...2 CORBA.............103 8......................................................115 8...............2............113 8..................117 8..............3 An Enrolled member wants to seek medical services..........131 __________________________________________________________________________________ 65736839.........................................................3 Appendix C: The Cash Flux of the US Healthcare Industry.................2 Workflow .......0 Page 4 of 132 ........103 8.....................................4 Agency for Health Care Research and Quality (AHRQ) ........................................12 References.........................

Historically. since these companies are service oriented.1 Introduction This unit provides a brief idea of the Health Care Industry in the United States.Healthcare Market Overview ___________________________________________________________________ UNIT . for the next few thousand dollars. When a member follows this rule. In these plans. he ends up paying a small fixed payment. which means the first few hundred or so dollars is fully paid by the Member. The concept has gained acceptance in the 90s and the Industry has grown rapidly and it caters to over 25% of all Insured members in USA. The member should always visit the chosen PCP and on his referral can visit other doctors.I 1 Healthcare Market Overview 1. After that.2 What is an HMO? HMO stands for “Health Maintenance Organization”. Though the primary information system is the OLTP system that runs the daily business. 1. The concept has gained in popularity mainly from employers who provide health insurance to their employees in the 1990s. The “For-profit” companies control 60% of the Managed Health Care __________________________________________________________________________________ 65736839.3 The Industry Outlook The concept of Managed Health Care gained popularity in the last 80s and the early 90s. In case of Indemnity Plans. On the other hand. The HMO concept has evolved over the last 15 years as a way to provide less expensive health coverage. Members enrolled in an HMO are expected to choose one of the Providers as a PCP (Primary Care Physician). The Industry is made up of both “For-profit” HMOs and “Non-Profit” HMOs. Also. 1. This Industry is highly regulated and captures high volume of data. a high computing power becomes imminent. and Individuals who look for coverage for themselves and their dependents. Also state mandated programs like Medicare and Medicaid also allow the recipients to be enrolled in HMOs. To process this high volume of data collected and maintain them for stipulated time. a certain percentage will be paid by the Member and the rest by the Insurance Company (co-insurance). All visits to any Doctor or Hospital have to be authorized by the HMO. It aims in providing the brief idea of the Industry and it’s the key players. Health Insurance in the United States was through Indemnity Plans. Any amount over the Deductible and the Co-insurance will be fully paid by the Insurance Company.0 Page 5 of 132 . there are also support systems like the Data Warehousing System that helps in decision support. Their primary function is to provide Health Insurance to Employer Groups and Individuals. HMOs typically interact with two types of customers: Employer Groups – These are companies that provide health coverage for their employees and dependents. Managed Health Care is provided by HMOs (Health Maintenance Organizations). The basic idea behind this is that the HMO ties up with a group of Doctors and Hospitals (Providers of Health Care) and allows the members enrolled to visit one of the Providers within their list. The industry has grown quickly and at present about 25% of all health insurance members are in some sort of Managed Health Care program. Traditionally insurance has been one of the largest users of Information Technology. there is a Deductible. response times become a crucial factor both to reduce cost and improve performance 1. the member is free to visit any Provider. violating this rule will make the member liable for the full amount.doc Ver. the Imaging system that scans all incoming documents for storage and retrieval.

Large corporations want see employee health insurance costs to reduce overheads. However. The US Congress is currently debating on a “Patients bill of rights” that will allow the patient to get better care under this system. reaching $30 billion by 2005. Before BBA. 1.Healthcare Market Overview ___________________________________________________________________ Industry. a decrease of about 11%.  HIPAA (Health Insurance Portability and Accountability Act) This act impacts all segments of healthcare industry with focus on standardization. privacy and security.310 Billion annually (2001) and is growing at 7%. Initially small players focused on local markets dominated the Industry. 1. 1999 . Also. will continue to grow as newer technologies and sciences (Genomics. there has been a tremendous pressure on the bottom line of these companies. The last few years have seen smaller provider sub segments face financial challenges.a whopping number by any standards. Furthermore. 70% of the Federal budget of the US. US also leads in the IT development of this market. But the Healthcare market. which are coming into place. which are going to have a major impact in the way healthcare providers operate presently. __________________________________________________________________________________ 65736839. which is a core focus for most governments around the world. struggling independent facilities in rural markets.S. however as a result of the BBA. The last few years have seen a rise in the Assisted Living Centers. will seek acquisition by larger chains. skilled nursing providers were slated to receive $83 billion during 9802.1 Trends in Healthcare – Provider Space There are two major regulations. At present. The world market for Healthcare is USD 3 Trillion presently. Furthermore. (Refer Appendix B). However. and is estimated to grow to a huge USD 4 Trillion by the end of 2003 (Dataquest. US is the largest spender in this market. This has resulted in more government involvement in this industry and there has been lots of debate on how to make this industry more transparent and patient friendly. it is estimated that about 13% of the overall industry bed capacity are operating in bankruptcy. This trend has slowed considerably and can be considered to be over for now. The trend is still continuing and the growth is expected to continue. the members participating in these plans feel that the HMOs squeeze the patients to maximize their profit. investment in IT in global Healthcare sector is as low as 3% as compared to an overall average of 6% and 12% for financial services.when CHRISTUS Health was formed. Proteomics and Bio technology) revolutionize health care. (Refer Appendix C). See Appendix A). These two regulations are:  BBA (Balanced Budget Act) The Balanced Budget Act of 1997 (BBA-1997) is designed to lower Medicare expenditures by about $112 billion over the five-year period 98-02.6 million) represents the largest number of users of long-term healthcare services. The last major merger happened in Feb 1. Industry sources project expenditures for senior living of $18 billion in 2000. The total health care spending (by private and public in the US) is 1. Cap on spending by government (BBA) is focusing efforts on cost cutting in this space. accounting for 43% of the world spending. In the last few years there has been an increasing number of acquisitions and the industry is moving into the consolidation phase. As a reciprocative step.3. they will now receive $74 billion over the same period. The past few years has seen a consolidation in the hospital and health sectors. due to increasing health care costs.0 Page 6 of 132 . population.doc Ver.3 Trillion. In the last few years. Individuals aged 85 and older (3. Provider Organizations are adopting some Cost Cutting measures.but low activity expected. The US is the largest player in the Healthcare market and is worth $ 1. also the fastest-growing segment of the U.

Large HMOs are notifying the HCFA of their intent to exit Medicare + Choice market in 2001.g.5% in 1999. on average. Managed Care Market Still Top-Heavy in the sense the managed care sector is fairly concentrated. Provides both Indemnity and HMO based Health insurance plans 21 million subscribed members in various health plans. The last few years have seen Rising Costs for the MCO (Managed Care Organization). Aetna. with the top 10 HMO chains accounting for close to 2/3 of total HMO enrollment in the US. Plans available across the country United Health Care Minneapolis.0 Page 7 of 132 . Property and Casualty.3 members of Prudential Health Care recently acquired. among others. MN www. Numerous companies have exited Medicare Choice markets following implementation of the BBA in 1997. the rapid expansion of the elderly segment of the population is presenting HMOs with a new set of challenges. Pharmaceutical costs are rising about 15 %. Cigna.com Leading provider of health and retirement benefit plans. Individuals. The largest privately held chain is the Blue Cross/Blue Shield Association. These companies cater to small and large Employer Groups. 1. resulting in more people covered. Medical costs rose 7. Furthermore Managed Care Consolidation has seen larger companies acquiring smaller.unitedhealthgroup.Healthcare Market Overview ___________________________________________________________________ labor costs (typically 40 -50 % of hospital operating costs) are steadily rising (specialized skills shortage). Recent times have seen HMOs exiting Medicare Choice plans. including Aetna (affecting 355. Aging Population Poses New Challenge for the Healthcare organizations. 1.000 members in 1999 and another 327.000 in 2000. Retirement and Investment Services.cigna. 10. which collectively serves 21.com Into Health Care.6 million Americans.000 members).3 million of those are Managed Health Care Members includes 5. and also provide coverage for members participating in government programs like Medicare and Medicare. Aging of the baby boom generation (born between 1946-1964).aetna. And this has resulted in higher costs. Hartford.5 Million members enrolled in Medical HMO Plans. HIPAA is going to have sweeping effect on HMO. People older than 65 years (currently 14%) are estimated to rise to 18. Hartford. Provides both Indemnity and HMO based Health insurance plans 6. CT www. which requires them to re-look at their transactions.2 Trends in Healthcare – Payer Space There has been a rise in Regulations & Lawsuits against payers.4 Key Players At present the Managed Health Care Industry is made of a few large Insurance companies that operate across the country and lots of small HMOs that operate in local markets.com __________________________________________________________________________________ 65736839.3.5% in 2025. the number continues to climb. More than 35 class-action suits have been filed against managed care companies to date. CT www. undercapitalized players. Prescription drug coverage has increased (95% of all members). Ongoing pressure to reduce healthcare costs will prolong the merger trend in coming years.doc Ver. E. 1. Group Insurance etc. HMOs cut 400.

com/ __________________________________________________________________________________ 65736839. 445. 1.gartner.0 Page 8 of 132 . operates in many markets.com/ http://www.5 References AETNA Intranet http://www.com/ http://www.8 million Fully Insured Managed Care Members.com/ http://www. About 5.com/ http://www.gartnerg2.aetna.000 Medicare members and 530.gigaweb.Healthcare Market Overview ___________________________________________________________________ Primarily into Managed Health Care.doc Ver. 1. no risk).jup.8 million self-insured members (fee basis. 1.000 Medicaid Members In addition to the above companies there are two large Non-profit Managed Care entities: Blue Cross Blue Shield Kaiser Permanente These operate in various states by having separate HMOs set up in each state.

Over the initial objections of physicians. “Provider-oriented” meant that. 2. prepaid health care remained a minor phenomenon until the 1970s. In some locations prepaid group practice plans were quite successful at attracting members. These members paid a predetermined fee and Dr. In the 1930s.II 2 Healthcare Overview 2. In 1954. This plan is considered the earliest example of an independent practice association (IPA) model prepaid health plan. Oklahoma 1929. and it paid the affiliated independent physicians and hospitals according to a relative value-based fee schedule. __________________________________________________________________________________ 65736839.Healthcare Overview ___________________________________________________________________ UNIT . developed peer review procedures. were all on the agenda. the Kaiser Permanente health plan had a growing network of hospitals and clinics and a half million people enrolled. Kaiser believed he could reorganize medical care to provide millions of Americans with prepaid and comprehensive services at prices they could afford. Shadid rendered care to his patients. Kaiser opened his plans to the public. politicians and interest groups promoted various proposals for reforming the healthcare system. Blue Shield) did not try to tell physicians how to practice medicine.doc Ver. Issues of cost containment. and the Blues would simply pay the bills on a fee-for-service basis. In adopting this policy. Michael Shadid started a rural farmers' cooperative health plan in Elk City.1 Unit Objectives This unit will present an overview of the healthcare industry to the reader. In 1929 Dr. and monitored quality of care. Other local physicians became concerned about their own patient base. 1. who argued that the structural incentives of traditional fee-for-service medicine had to be reversed in order to achieve positive reform. provider-oriented insurance organizations. efficient delivery systems and more. However. Thus early insurance was restricted to Indemnity insurance. financially stressed hospitals prevailed on state legislatures to legalize the insurance schemes that became known as Blue Cross which were created as non-profit. During World War II. consumer rights.2 Genesis Of Healthcare Until the early 20th Century. The foundation accepted capitation (fixed) payments from subscribers. coverage for the uninsured. In the late 1960s and early 1970s. Ellwood coined the phrase “health maintenance organization” to refer to prepaid health plans that enrolled members and arranged for their care from a designated provider network. The foundation heard grievances against physicians. The HMO Act of 1973 authorized $375 million in federal funds to help develop HMOs. Ten years after the war. Paul Ellwood of Minneapolis. access to services for the poor and minorities. the Administration was influenced by Dr. Blue Cross (and later. Dr. physicians in private practice almost always billed patients directly on a fee-for-service basis.0 Page 9 of 132 . during the Great Depression. When the war ended. the San Joaquin County (California) Medical Society formed the San Joaquin Medical Foundation in response to competition from Kaiser. Henry Kaiser whose name became synonymous with prepaid healthcare set up two medical programs on the West Coast to provide comprehensive health services to workers in his shipyards and steel mills. In 1971. President Nixon’s Administration announced a new national health strategy. Physicians were free to practice as they saw fit. the development of health maintenance organizations (HMOs). hospitals began to suffer from patients’ inability to pay their bills.

the figure can be said to portray the actual workflow for any managed care organization.3 How the industry Works? Managed care market dominates the healthcare industry. Overall. 2. __________________________________________________________________________________ 65736839. we will be better equipped to understand the workflow as depicted in the following figure. the managed care segment had 181 million members.Healthcare Overview ___________________________________________________________________ Managed care. the nature of this information being very generic.A). We will see each of these in greater details in the next section. State governments turned to managed care to help with the Medicaid program. Employers came to look upon managed care as a less expensive yet comprehensive and high quality form of insurance to offer to their employees. 1. The workflow for this model can be depicted as shown in the following figure. The major players in this flow. or. and the federal government implemented Medicare. however.0 Page 10 of 132 . enrolling about 65 million members (close to a quarter of the population of U. there were over 600 HMOs in operation. what can be said to be the ‘five pillars of healthcare’ are –      Member Provider Benefits Claims Sales In addition ‘External agents’ (agencies not directly involved with providing insurance) also form a major component. 1980s and 1990s. (HMO is a subset of managed care) continued to grow throughout the 1970s. This workflow is specific to Aetna-USHC (a leading provider of healthcare services). After the five pillars have been introduced. thereby dominating the healthcare market.doc Ver. By the end of 20th century.S. as it came to be called.

0 Page 11 of 132 .Healthcare Overview ___________________________________________________________________ Request Quotes Aetna Sales Quotes Customer Policy maint and billing Under writing Provider Admin Policy Entry Claim/Elig Inq Member Help Desk Provider Claim Policy Providers Claim Medical Service Claim Office Benefit/ Provider Inquiry Claim Routing/ Adjudication EOB Claim Reporting ERA EFT Members To Provider Bank Actuaries Figure 1: Managed care workflow __________________________________________________________________________________ 65736839. 1.doc Ver.

So. In such a case the employer becomes his plan sponsor and the insurance is known as Group Insurance.1 Healthcare pillars. While on one hand capitation ensures a fixed monthly income for the provider. have their advantages and disadvantages. There are other variants of insurance in the market. So. They offer a great flexibility to the company in providing insurance of choice to the employees. A doctor. The providers get this fee irrespective of the number of encounters (a visit by a member to a provider is known as an encounter) they had in that month. while in case of individual insurance the risk is concentrated on a single member and his dependents.Healthcare Overview ___________________________________________________________________ 2.4 2. Due to its bargaining power. as the total expenditure remains constant irrespective of the number of members having to seek medical services. or to those who do not have a employee sponsored group insurance scheme. This is a powerful perk used to retain good staff. A Provider is that entity which offers actual medical services to the members. Such groups are known as self-insured groups. depending on his popularity with the patients). Reduction in this cost to the member is a great advantage with group insurance. these companies do not have the infrastructure to perform as an insurance company. the members have to pay for healthcare coverage). group insurance schemes are able to get better deals for their members than in case of individual insurance.S. This way. __________________________________________________________________________________ 65736839. capitation helps them to forecast their spending. in return they are offered monetary benefits by the insurance company. 2. However.A. Individual insurance is restricted to people who need to have specific coverage not offered in their group scheme. Members. The providers enter into an agreement (contract) with the insurance company. a pharmacy or hospitals are all referred to as providers.2 Providers. 1.4. he has to pay for those services. A group has much more bargaining power due to the simple fact that group insurance is less risky for the insurer. from the provider’s point of view it’s a choice between a fixed income and a varying income (which may be more. For insurance company. Group insurance allows the insurer to spread the risk over a larger number of people. his employer will pay for his insurance coverage.0 Page 12 of 132 . The main advantage with group insurance is the freedom of choice for a member. they outsource the administrative part to the insurance companies while retaining the money reimbursement part with themselves. in which the employers pay for the healthcare subscription (in case of normal group insurance. but the trend is towards group insurance due to its basic advantage of reduced cost and enhanced services. they are feasible only in case of very large organizations. This is known as Individual Insurance.4. or less. However.doc Ver. One of the most popular of these forms is a fixed monthly fee (capitation fee). A member is a person who purchases insurance from (or enrolls with) an insurance company. In case of some large corporations like AT&T or IBM the company itself provides insurance to its employees. they are able to achieve a balance between providing desirable healthcare coverage to their employees without causing administrative overheads. A variant of this is the Company Paid Groups. it also restricts his earnings. He is free to choose any of the services offered by the insurance company. These monetary benefits are offered in various forms. In most cases. He can purchase this insurance coverage for himself and his family (also called his dependents). Under this agreement they provide medical care at reduced rates to the members. and is a very good illustration of the amount of importance that is attached to health insurance in U. Both individual and group insurance. Though self-insured schemes are quite popular.

In general.4. right from providing services to filing claims.e. In some cases. which contracts with the insurance company. This is one of the most stable models of managed healthcare. Though they offer great flexibility to members in their choice of providers. they file a claim (a request to refund the expenses incurred) with the insurance company. whom sets forth the terms and conditions of this agreement is called a Policy. In case of certain large hospitals with a significant patient base. In turn the insurance company is able to offer a range of providers to the members at a single source. we can say that a plan is the general range of benefits offered by the insurance company. company to the member. the hospital itself may function as the insurer. Benefits can be described in two ways 1. If the claim is found to be valid. they are very expensive. The insurance company offers a better deal to its members for using a provider within this network.3 Benefits. the insurance company may directly employ providers. Formation of an IPA gives the providers more bargaining powers with the insurance company and assures them of an increased patient volume. The insurance company may provide medical/dental/vision coverage. Then depending on the choice of coverage the member is said to have medical benefits or dental benefits or vision benefits. the members visit a provider and pay him for his services. In case of Indemnity plans. the IPA. The right of a member to receive services from the insurance company as per their mutual agreement. After that.doc Ver.Healthcare Overview ___________________________________________________________________ Sometimes. the insurance company pays a part (usually 80%) of the expenses. they may outsource the administrative functions to an insurance company while keeping the money reimbursement part with themselves. Due to the control over the choice of provider. Thus. the insurance company is able to offer healthcare at reduced rates. The major line of coverage provided by the insurance company. the insurance company contracts with providers and form a network of such providers. There has been a gradual shift in the choice of members from Indemnity (traditional fee-forservice) plans towards Managed Care (prepaid) plans. These when customized as per the member’s requirements and put down on paper as a legal document forms a policy.e. 1. This constitutes the Staff Model of managed care. Staff model is beneficial from the insurance companies point of view. The general agreement between the Insurance Company and the member that details the benefits that can be provided to the plan holders While the actual legal document issued by the insurance i. The providers themselves have an increased patient volume and hence offer services at reduced rates. Such a group is called an IPA or an individual practice association. __________________________________________________________________________________ 65736839. a group of providers in a designated area are contracted by the insurance company to form a network (a group of contracted providers within a designated area is said to constitute a network) of providers. as they are in a better position to regulate the expenses. individual providers form a group. The members pay a fixed monthly fee and need to choose a provider within the network as their primary care physician or a PCP. 2. or. In case of managed care.0 Page 13 of 132 . 2. This staff model however is feasible only in case of very large insurance companies. i. As with self-insured groups.The PCP manages their complete healthcare. The reduced cost of a managed care plan is the main reason for members preferring them to indemnity plans. the member is called a Plan.

4. validated for necessary information and then loaded into a database. It has a major disadvantage that it limits the choice of providers to a network. The checks can include. 2. thereby making the process more cost effective. while having the option of Indemnity type coverage at a higher fee. benefits. Hence. This is known as coordination of benefits (COB). PPO is also similar to POS with the added advantage that in the HMO type coverage the member is not needed to have a PCP. On completion of claims adjudication. Complex or ambiguous claims. is a recent addition to the stable of managed care plans. providers. POS provides the member with the option of having HMO type coverage at a lower fee. policy etc. In such cases the claim is first processed by the primary payer (there are standard rules to determine which insurer is the primary payer) and then sent to the secondary payer. referrals. The member is also sent a letter called the explanation of benefits (EOB). it also reduces the necessity for claim examiners. It also gives the amounts applicable to him.0 Page 14 of 132 .doc Ver. The claim is then adjudicated (or tested for authenticity) as per the company’s business rules and policies. Members cannot avail services from a provider not contracted with the insurance company. EOB gives the details of the services rendered to him by the providers and the amount of expenses to be borne by the member for the services he has used.4 Claims. also know as Claim Examiners. Sometimes. Claims adjudication is a very complex process and requires information of almost all the entities associated with health care such as members. __________________________________________________________________________________ 65736839.Healthcare Overview ___________________________________________________________________ The model of managed care as described above is known as a HMO or a health maintenance organization.EPO or exclusive provider organization. 1. In addition the claim turn around (time from a claim being filed to the final check being issued) is a major issue for members and providers while choosing an insurer. member receives a check for payment of the expenses. Claim is either filed on paper or sent electronically . also claims with any missing information are resolved manually by Adjudication experts. amongst other things -     Whether the member has satisfied his deductible (a deductible is a fixed dollar amount the member has to pay each year before be can claim benefits) Whether he has satisfied his copay (a fixed dollar amount the member pays every time he visits a provider) Whether he has satisfied his coinsurance (a percentage of the total cost which the member has to pay) Whether he had the necessary referral (or permission from the PCP) to visit the specialist. nowadays there is a major emphasis on automated claims adjudication. Members who wish to have a greater flexibility in the choice of providers have the option of going for other managed care plans POS or point of service plans and PPO or preferred provider organization plans. The recent trend has been to go for PPO plans. a Claim is a request filed by the member (or his PCP) for the refund of medical expense incurred by him. as it offers the best of both Indemnity and Managed care plans. Apart from speeding up the process. members may be enrolled with multiple carriers (insurance companies).The claim is received by the insurance company. As explained earlier. a hybrid of HMO and POS plans.

Clearinghouses perform auditing services on insurance claims. An insurance company has its own marketing workforce and also a pool of agents (brokers). it is forwarded to the insurance company responsible for payment. and logistical content errors. Health Care Financing Administration (HCFA) along with others are responsible for regulating the healthcare industry. Since claim adjudication is a complex process. The role of the actuary is to decide the rates for the various services offered by the insurance company. Government agencies such as Department Of Health And Human Services (DHSS).A. Usually. it is returned to the Provider/Member along with an explanation of what was wrong. 2. Apart from these regulating agencies.4.doc Ver. Health care is a highly regulated area in U. __________________________________________________________________________________ 65736839. 1.5 Sales. as there is stiff competition in the market. Following are some examples of such agencies. there are agencies that aid the insurance company on various other fronts. These organizations are known as specialized adjudication companies (Magellan and ADESSO are two such organizations).6 External Agents. Based on these rates the marketing department creates a Quote (or a draft outlining the services to be offered to the members and the rates for those services). Center for Medicare & Medicaid Services (CMS). So in case of very specific claims (such as processing of vision claims).Healthcare Overview ___________________________________________________________________ Also.0 Page 15 of 132 . it’s not possible for an insurance company to have a rule engine (or a software that adjudicates a claim) for all types of claims. Center for Disease Control and Prevention (CDC). This helps reduce the cycle time for claims adjudication. the process of adjudication may be outsourced to another organization that has the necessary rule engine in place. the underwriter’s function is to approve/ validate the group specific factors added to rates by marketing people and apply mark-up or discount based on their judgment.In addition. laws such as Health Insurance Portability & Accountability Act of 1996 (HIPAA) and Consolidated Omnibus Budget Reconciliation Act of 1986(COBRA) ensure the protection of consumer interests. Sales and Marketing form an important activity in the health insurance industry. These rates are based on a variety of factors and involve statistical and mathematical computations. the nature of claims processing being highly situation specific. All the services and management activities cannot be carried by the insurance company itself on it's own. It requires some help from some external sources or agencies. In return for their services the brokers are paid a commission (broker commission) User groups called actuaries and underwriters play key roles in deciding the policy rates and thus in selling the products even though they do not interact directly with customers. it is not possible for an insurance company to have a rule engine for adjudication of every type of claim. If errors are detected. claims which require very specific processing are sent to these specialized adjudication companies.S. 2. Meanwhile. After that come the Specialized Adjudication Engines/Companies who offer help on adjudication of claims.4. Together they use various methods and strategies to sell the plans to as many customers as possible. Agency for Health Care Research and Quality (AHRQ). syntax. If a claim is determined to be free of typographical.

adding beneficiary to the policy. Claim processing: The insurance company validates the member and provider information in the claim and makes payment to the provider for the services that are      __________________________________________________________________________________ 65736839. The member sets up an appointment with the provider and receives the medical service on a pre-defined basis described in the policy agreement. General agents provide end-to-end connectivity that allows brokers and their clients to shop. All these external agents help the correct regulation and effective functioning of the Healthcare industry.Healthcare Overview ___________________________________________________________________ Third Party Administrators are responsible for making payments on behalf of a group health plan. The insurance company promotes the drug manufacturer’s drugs amongst its members. Health insurance companies also enter into contracts with drug manufacturers to provide preferred services to their members. Now that we have a fair idea of major players involved in the business. the drug manufacturer provides discounts to the members. In return. claim posting address etc. the major steps in this flow are -  Quotes creation: The plan sponsor contacts the insurance company and expresses a need to buy health insurance. which permits them to sell their healthcare services in the market. enroll. dependents. Referring back to Figure 1. The insurer then collects data like number of members. which then prescribe the same to the members.doc Ver. census data or demographic details Underwriting: After the acceptance of quotes by the plan sponsor the underwriting department underwrites the actual policies in terms of plan coverage and commercial agreements.0 Page 16 of 132 . Claim filing: The provider prepares a claim that describes the services rendered to the member. OP explains the rating calculation done for the benefits selected by the Plan sponsor and also the terms and conditions under which the group is accepted for coverage. The quotes are based on the health industry statistics. They are especially useful in case of small insurance companies who may not have the necessary infrastructure to take care of claim payments. Providers in the insurer’s network are given a list of preferred drugs.5 Healthcare workflow. the policy department of the insurer creates a policy by assigning group policy number. ID cards are issued to the members that display the policy number. 2. and primary and secondary MC organization and submits it to the insurance company. 1. They are the people who work behind the scenes to reduce administrative hassles and resolve complex service issues. Provider access: A member seeking medical service contacts the organization to get the list of providers in the geographical area of the member. The claims are either sent by mail (paper claims) or electronically. Accreditation agencies are responsible for providing accreditation to organizations. we are in a better position to understand the managed care workflow. Typically. The schedule for premium payments is also defined at this stage. the members pay either a deductible or copay. Policy creation: After underwriting. average age etc for preparing a quote. cost of the service. adding beneficiary dependents to the policy etc. location of members. serve and renew policies. PCP address and contact info. purchase. Once the underwriting is done an OP (Offer presentation) is generated and sent to the quote requester. The member also specifies the primary and secondary MC organizations to the provider.

It’s the area responsible for setting rating algorithm and the pricing factors to be used in rate calculation.6 Summary. after a detailed description of all pillars has been given. The more accurate and detailed representation of the workflow of the healthcare industry is given the following figure. new products introduction etc 2. Analysis of claims from a particular geographic location may reveal an increase in claims in that region due to reasons related to environment. arranging for reinsurance. 1. It started with the genesis of healthcare in the U. future liabilities.g.S.doc Ver. E. The workflow shown in figure 1 represented the workflow of a managed care organization.  Actuarial: This involves analyzing the trends.Healthcare Overview ___________________________________________________________________ covered under the policy. Actuarial decides the factor to be applied to renewal rates of benefits offered in that region. This unit gave a brief overview of the healthcare industry to the reader. We shall analyze this figure at the end.A and then introduced the five pillars of healthcare. The details about the pillars and the other topics mentioned in this unit will be presented in the subsequent units. __________________________________________________________________________________ 65736839. contingency matters and prior details to come up with factors to alleviate risks.0 Page 17 of 132 . An Explanation of benefits (EOB) is sent to the member describing the payments made and indicates the share that the member has to pay. In case of multiple MC (primary and secondary) the primary MC coordinates the benefits between the two MC and sends a COB (Coordination of benefits) to the member. In the end the reader was given a brief overview of the managed care workflow.

2.8 References.yourdoctorinthefamily. Review Questions. 2.7 1.      www. Give a brief account of the development of the health insurance industry? What are the five pillars of healthcare industry? Explain the terms  Member  Provider  Benefits  Claims Explain in brief the workflow of a managed care organization.com http://trochim.insurance.edu/ “History of managed care” by Tufts managed care institute. 1.0 Page 18 of 132 .doc Ver. “Future of managed care” by Tufts managed care institute. 4.com www.Healthcare Overview ___________________________________________________________________ Figure 2: Detailed Workflow 2.cornell. __________________________________________________________________________________ 65736839.human. 3.

1.Healthcare Overview ___________________________________________________________________  “Managed care overview” by Amit Shukla __________________________________________________________________________________ 65736839.0 Page 19 of 132 .doc Ver.

doc Ver.0 Page 20 of 132 .Healthcare Overview ___________________________________________________________________ __________________________________________________________________________________ 65736839. 1.

Member's data Asks for Service Providers Check Eligibility Files Claims Claim's Adjudicatio n Files Claims Member's Enrollment Payment Insurer Payment Fig 1: Member Overview 3. __________________________________________________________________________________ 65736839. doctor) to avail the service.doc Ver.III 3 Members 3. The provider/ member then will file a claim to insurance company. Claim will be validated and the insurer will reimburse the amount to the provider/member.1 Insurance Business: An Overview. 1. Once enrolled. Member can go to a service provider (hospital.1 Unit Objective This unit will acquaint the reader with the role played by the member in the Healthcare Industry.2.Members ___________________________________________________________________ UNIT . 3. A person purchasing plans can cover himself as a member (commonly referred to as "Subscriber") and his/her family members as dependent members (commonly referred to as "Dependent"). an insurer provides ID cards to its members. Some employers sponsor healthcare plans to its employees and its dependents. These will be used to show the validity of the policy taken.0 Page 21 of 132 .2 Introduction Member is a person who is the actual beneficiary of the healthcare plan. Provider will check the eligibility of the member for that service. The pictorial view of the process is as shown in figure 1.

0 Page 22 of 132 . 1. Insurance: An Overall Picture. __________________________________________________________________________________ 65736839.doc Ver.Members ___________________________________________________________________ For the pictorial representation of insurance business and the member's interaction with other systems please refer to figure 2. Fig 2.

ironically. Deductible and co-payment affect the premium.0 Page 23 of 132 . If the insurer doesn't want to cover a particular health condition. When an individual apply for insurance. a person is directly in control of his/her policy. the insurer will want to know everything about his/her personal health history. since it is usually more comprehensive and less expensive than individual insurance. individual insurance is often more expensive to make up for the insurer's increased risk exposure. by contrast. a person may still be able to get a policy with an exclusion rider. This is generally done through a series of medical questions and/or a physical exam.doc Ver. Individual insurance coverage is. Individual insurance often doesn't provide as much coverage as group insurance policies in the same price range. because group insurance allows the insurer to spread the risk over a larger number of people. However. An unexpected illness or serious injury can put him/her and his/her family in financial peril. Advantages of individual coverage If available. Disadvantages of individual coverage Often. In case of individual insurance. The risk potential will determine whether person qualifies for insurance and how much the insurance will cost. the employer or association pays at least part of the cost of group insurance. he/she is taking a major risk by choosing not to get coverage.2 How to get individual insurance? To get individual insurance. just to make sure that he/she is getting the best coverage for his/her money. group insurance is generally a better option. Moreover. he/she is evaluated in terms of how much risk he/she present to the insurance company. a person can either contact the insurer directly. much easier to come by when someone is healthy. 1. Although someone may think he/she can do without health insurance. the provisions of the policy are negotiated between the insurer and master policy owner (usually an employer or association). he/she may find it difficult to obtain coverage.3. is usually available without taking a medical examination or answering health questions. For this reason. individual insurance is generally more difficult to obtain and more costly than group insurance.Members ___________________________________________________________________ 3. 3. He/She will probably want to get quotes from several insurance companies before choosing one.3 3. It is unwise to try to hide a pre-existing condition from the insurer. however. With individual insurance. In a group insurance situation. Individual insurance is somewhat more risky for insurers than group insurance. He/She can negotiate to have certain provisions included or excluded. his/her coverage could be canceled altogether. or get in touch with the insurance agent. and can often choose his/her deductible amount and co-payment percentage.3. Before issuing an individual insurance policy.1 Individual and Group Insurance in detail Individual Insurance Individual members are those who purchase insurance directly from an insurance company. Group insurance. __________________________________________________________________________________ 65736839. individual coverage is infinitely better than being uninsured in the event of illness or injury. a member is responsible for 100% of the cost. But. since many insurers use information from the Medical Information Bureau to determine whether an applicant is insurable. if it is later discovered that he/she withheld information from the insurer. If he/she is already sick or have a history of health problems.

although cosmetic and other truly "elective" surgeries are rarely covered. Waiver-of-premium provision This allows a member to skip the premium payments if he/she becomes seriously ill. It does no good to have guaranteed renewable insurance if the insurance company goes belly-up. x-rays. The provision can be very important if the person is unable to work for an extended period of time. here are some things he/she should look for:  Financial stability An insurer with an "A" or "A+" rating from A. and if someone might never have to worry about his/her out-of-pocket costs unless he/she becomes seriously ill. Choosing an out-of-pocket maximum is a personal matter.Members ___________________________________________________________________ What to look for in an individual policy? If someone can find one that offers individual insurance. an HMO. or Standard & Poor's. The premiums may go up over the years. Coverage of pre-existing conditions Many insurance companies impose a waiting period before covering preexisting conditions. Anything less than $1 million may be insufficient to cover you in the event of a catastrophic illness. anesthesia. if someone is getting individual insurance from a traditional insurer. The highest deductible and co-payment someone can reasonably afford Lower deductibles and co-payments mean the costs will be lower if someone actually ever gets sick. 1. he/she can cut his/her insurance premiums dramatically. tests. Some managed healthcare systems provide coverage on an individual basis as well. However. However. Anything over a year is extremely undesirable. someone will want to find a policy with the highest lifetime payout possible. or POS plan can often give the most cost-effective insurance coverage.        Providers who will offer individual insurance Most people purchase individual health insurance coverage through traditional insurers. his/her insurance coverage continues. As long as he/she continues paying premiums." this limits out-of-pocket costs.0 Page 24 of 132 . Major medical coverage Major medical coverage (which covers all hospital costs including rooms. PPO. he/she shouldn't have to worry about medical costs getting out of hand. __________________________________________________________________________________ 65736839. Out-of-pocket maximum Also called a "stop-loss. By agreeing to a higher deductible and/or co-payment. "Guaranteed renewable" provision This means the insurer can't cancel the coverage if someone becomes ill. The shorter this period is better.M. Moody's. Many policies do cover outpatient treatment. and drugs) is preferable to hospital-surgical coverage (which covers only hospital and surgical services). And as long as he/she retains a reasonable out-of-pocket maximum. emergency-room care. Lower out-of-pocket maximums can mean substantially higher premiums. High benefit ceiling Policies with unlimited payouts are rare in this day and age. but they will rise for all policies in the class (not just individual’s).doc Ver. Three months to one year is standard. Best. but he/she pays dearly for this protection. some states require HMOs to offer coverage to individuals during a special open enrollment period each year. In fact. since it really depends on how much someone can afford to pay.

The insurance company can then decide whether or not to insure him/her. Clearly. The premium for group insurance is calculated based on the characteristics of the group as a whole. Unlike individual insurance. With group health insurance. Advantages of group coverage Easy to obtain Under a group health insurance arrangement. modify his/her existing coverage. the insurance company has the right to treat him/her as though he/she was applying for individual insurance. the initial cost of establishing group coverage is lower than the cost of issuing a separate policy to each person. where each person's risk potential is evaluated to determine insurability. this is often the first 30 days of his/her employment. Also. instead of covering just one person.0 Page 25 of 132 . The specific policy provisions are all determined in advance.Members ___________________________________________________________________ 3.3 Group Insurance Group insurance is coverage of a number of individuals under single contract. The policy is typically negotiated between the insurer and the "master" policy owner (employer or association) with no input from the member. all eligible people can be covered by a group policy. The only condition is that the group members must apply for insurance within the specified eligibility period. who might be unable to get individual insurance. chambers of commerce. This means he/she will probably have to answer extensive health questions. How to get group health insurance? Find out the eligibility Many employers offer group health insurance as part of their employee benefits package. such as average age and degree of occupational hazard. Other groups that may offer insurance coverage include churches.3. Apply for coverage although one’s individual health is generally not evaluated when he/she apply for group health insurance. Employers pay healthcare subscriptions for some or all of their staff. this is better for those with chronic health conditions. he/she must apply during the specified eligibility period. Both employers and associations may also have an open enrollment period each year. The most common "group" is employees of the same employer. The purpose of the eligibility period is to reduce insurance costs by preventing people from waiting until after they discover a health problem to sign up for coverage. clubs. For employer-sponsored health insurance. this may be the first 30 days of his/her membership in the group. Each member of the group provided a group certificate. regardless of age or physical condition. or the first 30 days following his/her initial probationary period. group __________________________________________________________________________________ 65736839. during which one may sign up for coverage. In general. regardless of current physical condition or health history. and special-interest groups. For associational insurance. 1. the only real disadvantage of group insurance is limited or no freedom to customize the policy to individual needs.doc Ver. a single policy covers the medical expenses of many different people. as are deductible amount and copayment percentage. or add dependents to his/her coverage. trade associations. If a person fails to enroll during this period. and go through a physical examination. It shows the benefits provided under the group contract issued to the employer or other insured. the insurance company agrees to insure all members of the group. Cost Effective Because only one policy is issued for the entire group.

Since group insurance costs less for the insurance companies to establish and administer. Break on premiums In many cases. Company Paid Groups     3. he/she may be able to choose between two or more insurance plans. Lower out-of-pocket maximums can mean substantially higher premiums. 1.M. Moody's. since the risk is spread out among a larger number of people. This can make group insurance even more affordable. the employer or association will pick up some or the entire group insurance premium. the companypaid group healthcare scheme offers benefits for employer and employee alike. __________________________________________________________________________________ 65736839. one shouldn't have to worry about medical costs getting out of hand. And as long as he/she retains a reasonable out-of-pocket maximum. or Standard & Poor's.doc Ver. High lifetime payout Find a policy with the highest lifetime payout possible. What to look for in a group policy?  Financial stability Look for an insurer with an "A" or "A+" rating from A. The provision can be very important if he/she is unable to work for an extended period of time. employers pay Healthcare subscriptions for some or all of their staff. and his/her deductible amount and co-payment percentage are determined in advance. This scheme makes things easier for the employees and encourages employee loyalty. By agreeing to a higher deductible and/or co-payment. Choosing an out-of-pocket maximum is a personal matter. An individual member does not have the freedom to have provisions included or excluded. Advantage of company-paid groups Deduction Schemes A salary-deduction scheme comes into effect when a company or group organizes deductions from each employee’s salary and forwards them to Healthcare. A "stop-loss" provision This limits the out-of-pocket costs. it generally costs less to purchase.3. The highest deductible and co-payment one can afford Lower deductibles and co-payments mean the costs will be lower if one actually ever get sick. company-paid schemes are the fastest-growing segment of the market at present. A waiver-of-premium provision This allows one to skip the premium payments if he/she becomes ill. Anything less than $1 million may be insufficient to cover in the event of a catastrophic illness. Best. however. An increasingly powerful "perk" useful for both attracting and keeping good staff. In the increasingly tight labor market conditions prevailing in Ireland at the moment. Disadvantages of group insurance One can't customize the policy. the provisions of the policy are negotiated between the insurer and master policy owner (usually an employer or association). In a group insurance situation. Within a fairly large group. In some situations. he/she can cut his/her insurance premiums dramatically.Members ___________________________________________________________________ insurance is somewhat less risky for insurers than individual insurance. but he/she pays dearly for this protection. it is almost certain that the good insurance risks will equal or exceed the bad insurance risks.4 In these groups.0 Page 26 of 132 .

as it is helpful in growing their relationship. sports clubs and interest groups. Tax Relief for employees Employees are liable for Benefit-in-Kind (BIK) taxation on the paid Healthcare premium at their top rate of tax. quarterly or monthly basis.0 Page 27 of 132 . The SI group also has to maintain certain bank balance at all times to ensure the continuance of medical benefits to their employees. 1.) for their employees.) 3.  They will be given more priority for processing of their claims then others get. the company can claim healthcare payments under the Corporation Tax shelter. But these figures are much lower than paying premium to cover all the employees.3. Ease of Payment Payments can be made by direct debit through company bank account. The financial risk is borne by the Plan Sponsor. half-yearly. Benefit in the premium amount Some group schemes qualify reduction in the premium amount. leading to less stress for them and their employees. Self-Insured People are Profited by:  Getting more benefits for the same plan which an insurance company will not provide for others at low cost. __________________________________________________________________________________ 65736839. 3. In a company-paid scheme. Flexible cover options Once employer chooses a particular level of cover. professional bodies. retention and goodwill.Members ___________________________________________________________________ Fast access to the best in modern healthcare Members can choose admission dates to fit in with work and family commitments. a payment can be made directly on a yearly. Alternatively.5 Affinity Groups An Affinity scheme is appropriate for members of business organizations. the Credit Unions and the Small Firms Association. one can provide his/her company with significant benefits in terms of employee recruitment. Plan Sponsor is profited by:  They get the Health Insurance plan at a cheaper rate.3. thereby reducing their effective rate of BIK to the standard rate of income tax.doc Ver. Insurance Company is profited by:  Getting a fixed sum of money for adjudication of claims. (Examples are the Irish Farmers’ Association. SI Groups pay "Service Charges" to insurer for administration / management of medical insurance (adjudicating claims etc. Benefits to the company Introducing a Healthcare group scheme for employees. they are entitled to claim tax relief on the full premium.6 Self Insured Group Plan Sponsors / Companies who pay the Claims' amount of their employees themselves are called SI (Self Insured) Groups. staff members can select a higher plan and simply have the balance deducted from their salary.  Risk is moved to the Insurance Company.  Their Work will be given higher priority by the insurance company.

If someone meets the definition of a self-employed individual. 1..5 percent of AGI as are medical expense deductions. his/her spouse.7 Self-Employed Members Health insurance need of a self-insured person is probably greater than the average person. were eligible for an employer-sponsored health plan for any part of the tax year. These deductions aren't limited to amounts over 7. This option is not available to self-employed.doc Ver. he/she may deduct the amount by which his/her un-reimbursed medical expenses exceed this 7.Members ___________________________________________________________________ 3.5 percent threshold. his/her options may be limited to:  Individual health insurance coverage purchased directly from a provider  Group coverage purchased through a professional association or civic group (i. and physician's expense insurance. if the spouse of a self employed person. self-employed individuals can deduct a percentage of their health insurance premiums as business expenses. In terms of health insurance. and amounts paid out of his/her pocket for treatment not covered by his/her health insurance. However. then health insurance costs paid during that time cannot be used to calculate this deduction. he/she can deduct the following percentages of premiums for insuring himself/herself. surgical. funds in an Archer MSA are used to cover healthcare expenses.3. Also.5 percent of his/her adjusted gross income (AGI) in any tax year.e. Most people get their health insurance through their employers. hospital. Special rules for the self-employed In addition to the general rule of deducting premiums as medical expenses. instead of saving for retirement. because an extended illness or hospitalization could easily deplete his/her personal assets and endanger his/her business. The definition of self-employed individuals includes partners and 2 percent S corporation shareholders. Un-reimbursed medical expenses include premiums paid for major medical. chamber of commerce) Deductibility of un-reimbursed medical expenses In general If someone itemizes deductions and his/her un-reimbursed medical expenses exceed 7. Archer MSA--a way to save for health-care expenses Archer MSAs (previously called medical savings accounts) are tax-advantaged individual savings accounts that work much like an IRA. __________________________________________________________________________________ 65736839. and his/her dependents: First Year Second Year Third Year and thereafter 60% 70% 100% This deduction is limited to amounts less than the earned income. trade group.0 Page 28 of 132 .

4. 5. Enlist advantages and disadvantages of individual and group insurance. insurers are running into problems with state laws that prohibit such high-deductible plans. is not eligible to open an MSA. are those who pay the Claims' amount of their employees are Self Insured Groups. Plan sponsors/ Employers 4. Administrative /Management of medical insurance 5. Answers: 1. Employers 3. __________________________________________________________________________________ 65736839.  Someone. However.200 for individuals ($5. in some states. Individual Members 2.800 for families). are those who purchase insurance directly from an insurance company in case of an individual insurance.200 to $4. A highdeductible plan is defined as one in which:  The deductible is between $1. 2. are those who purchase insurance in an employer sponsored insurance.8 Exercise 1.0 Page 29 of 132 .850 for families). 3. For Self-insured groups insurance company may provide the services. Many financial institutions are also still in the development stage with their Archer MSA account products. and The annual out-of-pocket expenses do not exceed $3. The biggest challenge in setting up an Archer MSA may be finding a company that offers them. In fact.400 for individuals ($3. 1.600 and $2.doc Ver. 3.3. there are exceptions to this rule.Members ___________________________________________________________________ A self-employed individual (or the spouse of a self-employed individual) may be eligible to open an Archer MSA if he/she currently has a high-deductible health insurance plan. This includes Medicare coverage. Many insurance companies are still developing qualified high-deductible insurance plans and products with a savings component. having additional coverage under a health plan that is not a high deductible.

and making available all necessary eligibility information for enrollee membership. product issuance. For an employer ID numbers and passwords for its employees will be provided. 3. Data entry operators will make you enroll online. Enrollment through the employer based systems Employers do have employees data maintenance systems.1 Member’s enrollment What is Enrollment? The enrollment process comprises of collecting. benefit information that he/she has opted for.2  How is enrollment carried out? Traditional Paper Enrollment Enrollment forms would be available on the web sites or situated office outlets of the company.    __________________________________________________________________________________ 65736839. and claim adjudication. Required data will be captured and sent to the insurance company electronically. Member has to approach the office. Member will provide all necessary data to the insurance company that will include personal information. The enrollment process will then be automated. verifying. 1. This is the most commonly used approach.doc Ver. Member can fill up the forms and send it to the respective postal addresses. The data will be received and formatted fed to the systems. Employees are allowed to select the benefits they wanted to opt for. This is most commonly used methodology for large employers having more than 300 employees. billing. a member can start filling up the claims. Employer then validates and sends the information to the insurance companies electronically.Members ___________________________________________________________________ 3.0 Page 30 of 132 .4. Collecting and updating the systems with the data completes the enrollment process.4 3. There will be online systems set up there. Web-based applications For an individual web based application will facilitate online registration/ enrollment to get enrolled.4. Member will receive membership letter once the enrollment is over. Enrollment in the office outlets of the insurance company There will be city-based office outlets set up by the company. Membership letters and other details will be sent to the member once the process is over. Once the enrollment is over.

pharmacist). hospital. Member has to show his/her identity card when he/she approaches a service provider (doctor. membership number and other details. membership letters will be sent explaining the benefits he/she has opted.3  Output of enrollment process ID Cards A person insured under an insurance company is given an identity card.    __________________________________________________________________________________ 65736839. ID card would have details about the member's SSN. Name.4. Member Member Member Employer Associations Insurance Company Fig 3: Enrollment Data Flow 3. Employer Report A report will be sent to the employer giving the details of its employees enrolled and their details. 1.0 Page 31 of 132 . Provider Report Providers are made aware of the new members enrolled under his/her name. Membership letters Once the enrollment process is complete.Members ___________________________________________________________________ Enrollment Data Flow is shown in figure 3. eligibility information.doc Ver.

Traditional Paper transfer b. 3. Electronic data transfer from employers d. Employers having own member's database provide data to the insurer via _________. Web-based applications. 2.0 Page 32 of 132 . 4 Enrollment Process 3. Direct enrollment in the field offices c. Enlist the means of enrollment. 1.4 Enrollment: Overall Picture Please refer to figure 4 for the pictorial view of enrollment process. 3. Member needs to show _______ as a token of its membership in the insurance company.4. Answers 1. Electronic data transfer. Fig.doc Ver. ID card __________________________________________________________________________________ 65736839. Means of enrollment are a.Members ___________________________________________________________________ 3.5 Exercise 1. 2.4.

 Service related information.1 Member’s and Dependent’s eligibility Eligibility Eligibility is the ability of a person to use any kind of service. __________________________________________________________________________________ 65736839.0 Page 33 of 132 .5 3. Not all could be applicable for a member. There are different services that could be covered by the insurer. premium will be decided. Last name will be fed to the online system as input. The system will run eligibility checks and returns the data to the provider. The data will be sent from the insurer that will contain duration for which the policy will hold true for a member is defined in the contract. Employer Name. Data sent to and from the provider to validate the eligibility:  Member's information: The provider will send the identification information as SSN (Social Security Number). The system will crosscheck the eligibility for the service and inform the provider back. Provider need not do any eligibility checks when member is having indemnity plans. Insurers will set-up systems by which eligibility information will be available to the provider. will be given to the system. This data will be validated with the database of the insurer to make sure that the person is a valid member. Every service-provider is bound to check the eligibility when a member asks for any kind of service except for indemnity plans. ID number is validated with the insurer's database. Subscriber's name. Member when purchases a policy selects the services that we would want to be covered. Again this will be validated against the insurer's database to make sure that the subscriber is a valid member. Identification number etc. Every employer when signs a contract with the insurer are given identification number.5. the service will be provided and provider will file the claim for the payment of the service. member number (Identification number given by insurer). 3. If member is eligible.  Subscriber's information.2 Eligibility Process Provider will query on a member for getting a particular service.Members ___________________________________________________________________ 3. So the policy effective date. Provider gives basic information about the member (Member's identification number. Social Security Number) along with service he/she is asking for. Taking insurance business into consideration.  Policy Dates. a member’s eligibility for a service will be decided upon the benefits that he/she has opted for. In case of prescription drugs there is a cap held on the quantity drug to be consumed by the member in a period of time. 1. These validations are also carried away when the eligibility is validated. Provider will send subscriber's information only if the member is a dependent. If the member is not eligible to avail the service the service provided will not be insured. Depending on that various terms like rates.5.  Employers Information. termination date will be sent back to the provider. So every time a service is given a provider asks the system if member is eligible to get that service or not.doc Ver. Provider will also provide employer's data if the plan is sponsored by member's employer.

The Employer Eligibility information will be maintained and accessed by the employers. the information needs to be validated before giving any kind of service. By permitting healthcare providers to access this information directly.  Member having HMO plan __________________________________________________________________________________ 65736839.3 How a member should approach right provider? Eligibility also talks about the member getting service from a particular provider is valid or not. Every time a member visits a provider. providers and their administrative staff to quickly and easily get detailed information regarding submitted claim status and eligibility status of employees and their family members.0 Page 34 of 132 . Even an employer is given access to this data so that it can monitor eligibility status of its employees. Insurance companies set online systems through which providers can query for the eligibility data for the member approached to him. Employer groups normally use online administrative system that will provide eligibility status of a member. employers and to its members. The Provider Healthcare providers need vital information related to member eligibility and claim status. Insurer Member's Policy information Member's Policy information Member's Policy information Employer Member Provider Fig 5: Eligibility Data Flow The Insurer Insurance companies provide member eligibility information to the service providers.5.Members ___________________________________________________________________ A member is also allowed to monitor its own/ dependent's eligibility status. Some employers provide an online eligibility status inquiry similar to that given for employers. the deductible and all other information. Eligibility data flows as shown in the figure 5. 1. After getting confirmation from the insurer. The Member Member may be interested in looking for their benefit data. provider will give service to the member. 3.doc Ver.

(Y/N) Son Bill of age 21 got married and moved out will be a valid dependent of Joe. and children in a guardian-ward relationship are also eligible provided they live with member and are substantially dependent upon member for support and maintenance. So eligibility checks would be carried away but will not hold back the member from getting the service. coverage may be continued. Affidavits of Dependency and legal documentation are required with enrollment forms for these cases. This includes children who are away at school as well as divorced children living at home and dependent upon member for support. These are generally unattended. Coverage for children age 23 ends on December 31 of the year in which they turn age 23 If a child is not capable of self-support when (s) he reaches age 23 due to mental illness. automated transmissions that include security features like encryption technology and unique IDs and passwords for user verification and system access. 3. Provider need not do any eligibility checks for member’s eligibility. The service will be provided only if the person is eligible for the same. 2. children who do not live with the member are eligible if member is legally required to support those children.4 Eligibility Data Transfer Most of the insurance companies transfer the eligibility data electronically. (Y/N) Daughter July aging 26 passing through a phase of mental illness is treated as a valid dependent. 3.5. or turns age 23. cartridges and diskettes.5. If member is divorced. This methodology eliminates the need to submit paper forms or produce and send cumbersome tapes. (Y/N) Providing member's eligibility data to the providers is a responsibility of the insurer. mental retardation. moves out of the household. 1.6 Answers __________________________________________________________________________________ 65736839.5. If goes to in-network provider the co-pay will be less.Members ___________________________________________________________________ Every member has associated Primary Care Physician (PCP) for medical services and Primary Care Dentist (PCD).  Member having POS plan Member is free to go to any provider. legally adopted children. 3. which can get lost or damaged. Providers need not validate the member eligibility before catering any kind of service. 4.0 Page 35 of 132 . Provider validates the eligibility of the member for the service asked. But there is no restriction on the choice of the provider.  Member having PPO plan A member will fall under a network and can get service from any provider falling in that network. Stepchildren.doc Ver. (Y/N)    3. or a physical disability. foster children. Exercise 1.5  Eligible Dependents Eligible dependents are member’s spouse and/or unmarried children under age 23 who live with member in a regular parent-child relationship. Coverage for an enrolled child will end when the child marries.  Member having indemnity plan Member is free to go to any provider.

0 Page 36 of 132 .doc Ver. 1. 2.Members ___________________________________________________________________ 1. N Y N Y __________________________________________________________________________________ 65736839. 3. 4.

3. 1. Web-based application is the most common of all of above modes. Review coverage status for medical and/or dental care. claim eligibility.2  Services provided by the insurer View information/ Inquiry only Insurance companies do provide a facility via which a member can view his/her benefit information and the status of his/her eligibility. There are several ways this service is provided most common is through phone calls. Member has to register his/her name in the application and the data would be shared. o Claim Status When a member has filed a claim. Members can make various inquiries. o Personal Details This includes the name. where a member can enter personally to login a service request.Members ___________________________________________________________________ 3. Provider inquiry etc. Essential security features are incorporated in the applications to prevent the data loss and data disclosure. o Benefits Snapshot Review primary care physician or primary care dentist selections for the member and the covered dependents.6. contact numbers and other details. __________________________________________________________________________________ 65736839. web-based applications. he can keep track on what is the status of the claim.doc Ver. 3.  FAX Paper driven approach in which member has to fill up a service request form and send to the member service station where the requested service application will be taken care of. general description of your medical benefits and includes member cost-sharing information.0 Page 37 of 132 .  E-mail Member services e-mail address to which a member can send a mail and ask for the service. There could be menu driven recorded message that will provide you information you want.1 Means of services  Phone call Designed/Toll free numbers for member services. There will be webbased application where a member can login and avail the service or can login the service request.  Web based applications. address. like the status of his/her claims.6 Member Services Insurance companies provide plenty of services to make information available to its members.  Postal mail Paper driven approach in which member has to fill up a service request form and send to the member service station where the requested service application will be taken care of.  Walk in Situated are member service offices. o Benefits summary Talks about a partial.6. such as co-payment or coinsurance requirements.

Log issues and complaints: o Logging provider complaint Member is free to log in any complaint about the service or the provider.  Distribution of ID cards. web-based applications or the walk in offices situated. 1. booklets:  __________________________________________________________________________________ 65736839. o Add or delete family members at open enrollment.0 Page 38 of 132 . There will be company's officials sitting in the offices assisting the member in doing that plus there are designated mail-Ids a member can send a mail to. o Provider change facility Member may wish to change the primary care physician or primary care dentist he/she has a facility to do so. or adoption of a child of the employee  The termination or commencement of employment of the employee's spouse  The switching from part-time to full-time employment status or from full-time to part-time status by the employee or employee's spouse  The taking of an unpaid leave of absence of the employee or employee's spouse  The significant change in health coverage of employee or spouse attributable to spouse's employment  Other services o Providing forms Forms like medical claim submit form/ dependent care reimbursement form. Some times the employers update the insurer about these changes.doc Ver. o Clarification about the benefits Member can get the doubts about the benefits at any point of time. Internet also helps out by providing enough data on the site. are made available on the web-sites/applications that might be needed by the member. Some of the cases are:    A marriage or divorce of the employee The death of the employee's spouse or a dependent The birth.  Update information These services are catered through phone calls. can walk in the offices set up by the insurer and do the changes. proposed adoption. o Updating personal information Member may wish to update the personal information such as address or contact number etc. These forms could be submitted via postal mail to the claims offices (the address is generally specified on the ID cards). o Password change facility If there were a web-based application that caters all these facilities there would be a facility to change the password set up by the member.Members ___________________________________________________________________ o Provider directory Provider directory is that enlists the providers those are in the network of the insurer/in contract with the insurer.

Can print as many copies as needed.   3.  Updating member with new products. Can be stored electronically on computer for easy retrieval.1 Member Group Maintenance What are Groups? Groups are the frameworks used to organize billing. policy number etc. The facility to replace the ID card would be provided. Sending statements through email has many advantages. Charging to the member’s credit card Some times member authorizes the insurer to charge the premium to his/her credit card.pdf) attachment. o o o New benefits information. Once the money is transferred to insurer’s account. 3. The acknowledgement letter contains the detail about the payment such as premium amount.Members ___________________________________________________________________ o Issue ID Card Member may need to issue a new ID card if misplaced/lost. he/she receives a premium statement through post. Can be zoomed in for larger print and easier reading and can be printed on virtually any inkjet or laser printer to get perfect copies. The premium statement is sent to the member along with an envelope. an acknowledgement letter is sent to the member stating that so and so amount of money is transferred from member’s account to insurer’s account as an insurance premium for a particular month.7 Premium Collection A member can pay premium to the insurer by following means:  Transferring fund from member’s account to insurer’s account: The member authorizes the insurer to get money transferred to insurer’s account. fills in the detail (name. Monthly statements are emailed to the member portable document format (. A new card will be sent to the address we have on file for you. moth. accounting and reporting of data to the plan sponsors (employers/ associations).8. Member is kept updated with the information by weekly/ monthly reports or news on the websites.) and sends it along with the cheque in the envelope received with the invoice.doc Ver. cheque number. policy number etc. statements:   Can be viewed on computer. facilities: There are many upcoming services/ benefits newly provided by the insurance company. claim payments. __________________________________________________________________________________ 65736839.8 3. Payment by cheque If the member is willing to make a payment through cheque. The member receives the acknowledgement letter from insurer giving detail about the premium received. 1. recording. The member tears of the lower part of invoice. Address of the insurer is preprinted on the envelope.0 Page 39 of 132 . The member has to fill a form for the ID card issuance. New facilities information About products and programs that are available in the state.   Some insurance companies also send the premium statements through email.

Membership details (Effective Date Change. Payroll Change. Group Maintenance includes               Office Details changes (Contact Number. Membership Effective Date Change.0 Page 40 of 132 . Family Effective Date Change. Employment Change. Family Group to Group Change. groups are created and entered into the systems first then the enrollment for the individual members would be done. 3. Reinstatement. Provider Office Change. Third Party Phone Number Change. Being a parent entity some data is defined at a group level that will be inherited by the members following under that group. Recalculate Family Contract. Mass Id-Card Request. Office Effective Date Change. Mass Id-Card Request (Co-pay Change). Provider Office Change.Members ___________________________________________________________________ 3. Contact Address Changes) Third Party Address Change. ID-Card Request.doc Ver. The decision of the group structure will be based on Profit centers Unions Benefits Class of employee Locations Other categories specific to the plan sponsor For a group insurance. Suspended). __________________________________________________________________________________ 65736839. membership Termination date changes.8. Membership Termination. This data would generally contain Employer information Plan Effective Date Plan Termination Date Benefits Covered Network Information Co-pay rates Claim offices The members could override some of the features.8. Office Termination Change. The CONTRACT IS RENEWED for a group and the members are REINSTATED. Other maintenance performed on the member data is … Members Maintenance includes       Member's personal information changes (Address Change. 1. Most Groups' renew their Plans every year in January. Change Membership Termination Date. the breakdown of the employee into groups will be done. Third Party Address Maintenance. Member Name Change.2 Groups Formation When a plan sponsor enrolls its employees. Payroll Change. Employment Change.3 Groups Maintenance Member and Groups' maintenance is performed annually. Comment.

Guaranteed renewable. What types of services does the insurer provide? 2. Employers can provide coverage for employees too. The funds paid are not specified for medical expenses . Non-cancelable.0 Page 41 of 132 . Often. Answers: 4.they can be used in any way the member wishes them to use. When the groups are formed in case of a group insurance? 3. For a guaranteed renewable contract company cannot raise your premium on an individual basis. Disability benefits contracts in which policy cannot be canceled and premium cannot be raised are _________. A non-cancelable contract is preferable to a guaranteed renewable contract.doc Ver.2 Exercise Questions 1. __________________________________________________________________________________ 65736839.9. but the premium can be raised under certain circumstances (the state insurance department must approve the change. 4.9 Disability Benefits Disability income insurance provides members with an income if they become sick or injured and are unable to work. 5. 1.1 Member’s concern When a member buys an individual disability insurance policy.9. Guaranteed renewable means that the policy can't be canceled as long as member pays premiums. Enlist the services offered for group maintenance. 5. which would apply to all individuals in the same insurance classification). so may be premium will be raised only every few years. Non-cancelable means that the policy can't be canceled and the premium can't be raised for the life of the policy as long as member continues to pay premiums. noncancelable policies are offered only to low-risk occupational groups at a high premium. pay attention to whether the contract is non-cancelable or guaranteed renewable. 3. they must have the permission of state's insurance department.Members ___________________________________________________________________ 3. Opting for the guaranteed renewable provision may save as much as 30 percent of the premium cost. Disability benefits contracts in which policy cannot be canceled but premiums can be raised are _________. 3.

0 Page 42 of 132 . 1.doc Ver.Members ___________________________________________________________________ __________________________________________________________________________________ 65736839.

0 Page 43 of 132 .doc Ver. 1.Members ___________________________________________________________________ __________________________________________________________________________________ 65736839.

There can be numerous classifications of providers depending upon the facilities provided by them. NON-PREFERRED PROVIDER: These are those providers who are not contracted to furnish services or supplies within ‘PREFERRED’ network.g. Hospital etc. BACKUP-PROVIDER:   __________________________________________________________________________________ 65736839.  NON-PAR: These are those non-participating providers whose contract with Healthcare organization is terminated.e. Dentists.   SPECIALIST: A specialist is one who has one or more areas of specialization in medical field. Every member is supposed to approach the PCP first before going to anyone else. PREFERRED PROVIDER: These are those providers who work on contract basis by negotiating the compensation they charge.0 Page 44 of 132 .g.  Other way of classifying them based on the type of contract is as follows:  PCP: Primary care physician. the members. Provider types can be classified broadly in the following ways:  Individual providers: These are those person who are not part of any group or association e.1 Provider types Providers are those people. organization or institution that provide services to those enrolled into the system i. IPA or PORG: (Independent Practice Association or Provider ORGANIZATION) It is the legal entity that provides administrative and contract related services for providers. As the name suggests it is the PCP who is in constant touch with the members directly. Group Or Entity: These are group of people who provide services under a common name e.IV 4 Provider 4.doc Ver. COMMUNITY PROVIDER: These providers do not have a contract at all with Healthcare organization. 1.   Depending on contract the Providers can be classified as:  PAR: Such a provider is a participating provider and has a valid contract with Healthcare organization.Providers ___________________________________________________________________ UNIT . physicians etc.

Once a provider is accepted as a participating provider. Provider Participation HCO (Healthcare organizations) usually elicit provider participation (into their network) using some standard marketing strategies. • Minimum number of member visits Some HCO(s) guarantee providers. there will be routine visits to the provider's office and a re-credentialing process every two years. so as to assure a minimum amount of revenue by way of claims.2 Credentialing Criteria The process requires providers to present documentation of training. Maternity Home etc. Some HCO(s) have pioneered the E-Pay/E-Cash option. Hospital. Pharmacies. Health insurance companies usually consider:  Licensure and/or certification  Drug Enforcement Agency (DEA) registration (for Medical Doctors and Doctors of Osteopathy)  Professional liability history  Medical education and training  Specialty board certifications  Mental and physical health __________________________________________________________________________________ 65736839. Backup provider provides medical services to the patients of the provider when he is not available. large HCO(s) provider e-learning options to enrolled providers via virtual communities on the Internet. EQUIPMENTS: These are those providers who provide medical equipment for executing medical tests such as X-ray labs. 1.g. E.3 Provider Contract Contract is an agreement between the provider or group of providers and the insurance company about the services the provider(s) will provide and the payment that the insurance company will make to the provider for the services rendered. a minimum number of member (or dependent) visits. These are specialist networks of providers.0 Page 45 of 132 .Providers ___________________________________________________________________ A provider can specify another provider as his/her backup.2 FACILTIES: These are those providers who provide facilities such as wards. 4.3. e. 4. Based on nature of service. which involves clearing provider claims within a fortnight (subject to the provider electronically filing the claim in a prescribe format). SUPPLIERS: These are those providers who provide medicines and surgical instruments. individual practice associations (IPAs). Some of these are as follows: • Quick settling of claims Most HCO(s) attract specialist providers into their network by promising them quick turnaround of their claims. path labs etc. education and other relevant information..g. or an appropriately delegated credentialing process.1 Provider Contract Process Providers who wish to participate in one of the networks must complete an application and the corporate credentialing process. Health insurance companies sometimes delegate credentialing to some physician groups. and physician hospital organizations . which share knowledge and intellectual property via the Internet. providers can be classified as following:    4. • E Learning Virtual Communities As some of the fringe benefits.3. 4. ICU’s.doc Ver.PHO(s).

1. mental health companies and similar provider organizations that are compensated by us on a capitated basis or other basis Quality Care Compensation System Under the Quality Care Compensation System. specialists. a physician receives payment for a patient whether the physician sees the patient that month or not. independent practice associations (IPAs). Additionally.5 Provider Reimbursement Most health insurance companies incorporate the following payment methods to reimburse providers for services. Specialist contracts and Hospital contracts. Medicare/Medicaid) Work history Malpractice insurance coverage history Clinical privileges at a hospital hospital 4.3 Verification of Provider Credentialing Information Health insurance companies verify the information about providers through a variety of sources:  State medical boards  National Technical Information Service tape  American Medical Association master file  American Osteopathic Association directories  American Boards of Medical Specialties  National Practitioners Data Bank  Malpractice carrier  Court records  Office of Inspector General reports  Hospital providers 4. hospitals. In most areas. For example.doc Ver.0 Page 46 of 132 . physicians are paid by capitation.3.Providers ___________________________________________________________________     Disciplinary history (including licensure. the system uses a three-part quality factor to adjust the physician’s capitation payments.4 Types of Contracts All major health insurance companies have several different types of provider contracts based on the type of servicing provider. Quality Review considers: __________________________________________________________________________________ 65736839. physician hospital organizations. Under capitation.  Quality-Based Physician Compensation  Quality Care Compensation System Quality-Based Physician Compensation Participating providers in the network have agreed to be compensated in various ways. many participating primary care physicians are compensated in accordance with the Quality Care Compensation System* (QCCS) described below. DEA registration. 4. Some of the different types of provider contracts include PCP contracts. some primary care physicians and other providers in the network are paid in the following ways:  Per individual service (fee-for-service at contracted rates)  Per hospital day  Under other capitation methods (a certain amount per member. membership/privileges. professional organizations.3. This means the physician is paid a fixed amount twice a month for every member who selected that physician to be his/her primary care physician. per month)  By integrated delivery systems.3.

IPA. PORG etc) 2. Contract is an agreement between the provider or group of providers and the _________________.g. The information which needs to be entered are Member number.0 Page 47 of 132 . Answers: 1. 2. Referral maintenance – through this process one can modify the existing referral entry. Some plan has flexibility to visit any provider without any prior authorization in that case referral doesn’t come into picture. A referral once issued has a validity period.5. A provider is called as ________ provider if he has a valid contract with the company. 1. Referral entry can be done through batch or online processing however inquiry and maintenance is done through online screens. which is generally fixed and can be 30 to 90 days and to utilize the referral the initial visit must be within that validity period.5 Provider Referral A referral is a form of authorization given to a member to access services performed outside the Primary Care Physician’s (PCP) office. (E. True.4 1. A PCP can issue themselves referrals for non-routine services.doc Ver. Insurance Company 4.Providers ___________________________________________________________________ Results of member surveys Review of the care (like childhood immunization rates. Suppliers 4. It depends on the plan taken by the member. If some referral has to be cancelled then we can do that through this process. details of the provider for whom referral given. flu shots and cholesterol screenings) members get from their physicians  Number of our members who change their primary care physicians How well the physician provides access to care and manages the care of patients with chronic illnesses like asthma.   __________________________________________________________________________________ 65736839. The inquiry can be done either on the basis of member number or referral number which ever is known.1 Referrals processing  Referral entry – All the referral should be entered in the referral database so that it can be used if required. Referral inquiry by member or referral number – Once the entry is made then at any time one can inquire about the details of any referral. A PCP or an authorized provider provides it when special care is required. 4. Providers who provide medicines and surgical instruments are known as ___________. PAR or Participating 3. details of the provider who is referring. 3. Exercise The legal entity that provides administrative and contract related services for providers are also a type of provider – True or False. Referral is not always required to visit outside PCP. Encounter date. 4. diabetes and heart failure   4. referral validity ‘From’ and ‘To’ date and service code (it specifies the king of service/treatment).

6.  Tough Standards: All providers must meet our comprehensive credentialing standards. 1. If the referral meets the purge criteria below. 4. 58551. which will do the actual erase of the referral. the referral will not be purged. hospitals.5. 58552. laboratories. local practices. and the referral has been logically deleted. etc. it will be written to two output files.) who have agreed to treat AUSHC members at negotiated rates and have agreed to abide by patient and quality management programs. Our objective is to establish networks large enough to satisfactorily serve the targeted population to whom they will be available. the referral will not be purged. in particular.  Extensive Monitoring: Participating Primary Care Physicians are re-credentialed approximately every two years based on a number of criteria including chart audits and the results of member surveys. The second is a file that is used by another job. one of the toughest participation requirements in the country. and a visit has been taken within the last 6 months.Providers ___________________________________________________________________  Referral purging – This can be done in batch mode. 58560). 4. The first will be a detailed dump of the referral that will be written to a purge file. availability of health care services. primary care physicians. A rental network is an arrangement in which another organization (besides AUSHC) contracts with a group of providers.  Electronic referrals – Direct online entry by provider.doc Ver.2 Referral types There are two types of referrals:  Paper referrals – In case the provider is not connected to company’s network he can enter the referral details on a paper which can later be scanned to a microfilm or manually entered by a processor to the database of the insurer.g. 4. specialists.6 Provider Network A network is a group of contracted providers (doctors. This information will be written to a yearly archive file that is used to recall purged referrals. This is possible if the provider is connected to the company’s network directly or through a third party.0 Page 48 of 132 . and travel time are taken into consideration when contracting with local providers to join the networks. A Job will scan all referrals within the referral database. the referral will not be purged. All referrals over 18 months old are purged. and a visit has been taken within the last 30 months. AUSHC then reimburses that organization for allowing our customers to use the network. o If the referral is 18 months or older. and acute care hospitals. 58555. 58550. All providers’ performance in monitored regularly.  Specialized Care: National Medical Excellence Program helps members needing highly specialized medically necessary treatment such as transplants or cancer at national recognized institutions when the required procedure is not available locally. with the following exceptions: o If the date of the referral entry is less than 18 months from the current date. Primary care physicians. o If the procedure/service code indicates that it is an infertility referral (e. __________________________________________________________________________________ 65736839. must meet more than two-dozen criteria for admission into our networks. Factors such as population.1 Quality Provider Networks AUSHC believes members benefit from quality provider networks in the following ways:  Comprehensive: Several providers participate with AUSHC including.

1. and provide evidence of such insurance upon request. Provider name – it is the name of the provider if he is an individual provider. Aetna reimburses the rental network organization for allowing our members to use the network. and will remain during the term of the contract. In other words.doc Ver. 4.4 Network Hospital Standards Our current hospital contracts require network hospitals to represent and warrant that they are.6. The criteria used to select participating providers reflect minimum network composition standards. given to each provider to identify the provider easily. and when members have access to the various types of medical services they may need.6. one the major database is Provider database. network staff target providers to be recruited and contracted.. appropriately licensed and accredited by either the American Osteopathic Association (AOA) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).1 some common information of Providers Some of the common information that needs to be captured for a provider is given below:  Provider number – this is a unique number which is system generated. licensure or accreditation status.Providers ___________________________________________________________________ 4.7 Provider maintenance This process involves collecting information on all type of Health Care Providers. Doctors. The status can be retired. 4. but may vary to accommodate local supply and regulatory requirements. Provider status – Shows current status of the provider. All the inquiry or maintenance of providers is done based on provider number.3 Rental networks A rental network is an arrangement in which another organization (e. closed.2 Network Adequacy Network adequacy refers to both the availability of a participating provider within geographic perimeters and the availability of essential services from a participating provider. Pro Net) contracts with the providers. 4. They must also maintain adequate malpractice and general liability insurance or self-insurance.7. Almost all the system uses this database to get any information about any provider.g. In the healthcare organization.   __________________________________________________________________________________ 65736839.0 Page 49 of 132 . The local Network Management staff has the ongoing responsibility of ensuring that each network has the proper composition of providers. If it is any group or hospital then name of that should be stored. They compare the existing network with adequacy guidelines for the specific service area and identify whether there is a need for new providers. All facilities are also required by contract to notify us of any change in coverage. A PPO network must be complete enough to provide members’ access to a participating provider for a core of essential medical/dental services. Instead of engaging in direct contracting arrangement with individual providers. which includes hospitals. A provider who is providing healthcare services on current date is an active provider. Provider maintenance should be done everyday in order to keep the provider database up to date all the time. networks are adequate when there are enough providers available for the member population in a geographic area. Labs etc. 4.6. After developing a list of providers by type needed to meet customer needs. deceased etc.

Psychologist.09 Service addresses. It can be weekly. o This is CAP and Claims billing address. 1.g. Exercise Referral is mandatory to visit a specialist irrespective of insurance plan/policy – True or False. A unique number given to each provider. ____________________ is the interval of claim payment to the provider. If there are no levels 10. but the company needs to put their details as well.Providers ___________________________________________________________________ Provider type – Provider type is categorization of the providers depending on the type of healthcare services they provide. 2. he can specify level 14 billing address for payment of capitation and level 15 billing address for payment of claims. There are some plans available in which the member can visit any provider irrespective to his contract with the company. Clinical Social worker. The addresses of rest of the nine SLs are stored as 01. b) Members have access to the various types of medical services they may need.  4. If a provider has more than one service locations. one of their addresses is identified as principle billing address. Provider network is adequate when: a) There are enough providers available for the member population in a geographic area. Billing Address . which is different from all his SL addresses.All information maintained are time sensitive. Effective and termination date . If a provider wishes to have a billing address.0 Page 50 of 132 . Provider Specialty .doc Ver. 02…. Both claims and capitation payments go to this address only if provider has not specified level 14 and level 15 addresses. transportation etc. to process their claims. 14 or 15 billing address. Provider can have maximum of ten Service Locations (SLs).8 1. Providers will participate with an organization for a certain period and may discontinue. which ease in maintenance of that provider record. Dentist. 3. There would be providers in the database. If the code for billing address is o It’s the principle service address. which are not in contract with the company. A provider can have more than one billing addresses. Contract info – this information tell whether the provider is in contract with the company or not. __________________________________________________________________________________ 65736839. 14 & 15 – If a provider wishes to have separate addresses for capitation and claims payment.    o   Claims payment schedule – It is the interval of claim payment to the provider. he specifies a level 10 billing address. Nutritionist. Radiology center.The area in which a provider specializes is called his SPEC or specialty. Nurse Practitioner. is ____________. Midwife. E. d) None of the above. – Physician. only then the payment is made to the principle service address. 4. bi-weekly or monthly. c) Both of the above.The address at which the payment of claims is made to a provider is called the billing address.

2.com/healthcareproviderinfo. (E.org/ http://www. Provider number 3. Review Questions What are the various criteria for the provider type classification? What are the credentialing Criteria considered by the Insurance Company before making an agreement with the provider? Explain various stages in Provider referral processing? What is the difference between Provider Type and Specialty? What payment methods do insurance companies use to reimburse providers? 5.10 References AETNA Intranet http://www.0 Page 51 of 132 .htm/ http://healthcare.Providers ___________________________________________________________________ Answers: 1. In Indemnity plan referral is not mandatory) 2.masslegalnurse. False.healtheon.g. 4.9 1. 3.ucla.healthinsurance.doc Ver. 4. Claims payment schedule 4.doctorandpatient.com/www/provider.healthaffairs.com/ http://www.edu __________________________________________________________________________________ 65736839.com/ http://www.doctorquality. 4. 1.asp/ http://www.com/ http://www. C.

0 Page 52 of 132 .doc Ver.Providers ___________________________________________________________________ __________________________________________________________________________________ 65736839. 1.

Each Customer group should submit a stipulated minimum number of applications for corresponding broker to qualify for commission. As in every other business.3 Brokers An insurance company generally has a pool of brokers.000 per Customer group per calendar year. This bonus is in addition to commission a producer receives on premium paid by Customer Groups. as there is stiff competition in the market. The various entities involved like Brokers and Underwriters are also discussed. Key Producer Compensation – Sometimes the company identifies key producers and gives them bonus if they get more than a fixed number of new subscribers. The banding of the medicare promotion award could be something like this: Program To Date Application Level Payoff per Application   65736839. 5. Producer Data is frozen at the end of a year. Medicare Promotion Compensation – Some companies pay bonus to brokers for bringing in new Medicare Applications.1 Calculation for Brokers Broker Commission calculation can be divided into following main sub topics  Product-wise compensation: Sometimes a broker group deals with only a particular kind of product.1 Unit Objectives This unit aims to familiarize the reader with some aspects of insurance sales and quote creation. This bonus is one time payment for new application and it depends on number of new application submitted.Sales ___________________________________________________________________ UNIT . A substantial percentage from customer groups’ payments result in distributing some percentage as commission to brokers. In such cases the Customer and Cash receipts information is maintained and broker commission is calculated from that. here buyers being the customer group buying a plan and sellers being the insurance company. in health insurance too brokers bring together buyers and sellers against a commission. An insurance company has its own marketing workforce and also a pool of external agents (brokers).2 Introduction Sales and Marketing form an important activity in the health insurance industry.V 5 Sales 5. 5.3. User groups called actuaries and underwriters play key roles in deciding the rates and thus in selling the products even though they do not interact directly with customers. Brokers are also called Producers in this context. The bonus distribution could be something like this: Net Subscribers Produced Override % of Premium 150-750 1% 750-2500 2% 2501+ 3% Cap of $60.doc Ver 0. Together they use various methods and strategies to sell the plans to as many customers as possible.00a Page 53 of 150 . 5. Users within the company need to maintain particulars of brokers and information regarding broker-customer relationship.

a quote is a statement of cost.6 we will study in details how Actuarials arrive at these rates. In case of a group insurance policy the rates may be banded on basis of age/ gender/ family status). tax structures etc.  The location / service area of the customer group . do not take account of any factors specific to any customer-group.) 65736839. Service Area – Area in which the members will be based 3. Hence Book Rates are same for any customer group availing a particular plan in the same area and hence the name Community Rates. In context of health insurance.Government regulations often mandate certain kinds of coverage. Admin users usually do product setup. These rates need to be approved by the concerned department in some states. given by a seller to prospective buyers. But they do not apply these factors. State regulations affect prices. inpatient hospitalization etc) 5. It contains information about: 1. make certain products saleable in certain area and withdraw some products from some areas as and when required. Actuaries come up with rates for each product. 6. Name of Plan 4. They group and combine benefits into plans and maintain data about product-offerings in different service-areas i.rates are revised from time to time and hence the dae of commencement of coverage affects the rates.  The effective date . If not renewed by that time.4 5. They enter data about new/updated plans. Rates (the premium due per member.) These are all mainly data-entry operations. benefits and conditions of a chosen plan. (It is to be noted here that an insurance company needs an approval from the government in order to sell a plan in an area at any time.the benefits included in a plan are basis of the cost of the plan.1 Quote Creation What is a quote? A quote is a statement of rates of a particular product. for the member(s). benefits and new locations where plans will be offered for sale.2 The Process Of Quote Creation For the process of Quote Creation to begin Product-Benefit Setup and Rate Setup need to be completed as part of pre-sales activities. Some standard information – like applicable conditions. Name of the firm buying the policy 2. statutory information etc 5.4. (In section 5. Effective Date & Renewal Date (date from which the policy will take effect and date when the policy will be due for renewal. A highly specialized and trained user group called Actuarials does rate Setup. Actuaries also calculate the values of group-specific factors for different locations at different times.000 per Customer group per calendar year. These rates are called Community rates or Book Rates or Base Rates and they depend only on:  The plan chosen .doc Ver 0.e. possibly after relevant customizations.00a Page 54 of 150 . On the basis of statistical considerations and mathematical calculations and with the aid of rating applications. Details of coverage (benefits like pcp visit.Sales ___________________________________________________________________ 1-250 $100 250-500 $125 500-1000 $150 1000-2000 $175 2000+ $200 Cap of $60. All these affect the cost of the plan. 5. the policy becomes void) 1. However.4.

At this point the representatives approach the assistants to get the quotes for these plans.Sales ___________________________________________________________________ Figure 1 below depicts the setup workflow. A few examples of special rates could be increased rates due to industry specific risks. They suggest some suitable plans to these customer groups. and then apply special rates or group specific factors depending on the profile of the group and their specific needs. marketing activities begin. Prospective customers include new prospects and existing customers whose policies are approaching renewal dates. Generally marketing people are given privilege to create only very straightforward quotes. Through a few iterations customers see some generic rate sheets (like Copay sheets. reduced rates due to prior history of low number of claims and so on. Marketing personnel are broadly of two types . For most special rates they need to fall back for on another user group called Underwriters.00a Page 55 of 150 .doc Ver 0. Initially representatives approach prospective customers. requirement of extended coverage. Customers give their details and preferences. copay & coinsurance) of the chosen plan(s). 65736839. while some others can be used by marketing assistants also but need a validation / approval from Underwriters.Representatives who interact with customers and Assistants who have some (generally limited) access to applications generating quotes. The assistants first pull out the book rates. Figure 1: Workflow for Quote Creation Once set up is complete. product comparison reports etc) which give them a rough idea of the costs of the short listed plans. and narrow their selection to a few plans. Some special rates can be used only by underwriters. in order to let the customers know of the exact price (premium.

doc Ver 0.00a Page 56 of 150 .7). If rates are acceptable to the customer group they sign on the quote sheet. Once they approve the quotes the marketing people present them to the customers. (We will discuss activities of underwriters and special rates in detail in section 5. Fig2 below is a pictorial depiction of this workflow: Fig 2 To support these various activities a health insurance company typically has a suite of applications as shown in fig 2: 65736839.Sales ___________________________________________________________________ Underwriters have the final say on the rates. thus entering into a legally binding contract and members are enrolled for the accepted policy. They can make adjustments according to their discretion.

0 Here we see that central to the system are the Admin and the Rating Applications.Intranet for use of all internal users and Internet for use by customers to get data online. Exercises: 1.Sales ___________________________________________________________________ Marketing assistants Fig 3.doc Ver 0. Group-specific 65736839. The final say on the rates is with (a) marketing people (b)actuaries (c) underwriters (d)underwriters 3. Answers: 1. 3. The difference between Book Rate and final rate would be due to ______________factors. Renewal Applications pick up contracts that will be shortly due for renewal. Quoting Engines and Renewal Applications use the data generated by these applications.same 4. If two customer-groups in the same service area are buying the same policy at the same time would necessarily have ______________(same /different) Book Rates.2. Enveloping all these there may or may not be a Quote front end . 4. managerial and underwriter users to the suitable application. Underwriters and Marketing assistants use both of these. Admin applications are used by Admin Users for Product Setup. An optional layer above these would be a web-based front end . Actuaries to calculate the Base Rates of Products use rating applications. Product Setup is done by (a) admin users (b)marketing people (c)actuaries 2.which would act as a single interface or gateway for all marketing. Quoting Engines generate quotes with customer specific rates. and are also used for renewing contracts. a .00a Page 57 of 150 .c .

than Y days down the line. some show a long term trend III. the time between the occurrence of the illness and filing of claims. 65736839.5 Actuaries The role of the Actuary is said to be that of the designer. Total Claims . This is also called the pure insurance cost for a unit of coverage for each benefit or the PMPM (per member per month) for the benefit.g. from time to time. Actuarial conservatism means the use of any actuarial technique (usually but not always the choice of one or more assumptions) that leads to a higher price for a set of benefits.measures length of time that some well-defined status exists e. Some of the factors that are considered for this calculation are:       Statutes and regulations: state and federal laws mandate certain coverage in certain areas. the innovator.some coverages show a seasonal variation. the risk estimator. if Copay for a specialist consultation increases a member may go in for specialist consultation less frequently. Risks: the risks associated with providing the benefit. So. to provide that benefit to one member in a certain period of time. Actuaries apply i) Cost and utilization factor: This estimates how a change in the price of a benefit affects the members’ usage of that benefit and in turn the company’s income e. In the field of health insurance actuaries use statistical methods and some judgment to arrive at Book Rates for plans and the values for group-specific factors. by degree of security risk.The total dollar amount of claims arising from a particular block over a particular time period Rate of interest: (or more generally.Sales ___________________________________________________________________ 5. Actuaries first estimate the cost the insurer has to incur in terms of payments towards doctors / hospitals/ equipment etc. prices etc. in order to calculate Book Rates. the probability of occurrence of each risk and the severity of the impact of the risk Time value of money: this variable is based on the concept that X amount of money can yield more value today. the problem solver. Further. Time until termination . But too much of conservatism would make prices uncompetitive. Each plan is a collection of benefits.g. Examples of random variables: I. On this. the estimated duration of hospitalization for a particular coverage. the adapter. The PMPMs of all the benefits in a plan are added to get the PMPM of the entire plan. Assumptions. then this future income can be brought into the present e. In all these the actuaries must exercise utmost caution and judgment. Sometimes adjustments also need to be made in view of unusual circumstances.number of claims arising from a specified block within any given time . This is where the judgment factor comes in.doc Ver 0. if income is expected to increase in future. from place to place. Evaluation of benefits and estimation of costs is done along these lines. conservatism & adjustments: last but not least. when one takes a mortgage.g. the rate of investment return). and the technician of the continually changing field of financial security systems. the time between filing of a claim and the actual settlement etc. and by time to maturity and thus affect any financial assessment. Interest rates vary in many dimensions. a high percentage of all actuarial calculations is based on one or more assumptions. II. or a higher value of a liability.00a Page 58 of 150 . Conservatism would lead to higher prices. taxation laws. Number of claims . Random variables: actuaries use statistics and probability to estimate what they call "the certainty of uncertainty".

Retention factor. PMPM of a plan is the same as Book Rate. couple. Accordingly underwriters apply factors specific to the industry to adjust the rates. Class Rate/ Tabular Rate: Sometimes firms requests and sometimes state regulations mandate that the demographic composition of the group needs to be considered. Prior experience: Underwriters need to analyze the customer-group’s prior history of claims. Here each member pays more accurately for the risk he/she adds. (True/ False) Answers 1. For estimating the values of group specific factors also they use similar considerations. Exercises Q1. (True/ False) Q2. PMPM of a plan identifies the income of the company per member per month for that plan. and suitable factors are applied to account for these. This would affect the probable usage of relevant benefits. while the latter may be more prone to a heart attack. If number of claims for a plan is low.  Mutualized : Some customer groups may have outlets/ offices in various locations across the country. For example people working in S/w industry are likely to go for routine eye check-ups more frequently. Q2. false 2. Their main function is to approve/ validate the group specific factors added to Book Rates by marketing people and apply mark-up or discount based on their judgement. The probable frequency of members availing this benefit varies accordingly. E. Profits are included in the rates by applying _______________ factor. they have the final say on the rates.Normal profits are hereby built into the rates Thus the actuaries arrive at the Book Rates or the Community Rates for the plans. an unmarried males in age group 20-30 would be assumed to be more prone to accidents than a married male in age group 40-50.false Underwriters form a very important user group in any insurance industry. Tabular Rating is a rating methodology wherein multiple tier rates are exploded into age/gender bands. Class rating is a rating methodology where rates are banded into tiers (single. Some group specific factors that underwriters need to consider are:  Industry factor: Some industries expose employees to or protect them from some job specific risks. parent child and family) and members pay according to the kind of coverage they want.doc Ver 0. Thus. thus generating a table or matrix. Retention 5.6 Underwriters 3. Rates need to be raised or lowered accordingly. Depending on the geographical factors and state regulations even the 65736839.Sales ___________________________________________________________________ ii) iii) Trend factor: This takes care of market trends and possible changes in rates over subsequent quarters.g. they get a discount and vice versa. Sometimes underwriters have exclusive access to some special factors.00a Page 59 of 150 .    Dependant age: A firm may want employees’ dependents to be covered to a higher / lower age than the default coverage.

what age group of prospect should be targeted for a particular product. Depending upon the strategy. Underwriters cannot exercise any discretionary power.  Misquote: In case of repeat business underwriters need to analyze in retrospect whether some erroneous rates had been quoted in the previous cycle. or it may have to pay excessive claims if the underwriting actions are too liberal. should phone follow-up be done after sending mails etc. The sales manager decides the strategy for marketing like which service areas should be targeted. some expected change in the customer group’s business and so on. This calls for extreme caution and accurate estimation skills. underwriters need to identify and calculate the risk of loss from policyholders. dime or quarter. and accordingly adjust the final rates in the current cycle. recommend acceptance or denial of the risk. Exercises 1. (True/ False) Underwriters should always estimate risks very conservatively for the company to profit ( True/Fasle) While determining final rates for a cycle. some national calamity. c) Mailing – Sending product information to prospects through postal mails. sudden spread of a disease. b) Telemarketing – Calling up prospective customers and giving them information about the products. uniform rate across the organization. This can make much difference when a large number of members are involved. The group underwriter also needs to analyze the overall composition of the group to assure that the total risk is not excessive. Unusual: Underwriters need to consider various unusual factors to adjust final rates. target prospects are picked up from the database.00a Page 60 of 150 . 65736839. underwriters should take into account previous dealings with the same customer group. (True/ False) 3. 2. Underwriter Judgement: Underwriters reserve rights to adjust rates based on their discretion. Their judgement must be shrewd because an insurance company may lose business to competitors if the underwriters appraise risks too conservatively. 3. These may be as varied as unforeseen fluctuations in the economy.doc Ver 0. establish appropriate premium rates and write policies those cover these risks.    To sum up. In such cases the group may request a blended. Rounding: Underwriters may decide to round off rates to penny. false 5. how many prospects should be targeted in various region. true Answers: 1. Undewriters need to take care of this.7 Insurance Payer’s Sales Department The marketing of a healthcare product is done predominantly in three ways: a) Advertising – Putting up advertisements in various media.Sales ___________________________________________________________________ book rates could vary from place to place. false 2.

3. b) Vendors who supply data of all the deaths in a given service area.1 External Agents that deal with Sales Department of Insurance Payers External agents that deal with sales department of Insurance Payers are : a) Vendors who supply data of new prospects. False 2. To ensure if the mails are delivered. Code1 plus software validates addresses.doc Ver 0. c) Vendors who supply data of prospects who do not want telemarketing ie they do not want to be called and informed about new products. It also helps to ensure that same set of prospects are not getting selected for marketing too often. Postal mails sent by sales department fall in three categories: a) Regional mailing: Mailing is restricted to selected regions or states. Responders expire from the database after one year. b) Meeting mailing: Informing the new prospects about seminars or meetings conducted by Aetna and requesting them to attend the same. new prospects with phone numbers are loaded to the Dialers. True 4. Telemarketing department gets new prospective customers by calling people. 2. 4. it’s a fair assumption that all the prospects addressed in that batch of mails must have received the mails too. seeds are implanted in each batch of mails dispatched. Exercises True or False 1. • • • The various ways of obtaining the information about new prospects are External vendors Telemarketing Responders External vendors supply the list of new prospects every year. False 5. History of mailing is maintained for each prospect and each product to ensure that one product is not marketed to the same prospect twice. Meeting mailing informs prospects about meetings and seminars. Tele marketing department retrieves the names from Dialer box for phone follow-ups.7. These names stay on the database for one year from the date the names were received from the vendor. US Postal Department gives discount on CASS certified mails. Marketing by mailing involves sending e-mails to prospects. True 3. These prospective customers are entered into the database by Tel Marketing department. Answers : 1. Seeds are sales department employees and if the mail reaches the seed. d) Vendors who maintain latest information like addresses of all prospects and update our data files by matching it with theirs. who voluntarily contact healthcare company to get information on it’s products. c) Member mailing: Involves mailing to existing customers of Aetna.00a Page 61 of 150 . After sending mails. Their expiry date is one year from the date on which it was entered. Responders are customers.Sales ___________________________________________________________________ The mails to prospects are processed through Code1 Plus software which validates addresses and gives CASS certification. 65736839. Mailstream system is used to pre-sort the mails to obtain further discounts from postal department. The responders names do not expire from database.

Sales ___________________________________________________________________

5.8 1. 2. 3. 4. 5. 6. 7.

Review Questions Summarize the workflow involved in quote creation. Summarize the build up of the final rates in a quote(pmpm-book rate-final rate) How do actuaries arrive at Book Rates for a plan? Summarize some group-specific factors underwriters consider during quote creation. Define prospects. Who are responders? What is CASS certification? What is the role of external agents in sales department?

8.

65736839.doc

Ver 0.00a

Page 62 of 150

Sales ___________________________________________________________________

65736839.doc

Ver 0.00a

Page 63 of 150

Benefits ___________________________________________________________________
UNIT - VI

6

Benefits

6.1

Unit Objectives

This unit will acquaint the reader with different types of healthcare plans and the benefits they offer. 6.2 Introduction

Healthcare is very expensive in the U.S.A and it is essential for people to have some kind of health insurance. Insurance is available from various organizations in various forms. Each insurance company has its own, customized way of providing insurance, called a ‘Plan’. Plans can be broadly classified as – 1. 2. 3. 6.3 Indemnity plans also known as ‘Fee-For-Service’ plans. Managed Care plans. Other Plans. Indemnity Plans

Indemnity plans are the traditional fee-for-service kind of plans. The member is eligible to visit any provider of his choice. He has to pay the provider for services availed and then file a claim for reimbursement of the same. The amount of reimbursement will depend on whether, or not, the member has satisfied his deductible. In case the deductible has been satisfied the insurance company will pay its share. In case the deductible has not been satisfied, the reimbursement amount will be lesser. Advantages  Members do not have to choose a ‘Primary Care Physician’ (PCP, as he is known, is an entity associated with managed care plans, and will be explained later in the unit). No need of a referral (prior permission from the insurance company) to visit a specialist doctor. In case of managed care plans (as will be explained later in the unit) members are required to choose a provider from a network (or a group) to get higher level of benefits. In case of Indemnity plans, there is no concept of network and members can avail the services of any provider. Thus, Indemnity plans offer maximum freedom of choice to a member in choosing a healthcare provider. This is the primary reason why people may prefer to be in an Indemnity plan.

Disadvantages    Members have to pay high premiums. Members need to meet a deductible before they can start claiming benefits. Preventive care is not covered. This means that for a routine check-up, the member cannot file a claim.

65736839.doc

Ver 0.00a

Page 64 of 150

as explained earlier.   For the entire family to be covered. Indemnity insurance is not a good option.this means that. But.Above this. Managed care plans originated in the early 1970s. this freedom comes at a very high cost.4 Indemnity plans. i. Managed Care Plans   6. 65736839. which the member may have to pay is $1000.00a Page 65 of 150 . The insurer will reimburse only 80% of the costs.00 80% if true emergency. the maximum amount. Reduced benefits if not a true emergency 80%/20% 80%/20% No coverage 80% The member has to pay a deductible of $200 every year before he can start Table 1: A sample Indemnity plan claiming the benefits. insurer will provide 100% reimbursement of costs. rest the member will have to pay out of his pocket.Benefits ___________________________________________________________________  Filing of claims is the responsibility of the member.e. Members have to pay heavy premiums and need to meet deductibles before they can start claiming benefits. There is no coverage for any preventive care. a routine checkup is not covered. The coinsurance limit is $1000. which are more cost effective. this amount is $600. They prefer to use managed care plans. A typical Indemnity plan will look like this - Plan Feature Calendar Year Deductible Family Limit Deductible Co-payment Coinsurance Coinsurance Limit Emergency Room Hospital Physicians Preventive care Other Covered Expenses  Benefit $200 3 * Deductible None 80%/20% $ 1000.doc Ver 0. For people who cannot afford to spend large amounts on their healthcare. It involves a lot of paperwork and is time consuming. provide great flexibility to members in choosing a provider.

there is a group of providers contracted by the insurer who form a network. Members are required to choose a contracted doctor as their Primary Care Physician. regardless of how much medical care is needed in a given month. a HMO contracts with individual doctors who have a private practice of their own. Hence. HMOs provide medical treatment on a prepaid basis. which means that HMO members pay a fixed monthly fee. While. In return for this fee. A member has to choose any one of the doctors in this network as his PCP. Members do not have a choice in deciding which doctor they want to get treatment from. in 1973 the US congress passed the ‘Health Maintenance Act’ and set standards for the industry. Members of a HMO receive benefits by utilizing the insurer's HMO network.  Each provider is a given a fixed monthly fee according to the number of patients on his schedule.1 Health Maintenance Organization (HMO) A HMO is a managed care organization. They involve an agreement between an insurance company and a group of providers (also known as network of providers). This paved the way for the formation of ‘Managed Care Organizations’ (MCO). doctors. the doctors are employees of the HMO itself and the HMO can be seen as a central medical facility.Benefits ___________________________________________________________________ In 1970s healthcare costs had sky rocketed. to make insurance more affordable to the common people. a “PCP”. Without this permission the member is not eligible to receive any benefits. he would still receive his full monthly fee). The PCP will take care of all needs of the member. the insurer tries to increase their patient volume by offering greater benefits to its members when they use this network.00a Page 66 of 150 . the PCP will refer the members to a specialist. as 65736839. Members are also required to get permission (called a referral) from the insurer before availing services of outof-network providers. Thus. Individual Practice Association (IPA): In this form. even if not a single member went to this provider. MCOs’ are a collection of interdependent systems (the insurance company. He refers members to a specialist for medical care when necessary. This network consists of contracted doctors and hospitals that provide treatment to members of the insurer's HMO plans. from office visits to hospitalization and surgery. This fee paid is also called the ‘Capitation Fee’ and hence the plan is sometimes known as a ‘Capitated Plan’. For services outside the scope of his expertise.doc Ver 0. the “PCP” The PCP takes care of the member’s medical needs that fall under his expertise. pharmacies. There are two types of HMOs  Staff Model HMO: In this form of HMO. This fee is not related to the number of patients actually serviced (this means. most HMOs provide a wide variety of medical services. or under the direction of. All the care they receive is provided by. members are not eligible to claim benefits for services availed from a specialist doctor. Without the PCP’s referral.4. These providers agree to provide basic healthcare services to members of the insurer’s plans. To recap. hospitals) that integrate the financing and delivery of health care services. Following are the common managed care options: 6. insurance companies are able to provide coverage at reduced levels of cost. right from providing treatment to filing claims on his behalf. by increasing the patient volumes and regulating the use of providers.

HMO members pay a fixed monthly fee. HMOs encourage members to seek medical treatment early. The PCP provides general medical care and must be consulted before members seek care from another physician or specialist. Additionally. members are responsible for paying a percentage of the bill every time they receive medical care. This screening process helps to reduce costs both for the HMO and the members. Members cannot use services of any out-of–network provider (i. Advantages  With most types of insurance (other than HMO). the focus is on wellness and preventative care.The HMO will continue to cover his treatment as long as he is a member. In contrast. HMOs generally do not place a limit on the member’s lifetime benefits (i.doc Ver 0. many HMOs offer health education classes and discounted health club memberships. The HMO will not pay for non-emergency care provided by a non-HMO provider. there may be a strict definition of what constitutes an emergency.  A typical HMO plan will look like this - Plan Feature Calendar Year Deductible Family Limit Deductible Co-payment Coinsurance Coinsurance Limit Emergency Room Hospital Benefit None None $10.e.e. but it can also lead to complications if the PCP doesn't provide the referral needed by the member i. Instead of deductibles. a provider not contracted by the insurer) without prior permission of the insurer.e. HMO members are required to obtain all treatment from HMO providers. regardless of how much medical care is needed in a given month. HMOs often have nominal copayments.00 100% None $35. Additionally. before health problems become severe.00a Page 67 of 150 .Benefits ___________________________________________________________________ the PCP and the insurer manage their complete healthcare. the total amount of money he can claim during his lifetime) .00 copay 100 % 65736839. Except for emergencies occurring outside the HMO's treatment area. tight controls can make it more difficult to get specialized care. Besides reducing out-of-pocket costs and paperwork.   Disadvantages:  An HMO member must choose a primary care physician (PCP). This leads to ‘Low out of pocket costs’. Hence. Additionally. there may be a deductible that must be met before the insurer starts picking up the tab.

In order to avoid 65736839. the sponsor(s) attempts to increase patient volume by creating an incentive for employees or policyholders to use the physicians and facilities within the PPO network. For example. The PPO may be sponsored by a particular insurance company. A PPO is actually a group of doctors and/or hospitals that provide medical services only to a specific group or association. the insurance company will pay 100% of the providers charges  If compared with the Indemnity plan provided in the earlier section. PPO members usually pay for services as they are rendered. which are at the lower level of benefit coverage. When a member receives care from a participating provider they receive benefits. The PPO sponsor (employer or insurance company) generally reimburses the member for the cost of the treatment minus any co-payment. In case he has to use the emergency room facilities. the provider may submit the bill directly to the insurance company for payment. When members receive care from a non-participating provider they receive benefits. 6. known as ‘Non-Preferred Benefits’. there is a strong financial incentive to do so.  Every time he avails the service of a provider he has to pay $10 irrespective of the kind of services availed.00 copay 100%  For all kinds of treatment. However. usually 100% payment rate.  copay. The insurer then pays the covered amount directly to the healthcare provider. The healthcare providers and the PPO sponsor(s) negotiate the price for each type of service in advance. a preferred provider organization (PPO) is a managed healthcare system. members may receive 90% reimbursement for care obtained from innetwork physicians but only 60% for out-of-network treatment. known as ‘Preferred Benefits’. it becomes clear that the cost for the member is much less. Advantages  Free choice of healthcare provider. usually 80% payment rate.2 Preferred Provider Organization (PPO) Like an HMO. and the member pays his or her co-payment amount. as PPO members are not required to seek care from PPO physicians. by one or more employers. In return.00 copay $10.Benefits ___________________________________________________________________ Physicians Preventive care Other Covered Expenses Table 2: A sample HMO plan  A member who enrolls under this plan does not have any deductible to meet before he can claim benefits. which are at the higher level of benefit coverage.00a Page 68 of 150 . he will have to pay $35 as $10. or by some other type of organization.doc Ver 0. In some cases.4. However. PPO physicians provide medical services at discounted rates and may set up utilization control programs to help reduce the cost of medical care. there are several important differences between HMOs and PPOs.

The plan can be visualized as having 2 sides.doc Ver 0.4.00 80%/20% Same as preferred if true emergency.00 100% 100% Non-preferred Benefit $200. the POS plan mirrors an HMO. One side is for in-network services and the other side is for out-of-network services. The benefits are reduced in case of non-preferred option. For example.00 $200. A PPO member has to file claims on his own.  6. 80% / 20% 80% / 20% Preferred option closely mirrors the HMO option while the non-preferred option approaches the Indemnity option. but it will cost more.00 3x deductible None 80% / 20% $1000. Like an HMO. Disadvantages  As mentioned previously. and members may be required to meet a deductible. he may choose to continue seeing him. When a member uses the in-network benefits.00a Page 69 of 150 . Thus. the member pays no deductible and usually only a minimal co-payment when he uses an in- 65736839. there is a strong financial incentive to use PPO network physicians. if a member’s longtime family doctor is outside of the PPO network. else none. most PPOs have larger copayment amounts than HMOs. most PPO members choose to receive their healthcare within the PPO network. the expenses and paperwork are higher as compared to HMOs. Additionally.  A typical PPO plan will look like this – Plan Feature Calendar Year Deductible Per Confinement deductible Family Limit Deductible Copay Coinsurance Coinsurance Limit Physicians Emergency room Hospital Other Covered Services Table 3: A sample PPO plan  Preferred Benefit None None None $10.Benefits ___________________________________________________________________ paying an additional 30% out of their own pockets. Hence.00 copay $25.3 Point Of Service (POS) POS plans give two benefit levels. members may receive 90% reimbursement for care obtained from in-network providers but only 60% for treatment provided by out-of-network providers.00 office visit 100% None 100% after $10.

else none.   Disadvantages  There are substantial co-payments and deductibles for out-of-network care. The member will likely be subject to a deductible and co-payment. Like a PPO. while there is no PCP for out-ofnetwork services.  A typical POS plan will look like this – Plan Feature Calendar Year Deductible Per Confinement Deductible Family Limit Deductible Copay Coinsurance Coinsurance Limit Physicians Emergency room Hospital Other Covered Services Table 4: A sample POS plan In-Network None None None $10. he also must choose a primary care physician who is responsible for all referrals within the POS network. Unlike HMO coverage. POS plan encourages members to use innetwork providers but does not make it mandatory. he can mix the types of care he receives. In most cases.00 80%/20% Same as preferred if true emergency. When he uses the out-of-network benefits. As in an HMO. members always retain the right to seek care outside the network at a lower level of coverage. Usually.00 $200. co-payment is around $10 per treatment or office visit. the POS plan is an indemnity plan. while the member himself receives his healthcare from in-network providers.00a Page 70 of 150 .00 copay $25.Benefits ___________________________________________________________________ network healthcare provider.00 3x deductible None 80% / 20% $1000. For example. members must choose a primary care physician (PCP) and hence there is a tight control to get specialized care within the network. As with HMO coverage. members must have paid a specified deductible before coverage begins on out-of-network care. But.doc Ver 0. the member’s child could continue to see his pediatrician who is not in the network.00 100% None 100% after $10. No deductible is required for in-network services. as with HMO coverage. members pay only a nominal amount for in-network care. Advantages  POS coverage allows a member to increase his freedom of choice. 80% / 20% 80% / 20% 65736839.00 100% 100% Out-of-network $200.

there is no such thing as ‘the best plan’. EPO Plans—a hybrid of POS plans were developed. The choice of providers is greater than the typical HMO. Indemnity plans. in general. and the price is somewhat higher. also. This provides members with the ease and low cost of the HMO. These plans offer members great flexibility at the lowest price by combining various plans. The variation in the various plans can be understood more effectively by referring to the following table. Indemnity plans with more out-of-pocket charges (in the form of deductibles and co-payments) often limit the maximum amount of benefits that members may receive over their lifetime. some insurers will offer an EPO/HMO plan. 65736839. the PPO plan gives more flexibility for choice of provider. Exclusive Provider Organization (EPO)  6.5 Which plan is the best? The first thing to note is that. In contrast. Disadvantages  Members need to choose from the HMO and EPO networks. For example. which can be customized according to the members needs.4 In order to fulfill the diverse needs of participants. give more freedom than managed care plans in terms of using the healthcare provider of choice. Here.00a Page 71 of 150 .Benefits ___________________________________________________________________  The POS plan is very similar to a PPO plan. 6. A PPO may also make an EPO option available to members. providers. however. The major difference between them is in the in-network option. as compared to the POS plan. as there are no deductibles and very less copays. All the plans outlined till now are generic plans. while providing them with the option to make appointments directly with a larger group of providers (instead of just their primary care provider). However.doc Ver 0. and employers.4. with maximum benefits within network and reduced benefits out-of-network. managed care plans are better suited for the average individual because they end up being more cost effective in the long run. Advantages  Limited out-of-pocket expenses. this leads to less flexibility in choice of provider.

doc Ver 0. PPO plan members do not have to choose a PCP (Y/N). 2.5. Plot a graph of ‘cost to member’ (x axis) versus ‘freedom of choice’ (y axis) and place the various plans on it. Considering the cost for a member. 2.Benefits ___________________________________________________________________ Constraint PCP Deductible Indemnity Not required Required HMO Required Not required PPO Not required (In-network) not required (Out-of-network) required POS Required Same PPO as EPO Required Not required Out Of Network Coverage Referral for specialist visit Cost (1-5) 5 is max Freedom (15) 5 is max. 1. 5. On the other hand. Available Not available Required Available Available Not available Required Not required Not required Required 5 5 1 1 4 4 3 3 2 2 Table 5: Comparison of various plans So. If the goal is to minimize costs. 65736839. he is probably better off with a managed care plan. indemnity plans should be preferred. Answers Indemnity HMO N Y Indemnity Freedom EPO HMO PPO POS 1. the choice ultimately depends on the member’s personal circumstances and preferences. 3. if his goal is maximum flexibility and cost is not a major factor. 4. 6.1 Exercise Plan offers the maximum freedom of choice for a member. which plan is most effective? POS plans do not offer out-of-network coverage (Y/N). 5.00a Page 72 of 150 . 3. 4.

The basic difference between a Medical and Dental disease is that a medical disease can be unpredictable and catastrophic while most dental diseases are preventable. With some employer-sponsored vision plans.Benefits ___________________________________________________________________ Cost Figure 3: Variation of Freedom with Cost 6. Reasonable and customary charges generally don't include the cost of glasses and contact lenses.2 Dental Plans Dental insurance provides coverage for services relating to the care and treatment of teeth and gums. and then file a claim for reimbursement. It typically covers services delivered by an optometrist or ophthalmologist. It depends on the specific plan.1 Vision Plans Vision insurance provides coverage for services relating to the care and treatment of eyes. coverage may be even more narrowly limited to the medical treatment of certain eye conditions Vision care insurance may provide direct payment to the eye care provider for the services. while others may limit coverage to reasonable and customary charges incurred during routine eye exams. Regular dental checkups and cleaning will be sufficient to maintain dental health. 6. Or the member may be required to cover the charges out-of-pocket at the time of service. some or all of the following services may be covered:     Yearly eye exams Glasses (with an annual limit) Contact lenses and fitting (with an annual limit) Glaucoma screening Some vision plans may provide more extensive coverage (such as certain eye surgeries).6.6 Other Plans In addition to the common Indemnity and Managed care plans listed above. Dental plans are of three types based on the mode of treatment and payment. The regular dental visits allow problems to be diagnosed early and corrected without involved diagnostic testing or treatment.6. Most of these plans in some or other will belong to the two main categories listed above. The plans discussed till now were medical plans and did not cover:        Work related injuries Treatment provided by relatives Cosmetic surgery Government health services Vision benefits Dental benefits Over the counter medicines and non-prescription drugs To cover these. insurers provide the following plans: 6.doc Ver 0. Depending on the specific plan. 65736839. insurers offer a wide variety of specific plans. This keeps the cost of dental care much lower than medical care.00a Page 73 of 150 .

the employer reimburses the employee a fixed percentage of the dental care costs. Two tier plans  Lower copay for Generic drugs  Higher copay for Branded drugs 65736839. in conjunction with the dentist. Single tier plans  Fixed copay for all types of drugs mentioned in the plan. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules. rather than paying premiums to an insurance company. but often places no limit on services provided. The typical three tiers of a pharmacy plans are 1. patient copays may be required for each visit. which offers drugs to plan holders at reduced rates. A monthly premium is paid by the member.00a Page 74 of 150 . an employer or company sponsor pays for dental care with its own funds. Participating dentists receive a fixed monthly fee based on the number of patients assigned to the office. Insurance companies usually pay between 50 percent and 80 percent of the dentist's fee for covered services. The member pays the dentist directly and. but some have as many as seven. drugs with same chemical  Most health plans have three or four pharmacy benefit tiers. The plan may limit the amount of dollars a member can spend on dental care within a given year. Non-Formulary drugs . They usually involve a ‘Managed Pharmacy Benefit Network’ (network of pharmacists which contracts with the Insurer). the member pays the remaining. can play an active role in planning a treatment that is most appropriate and affordable. The dentist is paid on a per capita (per head) basis rather than for actual treatment provided. In addition to premiums. Members can select a dentist of their choice and.6. A Dental Health Maintenance Organization (DHMO similar to a medical HMO) is a common example of a capitation plan.3 Pharmacy plans enable the members to buy prescription drugs from participating or nonparticipating pharmacists at lower rates against a premium amount paid for the Plans. once furnished with a receipt showing payment and services received. Pharmacy Plans    6.Benefits ___________________________________________________________________ Indemnity Plans: This type of plan pays the dentist on a traditional fee-for-service basis. 2. Capitation Plans: This type of plan provides comprehensive dental care to enrolled patients through designated provider dentists. while generic medications are in the lower tier and are least expensive .doc Ver 0.which are Non-patented compositions and are relatively cheaper. Direct Reimbursement Plans: Under this self-funded plan. Brand-name drugs that are usually in the top tier are most expensive. which directly reimburses the dentist for the services provided.The types of drugs can be classified as   Branded drugs – which are patented drugs (10 yrs patent) and hence costly.which are the cheapest. Most pharmacy plans that pay for prescription drug benefits have benefit tiers that group certain medications together for pricing purposes. Generic Drugs .

Part A also covers hospice care and home health care. people may be eligible if they are disabled or have endstage terminal disease. the costs associated with an overnight stay in a hospital. Members may purchase a supplemental medical insurance policy called Medigap. Only ten standardized plans can be offered as Medigap plans.5 Medigap Medicare does not cover all health-care costs during retirement. Medigap policies pay most. and nursing service s). Medicare coinsurance amounts. regardless of their medical condition. A third part. They are in addition to the fee-for-service options available under Medicare Parts A and B. such as charges for the hospital room. All ten must cover certain services. and private fee-forservice plans. Medicare Part C (Medicare+Choice) is a program that allows members to choose from several types of health-care plans:  Part A covers services associated with inpatient hospital care (i. However.6. has overall responsibility for administering the Medicare program. and ambulance service.Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). a division of the U.e. Medigap is specifically designed to fill some of the gaps in Medicare coverage. or as an outpatient at a hospital or other health-care facility. Three tier plans  Lowest copay for Generic drugs  Medium copay for branded drugs  Highest copay for Non formulary drugs 6. or psychiatric hospital.  Part B covers other medical care. Physician care. whether it was received while member was an inpatient at a hospital. Most people become eligible for Medicare upon reaching age 65.S. the HCFA sets standards and policies.00a Page 75 of 150 . 6. Department of Health and Human Services. The Health Care Financing Administration (HCFA).4 Medicare Plans Medicare is a government-sponsored program that provides health insurance to retired individuals. physical therapy or rehabilitation services. they are standardized and regulated by federal and state law.doc Ver 0. Medicare coverage consists of two main parts .6.  Part C expands the kinds of private health-care plans that may offer Medicare benefits to include managed care plans. Although the Social Security Administration processes Medicare applications and claims. medical savings accounts. In addition. skilled nursing facility. There is no variation in the types of medigap policies provided by various insurance companies.Benefits ___________________________________________________________________ 3. Some also provide coverage for deductibles and services that are not covered by Medicare such as prescription drugs and preventive care. Medigap policies are sold through private insurance companies. if not all. at a doctor's office.. Also covered are laboratory tests. meals. 65736839.

services for the mentally retarded in intermediate care facilities. Some policies include special features like:    Key-person insurance to protect a firm against the loss of income resulting from the disability of a key employee. and long-term nursing home care. Within these guidelines. The treatments covered by long term care insurance usually include four general types of care: in home care. medical transportation.doc Ver 0. (3) chooses the rate of reimbursement for services. As with other insurance policies.6. However the maximum lifetime limit of benefits is high enough to cover the cost of catastrophic illness. Long-term care. 6. occupational therapy.6. The funds paid are not specified for medical expenses .8 Disability Income Insurance Disability income insurance provides members with an income if they become sick or injured and are unable to work. prescribed drugs. Some of the most frequently covered optional services are clinic services.Benefits ___________________________________________________________________ 6. which is usually very high. and speech therapy. as well as young and middle-aged people who have been injured or have suffered a debilitating illness. disabled.6 Medicaid Medicaid is a health insurance program for people with low income. members pay a set premium that offsets the risk of a much larger out-of-pocket expense. home health care. however. a disability buy-out policy disburses funds for one partner or business entity to buy a disabled partner's share of the company. each state (1) determines its own eligibility requirements. optometrist services and eyeglasses. dependent children) who cannot afford the necessary medical care. and types of services. Employers can provide coverage for employees too. offers the assistance people need if they have a chronic illness or disability that leaves them unable to care for themselves.they can be used in any way the member wishes them to use. and (4) oversees its own program. duration. prosthetic devices. It is a joint federalstate program to provide medical assistance to aged. States may elect to provide other services for which federal matching funds are available. Medicaid pays for a number of medical costs. (2) prescribes the amount.6. Recovery benefits that pay after members return to work full-time. They pay hospital and medical expenses above a certain deductible. 6. including hospital bills. 6. For jointly owned businesses. assisted living and nursing home living. adult day care.9 Catastrophic Coverage Plans Catastrophic coverage is not a separate entity by itself but forms a part of an existing plan.00a Page 76 of 150 . or blind individuals (or to needy. This may be used to help the aged.7 Long Term Care Most of plans discussed till now are the kind. physician services. 65736839. Each state administers its own Medicaid programs based on broad federal guidelines and regulations. and are reestablishing a customer or client base.6. which pay for hospital bills and doctor visits. Most of the plans seen till now can be customized to include coverage for catastrophic illnesses.

such as average age and degree of occupational hazard. the only real disadvantage of group insurance is limited or no freedom to customize the policy to member’s individual needs.00a Page 77 of 150 . Individual health insurance is a type of policy that covers the medical expenses of only one person. Medigap 4. because group insurance allows the insurer to spread the risk over a larger number of people. Individual insurance is somewhat more risky for insurers than group insurance. Answers 1. Unlike individual insurance.Benefits ___________________________________________________________________ The most common example is the Medicare plans which include a clause for catastrophic coverage.10 Exercise Pharmacy plans usually have tiers of benefits. they are evaluated in terms of how much risk they present to the insurance company. Y 7. Capitation 6. Employer-sponsored plans and associations are among the most common sources of group health insurance.7 Individual Insurance and Group Insurance. Unlike group insurance. Long Term care covers nursing home care? (Y/N) Who all are eligible for Medicaid benefits? 1. For this reason. 3 (hospital. all eligible people can be covered by a group policy regardless of age or physical condition. 6. 6. members purchase individual insurance directly from an insurance company. 4. 7. medical. 6.6. medicare+choice) 3. The policy is typically negotiated between the insurer and the "master" policy owner (employer or association) without any inputs from 65736839. Others include disability income insurance. In case of Dental insurance. Medicare has parts. The premium for group insurance is calculated based on characteristics of the group as a whole. In general. individual insurance is generally more difficult to obtain and more costly than group insurance. with the sponsoring employer or association paying all or part of the premium.doc Ver 0. This is generally done through a series of medical questions and/or a physical exam. When they apply for individual insurance. Because only one policy is issued for the entire group. 3 2. 8. Policy extends the Medicare policy by offering additional benefits. All people who cannot afford medical care. where each person's risk potential is evaluated and used to determine insurability. With group health insurance. 2. the initial cost of establishing group coverage is lower than the cost of issuing a separate policy to each person. 3. plans are similar to HMO plans The federal government regulates Medicare benefits? (Y/N). 5. Key person insurance 5. Y 8. Member’s risk potential will determine whether he qualifies for insurance and how much the insurance will cost. catastrophic PPO and catastrophic EPO coverage. Is used to protect a firm against the loss of income resulting from the disability of a key employee. a single policy covers the medical expenses of many different people (a group) instead of covering just one person.

A.  Require health insurance plans to provide inpatient coverage for a mother and newborn infant for at least 48 hours after a normal birth or 96 hours after a cesarean section. They could suffer a serious injury and become disabled.00a Page 78 of 150 . he can continue the coverage for 36 months.8. the Health Insurance Portability and Accountability Act (HIPAA) expanded on COBRA. The major provisions of HIPAA do the following:  Allow workers to move from one employer to another without fear of losing group health insurance.S. So the federal government has provided certain laws to help people cope with the situations mentioned above.  Increase the tax deductibility of medical insurance premiums for the selfemployed. These events can occur when least expected.8. 65736839. his dependents may be eligible for COBRA benefits if they are no longer entitled to employer-sponsored benefits due to divorce.2 Health Insurance Portability and Accountability Act (HIPAA) HIPAA is an extensive law that is intended to be the first major step toward healthcare reforms in the U. In 1996. However. The two most important of these are – 6. leaving them without health benefits. If a person is entitled to COBRA coverage for other qualifying reasons. As an employee.A count on their employer for health insurance coverage. A person can continue his health insurance for 18 months under COBRA. death.8 Laws and Legislations Most people in U. or in certain other situations. if his employment has been terminated or if his work hours have been reduced. as are the deductible amount and co-payment percentage. his employer is not required to pay any part of it. the person will have to pay the premium for COBRA coverage.1 Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) If a person and his dependents are covered by an employer-sponsored health insurance plan. The specific policy provisions are all determined in advance. In addition.doc Ver 0. 6.S. 6. he is entitled to COBRA coverage only if his employment has been terminated or downsized.Benefits ___________________________________________________________________ the member.  Require health insurance companies that serve small groups (2-50 employees) to accept every small employer that applies for coverage. But what will happen to their health insurance if they stop working or no longer qualify for benefits? Their company might begin downsizing. COBRA entitles him to continue coverage under circumstances that would otherwise cause him to lose this benefit. Most employers are required to offer COBRA coverage.

the other partner is no longer able to perform his duties. each partner can take out an insurance policy to cover the expenses.9 1.   Medicaid policy is the most expensive type of Indemnity plan. 6. in case. 4.com http://www. 3.  Coinsurance is the insurance provided by two insurance companies to one individual. http://www. 2. 6.yourhealthplans. “A to Z of Health Insurance” – By Prashant Burse. Long-term care is covered under Medicare.com 3. 4.doc Ver 0. 5.  Review Questions. 2.  In case of a joint business venture.00a Page 79 of 150 .Benefits ___________________________________________________________________ 6. 65736839. Abhishek Virginkar and Saurabh Kulkarni. “Managed Care – An Overview ” – By Amit Shukla. Copay is what the member pays to the insurance company for treatment. What is the difference between Managed care and Indemnity Plans? What are the various type of Managed care Plans? What is the main difference between POS and PPO plans? What are the various types of Dental and Vision Plans? In case of managed care plans.   Deductible is usually zero for most HMO plans.10 References 1.insurance. which plan is most cost effective and why? State whether true of false – Private insurance companies provide Medicare plans.

Benefits ___________________________________________________________________ 65736839.doc Ver 0.00a Page 80 of 150 .

7. are put in a ‘PEND’ status. Generally these visits by member are made to PCPs. as well as for catering to general claims enquiries. Receipts system performs basic edits on these claims and loads it to the Claims database. The HMO Reformat will be responsible for reading a CCFMQ record 65736839. If the primary physician deems fit he may refer the member to a specialist. All HMO electronic claims from the Envoy submitter will be directed to a system (pre-receipts) before sending them to core Receipts System. hospital or pharmacy to receive healthcare. to decide the payment to be made to providers or denials if any. Edits within the pre-receipts system are enhanced to include HMO claims.doc Ver 0. Complex or ambiguous claims. for a combination of fixed number of visits and fixed duration.1 Claim generation and submission to Providers Members enrolled in Insurance Company’s healthcare programs visit health services providers such as a primary physician. These claims are then adjudicated using Insurance Company’s business rules and policies. This pre-receipts system will identify each claim with a Universal Claim Key (UCK). This means that they get a fixed fee on a monthly or bi-monthly basis. Electronic forms are routed through a third party (Envoy). Paper claims are received on standard forms. The claims will be in a Common Claim Format (CCF) as opposed to the UB92 & NSF format that Receipts system used to receive. also claims with any missing information. Claims Online/Pend systems are used for this purpose. Claims that fail the edits are routed back to the provider for corrections. this process is known as HMO REFORMAT. This PCP files a claim with Insurance Company for non-capitated or specialist services he might have provided to the member.Claims ___________________________________________________________________ UNIT . validated for basic information necessary and then loaded into the Claims database. desired cheques are cut by AP (Accounts Payable). Each visit that a member makes to a provider is called an encounter. The Receipts system is required to receive a transaction in CCFMQ format. They do not bill Insurance Company for services provided. Manual intervention is required for further processing such claims. This specific combination depends on plan to which the member has subscribed. specialist. The referral acts as an authorization for the member to visit a specialist. A record of this referral is maintained in the system. The users have the ability to modify the claims online.1 Claims Intake Process Claims are received from health services providers either as paper documents or in electronic form. On completion of claims adjudication. The UCK is passed along with each transaction to the appropriate adjudication engine. The claims are received by the Integrated Receipt system. Feedback is sent to Claims system again which is used to store the completed claims history in Claims database/files. who are Primary Care Physicians and are Capitated Providers. They are scanned to capture image copies that are then translated to electronic form. The claim may be filed either on a standard paper form or electronically.VII 7 Claims 7.1.00a Page 81 of 150 .

The generation of a status response is required to be sent back to Pre-receipts system at this point. If a claim is split in the Conversion. subject to existing Receipts system edits. Encounter PROVIDER MEMBER EDI Claim 7. The modifications consist of inquiring on the UCK database table or file and generation of the event response for pre-Receipts system.1. claims will flow into the Generate Response process. When Hospital claims are processed Revenue codes are grouped and rolled and then translated into Benefit codes. This process will evaluate each edit flag. modifications are made to establish the UCK segment number. Users enter these claims online. The last process within the Receipt System is the Load to the HMO database. The newly reformatted claims will follow the existing Receipts system path for electronic claims. Some paper claims cannot be loaded into Receipt System usually due to non-standard formats. Due to limitations of the HMO Adjudication. The response for claims that have been rejected also represents a final response. At the completion of all Receipts system edits. These claim forms are captured on microfilm. in order to determine if a claim will be Accepted or Rejected. directly into the Claims Online Adjudication system. The Reformat will also be responsible for passing the UCK along to the HMO system on each transaction. claims that have more than a specific number of detail lines after the grouping and rollup logic will be split in segments consisting of that specific number of detail lines. The Load is responsible for passing the UCK to the HMO Adjudication system.Claims ___________________________________________________________________ as input and produce a UB92 Hospital transaction format or a NSF1500 Specialist transaction format as output.doc Check Information CLAIMS SYSTEM Ver 0. This response status serves as the initial response for all HMO claims. Each benefit code represents a detail line. Receipts system Conversion.2 ENVOY Claims Intake : DiagrammaticIKFI Paper Claim EDI Referral Prereceipts REFERRAL SYSTEM Receipts Verification 65736839. The Conversion process handles Hospital and Specialist claims differently.00a DENIALS Page 82 of 150 ACCOUNTS PAYABLE Check to Provider/ Member .

The provider information is validated. o Provider no is validated. o Determination of whether this claim is a fraudulent specific member claim. o Provider type is evaluated i. Determine if the claim is timely filed    65736839. DOS > suspense or term date).2 Claim Adjudication Process Claim adjudication is a process in which the actual data on the Claim is compared with the data in the system and based on the business rules or policies the payment of the Claim is decided. o Determination of whether member is suspended or terminated ( i.2.1  Claim Preparation and determining eligibility The member information is validated. o Provider name and address is validated. o Check is done for whether Provider is suspended.doc Ver 0.Claims ___________________________________________________________________ 7. o Provider Specialty is validated . o Par status of Provider is validated . o Date of Service of the Claim is compared with the current date.e if the provider is hospital type or a specialist etc.00a Page 83 of 150 . Determination of whether the claim is too old. The paid amount need not be equal to the billed amount Claim adjudication process can be divided into three processes as below which can be further subdivided 7.e.Capitation of the Provider is validated . o Member no is validated.

00a Page 84 of 150 .This process will dictate what component leg a claim is adjudicated against based on the following scenarios:  No accumulator is maxed out on either indemnity or hmo legs Result: Claim will process as normal  Accumulator maxed out on indemnity but not hmo leg Result: claim will be processed as hmo  Accumulator maxed out on hmo leg Result: claim will be processed as indemnity.Claims ___________________________________________________________________ o Date of service of the Claim is compared with the received date of the Claim. Product exception o In this. o Here a determination is made whether the member has to be directly reimbursed ( like in Indemnity Claims) or the provider ahs to be paid ( like an HMO plan). The difference of the dates is compared with the timely filing limits which is predecided based on different types of Provider. AND PRODUCT which for which the Claim has has been filed Benefit eligibility is checked o Here depending on the Provider type. etc it is determined if there is to the benefits payable for the product for which claim is filed. Provider no .  Provider network. Place of service and the benefit code of the claim . Group/plan eligibility is checked. diagnosis code. Group. it is determined if the member is eligible to receive the particular benefit for which claim has been filed.  Presence/Absence of referral. o Here the Date of service of the claim. if the claim has not been file within the proper timeframe it is denied .  Par status of provider.  Direct access ( i.member category etc . Place of Provider network. and presence of any rider .  Check for Product component eligibility  Here it is decided if the claim should be processed as in network or indemnity depending on  Product component of the Claim.  Claim emergency or non emergency. o Determination of whether the member is covered under the GROUP. depending on the member region. it is determined if the member is eligible for the benefit of the product under which the member is covered.doc Ver 0. Also a 65736839. PLAN.   Determination of whether this is a member reimbursement or provider is already reimbursed.e for which no authorization needed). any exception override is checked on various factors like service start and end dates .  Determination of whether the claim is duplicate ( by comparing with history).Place of service is checked with a history claim for determining duplicity.Area . procedure code . based service. proc code . member no . provider specialty .  Check stacked benefits o This involves checking of existing accumulators that are under the indemnity component and then under either the rider or base medical component. CONTRACT.types of benefits provided.    Product benefit eligibility is checked  Here.

Claims ___________________________________________________________________
this involves a check to see if provider has already been reimbursed for the services e.g – capitated providers  Verify Referral o Is member no on referral same as on claim ? o Is this Direct access referral ? o Is referral OON ? o Is referral denied ? o Validate provider no on referral and provider speciality. o Validate referral dates o Validate referral visit o Validate referral diagnosis o Validate referral procedure Verify precertification : Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures, and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or member. It also allows the health care service company to coordinate the patient’s transition from the inpatient setting to the next level of care (discharge planning), or to register patients for specialized programs like disease management, case management, or our prenatal program. A pre-cert penalty will be applied to the claim when: o The claim is non-referred, and o The service requires pre-certification, and o A "PS" pre-cert referral or authorization is not found All three conditions must be met before the pre-cert penalty can be charged. This applies to both par and non-par providers. The percentage pre-cert penalty is assessed on the payable benefit, after any deductible and co-insurance have been taken. Pre system is not applied generally for the following types of services: o Cardiac Rehab o Chemotherapy o Radiation Therapy o Respiratory Therapy Who precertifies medical services? o admitting physicians o primary care physicians (PCP) o specialists o hospitals o Members on plans that allow out-of-network benefits must precertify certain services themselves and failure to do so will result in a reduction of the benefit paid. Where precert and referral are not required, only refers to participating providers. Any non-par usage requires authorization by patient management on order to obtain HMO benefits.

65736839.doc

Ver 0.00a

Page 85 of 150

Claims ___________________________________________________________________
 Diagnosis code of the claim is verified i.e whether the diagnosis is effective for DOS of the claim. Drug code (drg) is validated Procedure/service code is validated . It also involves verification of service code for sensitivity ( i.e sex restriction for a particular procedure) Claimcheck Any claims system needs to do have the following checks either through interface to the HBOC/GMIS Claim Check software package or by other means which performs the following edits: o Unbundling-the use of two or more CPT procedure codes to describe a procedure performed in a single session when one comprehensive code exists. o Incidental Procedures-one or more procedures performed concurrently with a primary procedure, but which require little additional physician resources and/or is clinically integral to the performance of the primary procedure. o Mutually Exclusive Procedures-two or more procedures that by medical practice standards should not be billed on the same patient on the same date of service. o Age/Sex discrepancies and cosmetic and duplicate procedures. Determine payment

 

7.2.2

Following are the processes that affect the amount and extent of payment of a Claim.  Prorated maternity o Determine maternity pct i.e for a female member joining during pregnancy,the system will automatically prorate the claim as follows based on her effective date with the health care company e.g . Date of Delivery 1-30 days after member became effective 31-61 days after member became effective 62-91 days after member became effective 92 days or more after member became effective  % of Reimbursement 70% 80% 90% 100%

Contract interface o Contract is an agreement between the provider or group of providers and the insurance company about the services the provider(s) will provide and the payment that the insurance company will make to the provider for the services rendered. o Providers are generally contracted to provide services for specific benefit codes, Diagnosis codes, Procedure codes.The Payment method used in for paying of Contracted provider is based on Flat rate,Per unit rate , Rating system. Balance bill processing o Balance billing occurs when a doctor or other health care provider charges the patient more than the maximum allowable charge (the amount paid by the healthcare company for the health care services provided by the provider.) o Providers who balance bill can charge approx upto 15% over the maximum allowable charge and this must be paid in addition to the Prime copayment, or extra and Standard deductible and cost-share. o Balance billing fees can only be charged by non-participating providers. Facility fee processing if applicable

65736839.doc

Ver 0.00a

Page 86 of 150

Claims ___________________________________________________________________
o This fee is applicable if the member receives the health care in a facility . It checks for place of service , start and end of the service and presence of any contract of the Facility with the Healthcare company in determining the facility fee .

Product exception override o If it is determined that there is a product exception overide then then various overrides and their values are determined like Copay ,deductible, counsurance , precert penalty etc which are applicable to the claim. Copay processing interface o Copay is the amount payable by the member i.e. it is the member’s responsibility. It is some fixed part of the claimed amount that the member has to pay for the diagnosis or treatment he has undergone. o There are different types of copays like per stay, per day, per visit etc. o In the member’s contract there is also mentioned about the maximum amount of copay for the member and the family for the particular procedure code that is to be paid. o Copay based on no. of days is also dependent on the number of days of stay. It is in ranges. For Ex : Copay has one value for first five days, another for next fifteen days & another for the rest. o Copay can also be zero. Accumulators o Claim that have been denied or contain a benefit that is not covered or that do not have an accumulator are deemed exempt from the accumulator processing. The possible product components are checked. If the indemnity component has been valued, the process will use this component first .All the accumulators that have been defined under the product benefit are retrieved. Once an accumulator is retrieved, the following are checked:  The accumulator must be effective.  There are age requirements set up within this accumulator. The members age is checked against these parameteres. o Accumulators are used to track Individual member out of pocket payments as well as family amounts. o There are various types of accumulators which are used for tracking Copay, Deductible, Coinsurance, Precertification amounts, visits, etc of the member. o The accumulator year to date amounts are compared with the pre-decided limits of these amounts and the payment amount of the claim is adjusted accordingly. Indemnity processing if applicable o Indemnity processing comes into picture if the claim is not a emergency or does not have a referral . Here the claim is processed as fee-for-service or out of network claim.It calculates various payements pertaining to indemnity claims like deductible,coinsurance,precert penalty,out of pocket payments etc . It determines the various amounts that can be applied according to the member and the family limits ( referring to amounts already taken in previous claims) . Coordination of Benefits o Coordination of benefits (COB) allows insurance carriers to offset payments when a claimant carries insurance with multiple carriers. For example, a claimant may have dental insurance with AUSHC and with Blue Cross/Blue Shield. The dental claim is submitted first to the primary payor (in this example, AUSHC), which pays as the plan allows. The claim is then submitted to the secondary payor (Blue

65736839.doc

Ver 0.00a

Page 87 of 150

2. o o 7.3  Update Claim Accumulator updates o This involves updating of Various accumulators for Copay .  Inform the provider that he/she can write or call the person signing the notification if there is additional information that would alter the proposed process. Reporting o A host of reports to provide summary and detail information and statistics Claims History o Claims history records generated and used for future Claims adjudication and used for reporting and financial reconciliation of Self-Insured groups.2. Referral updates o Referrals are updated for no of visits after the claim has been processed properly. The insurance industry has established standard rules to determine which insurer is primary payor. Letters o Letters are sent to the member and/or provider giving information as to why :  A claim was denied  A claim is delayed  Is still Under review  Waiting for Additional information  Extra Payment done . Claims database updates o Processed Claims stored for maintaining History. a.4  Claim adjudication outputs Check extract o Adjudicated claims that are passed to Accounts payable for check printing. they will:  Notify the provider that they have discovered that another insurer is the primary carrier.doc Ver 0.   7.Penalties etc that a Healthcare company liable to pay in certain cases  Any Other Information required . coinsurance etc depending upon the processing of the claim. after a provider has been paid.  Provide the name and address of the primary carrier and the patient’s name and address and any other pertinent information. o Denial letters are sent if :  other insurance paid in full  experimental procedure not covered  Cosmetic surgery not covered    65736839.Claims ___________________________________________________________________ Cross/Blue Shield). the process followed is . deductible . thereby giving him/her an opportunity to seek reimbursement from the member’s primary insurer.  Inform the provider that he/she can return their previous payment or elect to have them debit his/her account after 60 days. This provision prevents double or over-payment by the carriers. Healthcare company discovers that another insurer is the primary carrier. If.00a Page 88 of 150 .

no change Explanation of benefits – (covered in other section) 65736839.00a Page 89 of 150 .doc Ver 0.Claims ___________________________________________________________________   Decision re-reviewed.

00a Page 90 of 150 .Claims ___________________________________________________________________ ADJUDICATION CLAIM PREPARATION AND ELIGIBILITY DETERMINE PAYMENT CLAIM UPDATION CLAIM OUTPUTS Validate member no Validate provider no Maternity percent Contracts Referral updates Accumulator updates Check extract Reports Is Claim too Old ? Is Claim timely filed ? Indemnity processing Product exception override Facility fee Claim history Letters Is Claim duplicate ? Group/Plan eligibilty Product component eligibilty Product exception override Copay processing Benefit eligibility Product bebefit eligibility Check Stacked benefits Memb reimburseme nt /Prov reimburseme nt ? Verify precert Coordination of benefits Accumulator processing Verify referral Veryify Diagnosis code Verify Proc code Figure 2 : Claim adjudication process Validate drug code Claim check 65736839.doc Ver 0.

1 Capitated Provider If provider is a Capitated Provider. these amounts are then adjusted during adjudication against the claims filed by provider. 7.Claims ___________________________________________________________________ 7.4 COB Adjustments If Coordination of benefit applies for any member. which means he gets a fixed fee by Insurance Company on monthly basis irrespective of actual services provided by the provider during the period under consideration. 7. Mostly all the In-patient type of services and none of the Out-patient type of services are eligible for this incentive.3. If the provider is non-capitated. assign points / marks.1. a survey is conducted where in the member fills in a form to comment about the quality of service provided by the hospital.  Efficiency of Care 65736839.3 7. which should be covering the visit and specific services for the member. 7. These routines (which are black box to the insurance company’s system). 7. Higher these points.5 Duplicate Claims In case of late payments by insurance company.00a Page 91 of 150 . in most of the general scenarios. both with a few exception. Over a specific period of time. provider has tendency to file the same claim again. would come in the form of claims filed by the providers. In the physician surveys.1. Procedures are in place which detect such duplicate claims and avoid the repayments. Hospitals send the survey results to Insurance company.3. This data is then passed through ‘United States Quality Algorithms (USQA)’ routines. Otherwise claims without proper referral get denied. then all his claims are bound to get denied if filed for services covered under capitation. then claim gets adjudicated against Insurance Company’s business policies and rules as imposed by federal/state laws.doc Ver 0. These claims then are taken through claim adjudication process to decide how much amount should be paid to the member or the claim should get denied.3. 7. Principle categories for this payment are as follow:  Quality of Care It measures the quality of care based on physician and member surveys.3.3. the physicians fill in the data such as quality of operating rooms.2 Provider as Specialist If a provider is giving services to member as a Specialist. then the claims filed would require specific referral already in place.1.1 Claim Payments Provider Payments Inputs for any provider payment.7 Provision for Advance Payment Some providers.6 Provision for Advance Payment Some insurance companys also have a facility to pay the providers some lumpsum amount in advance. Once the service is provided to a member. 7.1. especially the big providers like Hospitals. are paid extra for the quality of services they provide. This incentive to be paid is decided as fixed % of the contractual amount between Insurance company and the provider. then the insurance company will pay the provider adjudicated amount less the copay amount as described by member’s plan. He has to file claims with all the involved insurance companies.3 Copay Adjustments If the claim filed required member to pay some copay amount. It becomes mandatory to identify all the types of services that will become eligible for consideration under quality incentive. administration in the hospital etc. then provider receives payment from primary and secondary insurance companies.3.1.1. these providers will file claim for the services rendered to the member. 7.3.3. based on some algorithms.1. the higher will be the incentive. When members have encounters with provider.

2. 7.2. 7. So. If a member spends more time in hospital for a service.doc Ver 0. higher will be the payments. the lesser will be the incentives paid. the provider is informed by the Insurance Company regarding the reasons and split of payments.4 Claim Adjustments These are the various types of adjustments that can be made to the claim. adverse events and C-section rates. higher the adverse conditions. 7.3.3. through USQA routines. When provider’s claim is adjudicated.Claims ___________________________________________________________________ It measures the efficiency of the care based on length of stay for surgery. 65736839.2. 7. If the member has not reached the Deductible limit. the payment is made.3. insurance company intimates provider of the extra payment made and provider is required to repay to the company accordingly.00a Page 92 of 150 .1.4 Co-insurance Applies In this case. whether denied or paid.3 Deductible Applies Member pays to the provider Out-of-Network and files a claim with the Insurance company. In this case insurance company pays directly to member. then the insurance company will reimburse all the amount paid towards copay back to member. lower will be the payments. medicine and OB/GYN. 7. points are assigned and based on the points. a fixed % of adjudicated claim amount is paid back to the member. Higher the points. system assigns points. as defined in the plan adopted by member. Based on the answers.1 Copay Limit Reached If member has already reached the copay limit mentioned on his plan and in the next encounter he still pays the copay. Also.3. then Insurance Company will then deny such a claim.2.8 Payment to Insurance Company It may happen that provider claims are incorrectly adjudicated and provider is overpaid. lower will be the payments as it is hospital’s responsibility to see that fewer adverse events arise. 7.  Commitment to Managed Care Principles The negotiators have the providers fill in a questionnaire that contains the questions such as: o if the provider sends the data to Insurance Company electronically o if there exists long term contract between hospital and Insurance Company o if nurses from the hospital participate in training programs conducted by Insurance Company The provider has to fill in either Yes or No to each of these questions.3. longer the stay.2 Member Re-imbursement Following are various scenarios when member is eligible for re-imbursement by The Insurance Company. For each of these measures.3. 7. Under such circumstances. For this category: higher the points.2 Member goes Out-Of-Network If member visits a provider out of network then he has to file a claim for the benefits provided under his plan. then higher will be the costs that hospital incurs and hence the claim amount. part or full payment made by him to provider.

doc Ver 0. there has to be a claim for which a check is created. a letter is sent to the provider notifying of over-payment. cash date for check is recorded and necessary deductions are applied to claim.4. the original claims remain untouched. The claim does not undergo adjudication. This is to account for the payment being made using the manual check.1 Refund Adjustment This type of adjustment takes place when a Health Services Provider overpays the provider.Claims ___________________________________________________________________ 7. Only in this scenario a stop can be issued on the check. The check status is also changed from open (blank) to Void (V). 65736839. 7. Such a check is created by entering data into the system manually.00a Page 93 of 150 . The check status is changed from open (blank) to Stopped (S).5 Stop Adjustment The Claim is completed but the check is still open (check information has been sent to the bank but not been encashed yet).4. When provider agrees and refunds over-payment (provider will cut check and send in). Provider over-payment letter is generated one claim per letter.2 Minus Debit Adjustment In case of overpayment to providers. If provider does not agree to cut and send check to refund over-payment. In the process.4 Void Adjustment The Claim is completed but the check is still in open status (Check information has still not been sent to the bank) only in this scenario a void can be issued on the check. Original completed claim remains unchanged. Further claims of the provider are not paid till the all the amount on the negative claim has been recovered.3 Manual Check Adjustment Sometimes a check is required to be created manually if there is a need to adjust amount of payment.e. It is completed and stored. 7. Claim gets completed without adjudication. The original claims are overridden with new payment codes. Once the whole dollar amount is adjusted the process stops and all the claims get completed and letter is sent to the provider stating why payment has not been made to him. Deduction may be split across multiple claims.4.4. On receipt of the manual check paperwork a Manual claim is entered. 7. 7. minus debit option is used to create an equal amount negative check.4. when stop payment is done. A connection is established between the manual check and the claim entered. i. A new set of claims are generated which have amount equal to negative of the amounts of the original claims. The manual check request paperwork is then sent to Claims system. When void is done then a new set of claims are generated which are associated with the same check with negative amounts as the original claims. New negative claims created with negative dollar amount.

Claims ___________________________________________________________________ 7. Meaning that now the government would also consider the health of the member when it makes a payment for that member to the health care company. Medicaid . It covers approximately 36 million individuals including children. Hence now it was important for the health care company to report each and every claim that it received.Medicaid is a jointly funded. Federal-State health insurance program for certain low-income and needy people. to the government. Thus.S. And similarly no matter how much money the health care company spends on a person who was a frequent visitor to the hospital. the risk adjustment model emerged. the Federal government sponsors Medicare while the Medicaid plans are specific to the particular state.00a Page 94 of 150 . Health care company reports the claims that have been filed by the providers to the government. the aged. it still doesn’t form a significant portion in the payment model. and people who are eligible to receive federally assisted income maintenance payments. The score calculation and the payments are made on an annual basis. Depending on the diagnosis that has been performed on a particular claim. Medicare provides health insurance to people aged 65 and over and those who have permanent kidney failure and people with certain disabilities. But sometime around the end of 2000. Since the number of encounters and the particular diagnosis that was performed had very less significance in the payments that were made. If a Health care company has Medicare and Medicaid as the two sponsored programs. the nation's largest health Insurance program. This is the reason why government reporting is important for a Healthcare industry. a government body administers Medicare. the healthcare company would still get paid for that member. meaning that all the claims belonging to this category that Health care company sends to the government would mean an additional revenue to Health care company from the government. It means that no matter a person visited a hospital or not. and/or disabled. The scores for AIDS/Chemotherapy are the highest. the government assigns a severity code (PIP SCORE) to the particular member. If a person has not visited a hospital during the entire year.doc Ver 0. then government assigns a score of 04 (which is the least PIP SCORE) to this member and Health Care Company would be paid at a flat rate for this member. Although the risk adjustment model has come up.          65736839. earlier the government used to pay the health care companies a flat rate per member. blind. it would still get the same flat rate from the government. which covers 37 million U. it needs to report all of its encounters (visit of a member to the provider or health care) to the government.S  Medicare Health Care Financing Administration (HCFA). With this model there is not a very stringent need for the healthcare company to report all of its encounters correctly to the government. But there’s a gradual increase in its share. This is where Encounter data reporting started coming into picture. For Medicare encounters. Government reporting is needed in a Healthcare industry especially for those plans that are funded by the government.5 Government reporting There are two types of government-sponsored plans in U. Citizens.

It also gives the cap amounts applicable to him. Medicare submissions are sent to CMS (Center for Medicare and Medicaid services).1 What are Accumulators? Accumulators are generally database records.7.7. which acts as an intermediary between Health Care Company and the Federal government. etc are applicable and not for all type of claims.  Explanation of Benefits (EOB) EOB is the letter sent to a member by the Insurance company giving the details of the services rendered to him by the providers and the amount to be borne by the member for the services he has taken. dedicated to accumulating specific type of data over a specific period. 65736839. The encounters have to be submitted in a fixed format called the Uniform Billing Code1992 form. The list of claims in the wait status for more information. coinsurance. When requesting payment from a secondary payer it is extremely important that the EOB/remittance information be provided from the primary payer. It is not a bill but an explanation of the benefits. The Explanation of Benefits provides members a statement of claim payments. It gives the member a detailed explanation of these amounts.7 7.      The The The The The charges for which the provider has billed the Health Insurance company charges whcih are for services covered by Group Benefits charges that the member must pay to meet his/her deductible amount the Healthcare Insurance company paid amount that the member owes The EOB for the National Advantage Program lists:  billed charges  allowable amount  non-covered amount Some health insurance companies may prefer to generate EOB only for certain type of services e. 7.Claims ___________________________________________________________________  Balanced Budget Act of 1997 mandates all healthcare organizations to electronically transmit Medicare hospital inpatient encounters to Healthcare Financing Administration through a fiscal intermediary.doc Ver 0. After the submission the intermediary is supposed to send an acknowledgement back to the health care company which gives details of o o o 7.00a Page 95 of 150 .g.1 Accumulators 7. Claims rejected and reasons for the same. While the Medicaid submissions go directly to the state. for indemnity or fee for service claim where deductible. In case of multiple MC (primary and secondary) the primary MC coordinates the benefits between the two MC and sends a COB (Coordination of benefits) to the member.6 Claims accepted.

It comes into picture when deductible limit is met. 65736839. will be considered as deductible paid towards next year. during predefined period.1 Periodic Accumulators These accumulators will cover up the amounts for period as mentioned in the effective plan for the member.7. In this case.3.3 Deductible . the amount of money that is going to be paid to/from a member is decided based on the accumulator amounts. member + family These accumulators include combined figures of co-insurance and deductibles. deductible paid by member in a specific later portion of the effective year. o Accumulator for yr. 2001 will go on accumulating the data till end of Nov-2001. Accumulators records are updated accordingly in such cases. Carry over Deductible Updates Some plans provide for the provision that. accumulators for the next period will get updated for the deductibles paid. Example: o If a member XYZ has plan year 01-Jan-2001 to 31-Dec-2001.7.3.2 Function/Purpose of Accumulators The main use of accumulators is during the claims adjudication process. o Members pays remaining deductible (part or full. o Plan provision says Carry over deductible is applicable for last 30 days of the plan year.3.3.4. member no more pays copay to provider. 7. Some plans provide for facility of carry over deductible.4 Types of Accumulator  7. o Member’s deductible limit is say $ 500.4 Visits – for member Visits of the member to provider are accumulated.2 7. it accumulates $ 350. 7.7.7.7. When the same has been decided.3.6 Out of Pocket . depending upon how many visits covered for a specific service to same provider. 7.00a Page 96 of 150 . The accumulator amounts are checked to find if they are exceeding the limit for a particular member (which is decided when a member enrolls to a PLAN). the corresponding accumulators are updated with those amounts for the latest instance under consideration. in case member chooses to continue. 7.for member. So. 7.7.doc Ver 0.Claims ___________________________________________________________________ 7.2 Co-insurance – for member. In a general scenario. this figure may be used to decide the method of payment.7.3. member + family Copay is accumulated separately for member as well as member and all his/her dependents. member + family Co-insurance is also accumulated separately for member as well as member and all his/her dependents. This reduces burden on member and acts as incentive for member to continue with the co-insurance company.7.1 Copay – for member. say $100) during the last 30 days of plan year. member + family Co-insurance is also accumulated separately for member as well as member and all his/her dependents.5 Family Dollars Insurance company’s disbursement to member or the provider. (Details will come down the line in the document) 7. 7. say partial/full/some percentage of billed.member.7. Once the maximum limit set by plan is met.3 What is accumulated? 7.7.7. Say.

7. Why are letters required? What are different types of letters? What are the various types of Claim adjustments? What does Government reporting consist of? What are the various criteria for deciding the payment of a claim? What is the significance of maintaining Claims history? 65736839.Claims ___________________________________________________________________ o o Then new accumulators will be generated as if paid for the next year 2002. 2. because of this facility.7. Review Questions. If member chooses to continue.doc Ver 0. he now needs to pay $100 less towards deductible in the next plan year.2 Lifetime Accumulators These accumulators will sum up the amounts for the life time for a member. 4.00a Page 97 of 150 . 7.9 1.4. $100 will get updated in these accumulators. 3. 5.8 Overall Claims system diagram : Figure 3: Claims overview 7.

 Pre-certification penalty is in excess of any deductible and/or coinsurance applicable to the claim. Claim adjustments can be done before Claim adjudication.10 References http://www.DRIVER) SA_AETHMOM2. Accumulators are updated for denied claims.ehealthinsurance.doc Ver 0.   Member encounters have to be submitted to the government in a fixed format. EOB is letter sent after adjudication. 7.    State whether true of false – COB deals with claim payment.com/ Aetna Batch driver file (CLPRD.00a Page 98 of 150 .Claims ___________________________________________________________________ 6.CLDJABDJ. Copay is not the member’s responsibility.DOC (System appreciation document) and other docs from Encounter data reporting project 65736839.DOC (System appreciation document for Claims maintainance project) SA_AETEDR2.

Claims ___________________________________________________________________ 65736839.00a Page 99 of 150 .doc Ver 0.

3 8. CMS runs the State Children's Health Insurance Program (SCHIP). Medicaid and SCHIP.  conducts research on the effectiveness of various methods of health care management.VIII 8 External Agents 8. and financing. treatment. 8. Approximately 158. Department of Health and Human Services. CMS:  assures that the Medicaid.two national health care programs that benefit about 75 million Americans.3. CMS maintains oversight of the survey and certification of nursing homes and continuing care providers (including home health agencies. researchers and State surveyors information about these activities and nursing home quality. And with the Health Resources and Services Administration. CMS also regulates all laboratory testing (except research) performed on humans in the United States. including regulation of laboratory testing (CLIA). It requires some help from some external sources or agencies.00a Page 100 of 150 . helps millions of Americans and a small company get and keep health insurance coverage. CMS runs the Medicare and Medicaid programs . providers.  establishes policies for paying health care providers. 65736839. This unit deals with the various different agencies in a Health Care Industry and the role played by them. CMS also performs a number of quality-focused activities. and helps eliminate discrimination based on health status for people buying health insurance.1 Government Agencies Centers for Medicare & Medicaid Services (CMS) The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U. all the services and management activities cannot be carried by the insurance payer itself on it's own.000 laboratory entities fall within CMS's regulatory responsibility. And CMS. development of coverage policies. intermediate care facilities for the mentally retarded. with the Departments of Labor and Treasury. 8. and hospitals).S.2 Introduction In Heath Care Industry. and quality-of-care improvement.1 Unit Objectives This unit will acquaint the reader with the role played by the external agents in the Healthcare Industry.External Agents ___________________________________________________________________ UNIT . CMS spends over $360 billion a year buying health care services for beneficiaries of Medicare. a program that is expected to cover many of the approximately 10 million uninsured children in the United States. Medicare and SCHIP programs are properly run by its contractors and state agencies. and makes available to beneficiaries. and  assesses the quality of health care facilities and services and taking enforcement actions as appropriate.doc Ver 0.

External Agents ___________________________________________________________________

Figure 1 below describes the interaction of CMS and State Government with a Healthcare Industry.

Claims Claim info

Enrollment Member Info

Provider Provider Info

Provider Network Area

Provider Validations

Claims

State Government Rules Medicaid Data State Governments

Encounters

Pharmacy Aetna Internal
Systems

Business Raw Data

Business Criteria + Refined Data

Errors from State I.T. Enrollment Info Reformatted relevant data Medicare Data CMS Federal Government

External sources of data Make Corrections

Federal Rules

Errors from Federal Gov. Members

Users

Letter Generator Letters

Members Make Corrections Corrected Errors Error Correction System Errors

Government Programs

Figure 1 : CMS - Center for Medicare and Medicaid Services

8.3.2

DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHSS)

The DEPARTMENT OF HEALTH AND HUMAN SERVICES is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. The Department Include more than 300 Programs, covering a wide spectrum of activities. Some highlights include:            Medical and social science research Preventing outbreak of infectious disease, including immunization services Assuring food and drug safety Medicare (health insurance for elderly and disabled Americans) and Medicaid (health insurance for low-income people) Financial assistance and services for low-income families Improving maternal and infant health Head Start (pre-school education and services) Preventing child abuse and domestic violence Substance abuse treatment and prevention Services for older Americans, including home-delivered meals Comprehensive health services for Native Americans

HHS is the largest GRANT-MAKING AGENCY in the federal government, providing some 60,000 grants per year. HHS' Medicare program is the nation's largest health insurer, handling more than 900 million claims per year.

65736839.doc

Ver 0.00a

Page 101 of 150

External Agents ___________________________________________________________________
HHS works closely with STATE, LOCAL AND TRIBAL Governments and many HHS-funded services are provided at the local level by state, county or tribal agencies, or through private sector grantees. 11 HHS operating divisions, including eight agencies in the U.S. Pubic Health Service and three human service agencies administer the Department's programs. In addition to the services they deliver, the HHS programs provide for equitable treatment of beneficiaries nationwide, and they enable the collection of national health and other data.

8.3.3

Centers for Disease Control and Prevention (CDC)

The Centers for Disease Control and Prevention (CDC) is recognized as the lead federal agency for protecting the health and safety of people - at home and abroad, providing credible information to enhance health decisions, and promoting health through strong partnerships. CDC serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. CDC, located in Atlanta, Georgia, USA, is an agency of the Department of Health and Human Services. Infectious diseases, such as HIV/AIDS and tuberculosis, have the ability to destroy lives, strain community resources, and even threaten nations. In today's global environment, new diseases have the potential to spread across the world in a matter of days, or even hours, making early detection and action more important than ever. CDC plays a critical role in controlling these diseases, traveling at a moment's notice to investigate outbreaks abroad or at home.

8.3.4

Agency for Health Care Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) research provides evidencebased information on health care outcomes; quality; and cost, use, and access. Information from AHRQ’s research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research. AHRQ's strategic goals reflect the needs of its customers. These goals are to

Support improvements in health outcomes. The field of health outcome research examines the end results of the structure and processes of health care on the health and well being of patients and populations. A unique characteristic of this research is the incorporation of the patient's perspective in the assessment of effectiveness. Public and private-sector policymakers are also concerned with the end results of their investments in health care, whether at the individual, community, or population level. Strengthen quality measurement and improvement. Achieving this goal requires developing and testing quality measures and investigating the best ways to collect, compare, and communicate these data so they are useful to decision-makers. AHRQ's research will also emphasize studies of the most effective ways to implement these measures and strategies in order to improve patient safety and health care quality. Identify strategies that improve access, foster appropriate use, and reduce unnecessary expenditures. Adequate access and appropriate use of health care services continues to be a challenge for many Americans, particularly the poor, the uninsured, members of minority groups, rural and inner city residents, and other priority populations. The Agency will support studies of access, health care utilization, and expenditures to identify whether particular approaches to health care delivery and payment alter behaviors in ways that promote access and/or economize on health care resource use.

65736839.doc

Ver 0.00a

Page 102 of 150

External Agents ___________________________________________________________________
8.3.5 National Information Center Care Technology (NICHSR) on Health Services Research and Health

The 1993 NIH Revitalization Act created a National Information Center on Health Services Research and Health Care Technology (NICHSR) at the National Library of Medicine to improve "the collection, storage, analysis, retrieval, and dissemination of information on health services research, clinical practice guidelines, and on health care technology, including the assessment of such technology." The Center works closely with the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), to improve the dissemination of the results of health services research, with special emphasis on the growing body of evidence reports and technology assessments which provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The overall goals of the NICHSR are:  to make the results of health services research, including practice guidelines and technology assessments, readily available to health practitioners, health care administrators, health policy makers, payers, and the information professionals who serve these groups  to improve access to data and information needed by the creators of health services research  to contribute to the information infrastructure needed to foster patient record systems that can produce useful health services research data as a by-product of providing health care.

8.3.6

Health Resources and Services Administration (HRSA)

The Health Resources and Services Administration's mission is to improve and expand access to quality health care for all. HRSA assures the availability of quality health care to low income, uninsured, isolated, vulnerable and special needs populations and meets their unique health care needs.

8.3.7 5. 6. 7.

Exercise ___ is the Federal Agency that runs the Medicare and Medicaid programs. Information from ______'s research helps people make more informed decisions and improve the quality of health care services. The ____ is the United States government's principal agency for protecting the health of all Americans.

Answers: 5. CMS 6. AHRQ 7. DHSS

8.4 8.4.1

Government Acts and Regulations HIPAA

The Health Insurance Portability & Accountability Act of 1996 (August 21), Public Law 104-191, which amends the Internal Revenue Service Code of 1986. Also known as the Kennedy-Kassebaum Act.

65736839.doc

Ver 0.00a

Page 103 of 150

life insurers." Many of the rules and standards are still 65736839.External Agents ___________________________________________________________________   Improved efficiency in healthcare delivery by standardizing electronic data interchange. employers." past. Required compliance responses aren't standard. health plans and health care providers Security standards protecting the confidentiality and integrity of "individually identifiable health information. health plans. but due to minor glitch didn't become effective until April 14. 2001. 2002.depending on its network environment." "role-based. or adapting. administrative and financial data Unique health identifiers for individuals. ARE THERE PENALTIES? HIPAA calls for severe civil and criminal penalties for noncompliance. and Protection of confidentiality and security of health data through setting and enforcing standards. Steps will include:            Building initial organizational awareness of HIPAA Comprehensive assessing of the organization's information security systems. present or future. The Privacy Rule was published on December 28. HOW WILL WE BE AFFECTED? Broadly and deeply. So the compliance date for that rule is October 16. More specifically. for many of us. an organization with a computer network will be required to implement one or more security authentication access mechanisms .specifics that. 2000. including Developing new policies.00a Page 104 of 150 . policies and procedures Developing an action plan with deadlines and timetables Developing a technical and management infrastructure to implement the plan Implementing a comprehensive action plan. and universities. cause more confusion than clarity. information systems Developing new internal communications Training and enforcement Now. Compliance is required for the Privacy Rule on April 14. public health authorities. we'll explore the next level of HIPAA . clearinghouses. Effective compliance will require organization-wide implementation. 2000. employers. WHO IS AFFECTED? All healthcare organizations. HIPAA calls for:    Standardization of electronic patient health." and/or "context-based" access . information systems vendors. including: -.doc Ver 0. because organizations aren't.fines up to $25K for multiple violations of the same standard in a calendar year -. This includes all health care providers. Normally. Let's try to make "Administrative Simplification" simple! HIPAA's "Administrative Simplification" provision is composed of four parts. even 1-physician offices. service organizations. For example. billing agencies. and procedures Building "chain of trust" agreements with service organization Redesigning a compliant technical information infrastructure Purchasing new. each of which have generated a variety of "rules" and "standards. processes."user-based. 2003.fines up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information COMPLIANCE DEADLINES? Most entities have 24 months from the effective date of the final rules to achieve compliance. the effective date is 60 days after a rule is published. The Transactions Rule was published on August 17.

this is intended to reduce mistakes.00a Page 105 of 150 . coding systems that describe diseases. and related transactions. It applies not only to the transactions adopted under HIPAA. Proposed regulations for these exceptions are not yet out. first injury reports. and non-repudiation. will often have different compliance deadlines. All parties to any transaction will have to use and accept the same coding. most are expected to become "final" rules within the year 2000. health providers and plans use many different electronic formats. coordination of benefits. the rules. The four parts of Administrative Simplification are:  ELECTRONIC HEALTH TRANSACTIONS STANDARDS  UNIQUE IDENTIFIERS  SECURITY & ELECTRONIC SIGNATURE STANDARDS  PRIVACY & CONFIDENTIALITY STANDARDS ELECTRONIC HEALTH TRANSACTIONS STANDARDS The term "Electronic Health Transactions" includes health claims. in the long run. symptoms and actions taken must become uniform. SECURITY OF HEALTH INFORMATION & ELECTRONIC SIGNATURE STANDARDS The new Security Standard will provide a uniform level of protection of all health information that is  housed or transmitted electronically and that  Pertains to an individual. Again. 65736839.External Agents ___________________________________________________________________ in the "proposed" (by DHHS) stage. and access to individual health information. conducive to error and costly. and other health problems. even if a transaction is on paper or by phone or FAX. For example. Implementing a national standard will mean we will all use one format. Virtually all health plans will have to adopt these standards. However. Fortunately. user authentication. It is expected that standard identifiers will reduce these problems. organizations that use Electronic Signatures will have to meet a standard ensuring message integrity. clearinghouses and providers. Health organizations also must adopt STANDARD CODE SETS to be used in all health transactions. they will have to contract with a clearinghouse to provide translation services. the American National Standards Institute. although if they don't. Even more confusing. Providers using non-electronic transactions are not required to adopt the standards. but to all individual health information that is maintained or transmitted. the Electronic Signature standard applies only to the transactions adopted under HIPAA. Today. the code sets proposed as HIPAA standards are already used by much health plans. EMPLOYERS. as well as their causes. duplication of effort and costs. thereby "simplifying" and improving transaction efficiency nationwide. which HIPAA sees as confusing. claim status. health plan eligibility. enrollment and disenrollment. for most transactions except claims attachments and first reports of injury. which should ease the transition. In addition. when final. The Security standard mandates safeguards for physical storage and maintenance. however. UNIQUE IDENTIFIERS FOR PROVIDERS. payments for care and health plan premiums. HEALTH PLANS and PATIENTS The current system allows us to have multiple ID numbers when dealing with each other. injuries. transmission.doc Ver 0. The proposed rule requires use of specific electronic formats developed by ANSI.

doc Ver 0. terminated employees or those who lose coverage because of reduced work hours may be able to buy group coverage for themselves and their families for limited periods of time.  establish new requirements for access to records by researchers and others. There was a time when group health coverage may have been terminated when a worker lost his job or changed employment. Also. The Privacy standards:  limit the non-consensual use and release of private health information.4. The rule covers all individually identifiable health information in the hands of covered entities. A paperwork glitch delayed notification of Congress. You have 60 days to accept coverage or lose all rights to benefits. Now. for the first time. 2001. What Is the Continuation Health Law? 65736839. depending on the needs and technologies in place. The new regulation reflects the five basic principles outlined at that time:  Consumer Control: The regulation provides consumers with critical new rights to control the release of their medical information  Boundaries: With few exceptions. an individual's health care information should be used for health purposes only. privacy is about whom has the right to access personally identifiable health information. In general. 2001.External Agents ___________________________________________________________________ The Security Standard does not require specific technologies to be used. That changed in 1986 with the passage of health benefit provisions in the Consolidated Omnibus Budget Reconciliation Act (COBRA). there will be specific federal penalties if a patient's right to privacy is violated. conducting medical research. regardless of whether the information is or has been in electronic form. DHHS received over 11.00a Page 106 of 150 .  restrict most disclosure of health information to the minimum needed for the intended purpose. so the Congressional Review period didn't begin until February.  Security: It is the responsibility of organizations that are entrusted with health information to protect it against deliberate or inadvertent misuse or disclosure. pushing the effective date of the rule until April 14. your health plan must give you a notice stating your right to choose to continue benefits provided by the plan.  Public Responsibility: The new standards reflect the need to balance privacy protections with the public responsibility to support such national priorities as protecting public health. you may be required to pay for the coverage. These programs can be one of the most important benefits provided by an employer.000 comments and plans to issue guidelines and clarification of the final rule in response. improving the quality of care. Once COBRA coverage is chosen.  establish new criminal and civil sanctions for improper use or disclosure. and fighting health care fraud and abuse.2 CORBA Health insurance programs allow workers and their families to take care of essential medical needs.  give patients new rights to access their medical records and to know who else has accessed them. Compliance will be required on April 14. 2003 for most covered entities. no transactions adopted under HIPAA currently require an electronic signature. PRIVACY AND CONFIDENTIALITY The Final Rule for Privacy was published just as President Clinton was leaving office. If you are entitled to COBRA benefits. DHHS Secretary Tommy Thompson used the time to solicit additional comments during March.  Accountability: Under HIPAA. including treatment and payment. solutions will vary from business to business. on December 28. 8.

retirees. ERISA neither establishes minimum standards or benefit eligibility for welfare plans nor mandates the type or level of benefits offered to plan participants. than individual health coverage. Group health coverage for COBRA participants is usually more expensive than health coverage for active employees. health maintenance organization. The law does not. the employee's spouse 65736839. reimbursement or combination of these. spouses and dependent children the right to temporary continuation of health coverage at group rates. though. apply to plans sponsored by the Federal government and certain church-related organizations. since usually the employer pays a part of the premium for active employees while COBRA participants generally pay the entire premium themselves. however. Group health plans sponsored by private sector employers generally are welfare benefit plans governed by ERISA and subject to its requirements for reporting and disclosure. beneficiaries and events. For this purpose. It applies to plans in the private sector and those sponsored by state and local governments. the Internal Revenue Code and the Public Health Service Act to provide continuation of group health coverage that otherwise might be terminated. however. however. A qualified beneficiary may be an employee. Plan Coverage Group health plans for employers with 20 or more employees on more than 50 percent of the working days in the previous calendar year are subject to COBRA. Under COBRA. This coverage. however. is not covered under COBRA. It is ordinarily less expensive. fiduciary standards and enforcement.00a Page 107 of 150 . require that these plans have rules outlining how workers become entitled to benefits. Medical benefits provided under the terms of the plan and available to COBRA beneficiaries may include:  inpatient and outpatient hospital care  physician care  surgery and other major medical benefits  prescription drugs  any other medical benefits. It does. independent contractors and directors. self-funded pay-as-you-go basis. Who Is Entitled to Benefits? There are three elements to qualifying for COBRA benefits. the term employees also include agents. The law generally covers group health plans maintained by employers with 20 or more employees in the prior year. which initiate the coverage. but only if they are eligible to participate in a group health plan. COBRA establishes specific criteria for plans. is only available in specific instances. such as dental and vision care Life insurance. COBRA contains provisions giving certain former employees.doc Ver 0. as well as self-employed individuals.External Agents ___________________________________________________________________ Congress passed the landmark Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986. The term "employees" includes all full-time and part-time employees. The law amends the Employee Retirement Income Security Act (ERISA). a group health plan ordinarily is defined as a plan that provides medical benefits for the employer's own employees and their dependents through insurance or another mechanism such as a trust. Beneficiary Coverage A qualified beneficiary generally is any individual covered by a group health plan on the day before a qualifying event.

and plan administrators and qualified beneficiaries.00a Page 108 of 150 . The type of qualifying event will determine who the qualified beneficiaries are and the required amount of time that a plan must offer the health coverage to them under COBRA. The qualifying events contained in the law. a retired employee. the retired employee's spouse and dependent children. at its discretion.doc Ver 0. A plan. Employers and plan administrators have an obligation to 65736839. an individual to lose health coverage. Qualifying Events Termination Reduced Hours Beneficiary Employee Spouse Dependent Child Spouse Dependent child Coverage 18 months Employee entitled to Medicare Divorce or legal separation Death of covered employee 36 months Loss of "dependent child" Dependent status child Figure: 2 Periods of Coverage Your Rights: Notice and Election Procedures 36 months COBRA outlines procedures for employees and family members to elect continuation coverage and for employers and plans to notify beneficiaries. Qualifying Events "Qualifying events" are certain types of events that would cause. The types of qualifying events for employees are:  voluntary or involuntary termination of employment for reasons other than "gross misconduct" reduction in the number of hours of employment The types of qualifying events for spouses are:  Termination of the covered employee's employment for any reason other than "gross misconduct"  Reduction in the hours worked by the covered employee  Covered employee's becoming entitled to Medicare  Divorce or legal separation of the covered employee  Death of the covered employee The types of qualifying events for dependent children are the same as for the spouse with one addition: loss of "dependent child" status under the plan rules as shown in Figure 1. create rights and obligations for employers. may provide longer periods of continuation coverage.External Agents ___________________________________________________________________ and dependent children. except for COBRA continuation coverage. Qualified beneficiaries have the right to elect to continue coverage that is identical to the coverage provided under the plan. and in certain cases.

A notice must be provided within 60 days of a disability determination and prior to expiration of the 18-month period of COBRA coverage. A qualified beneficiary must notify the plan administrator within 60 days after events such as divorce or legal separation or a child's ceasing to be covered as a dependent under plan rules. Plan administrators. The notice must be provided in person or by first class mail within 14 days of receiving information that a qualifying event has occurred. Plan administrators are responsible for determining whether these qualifying events have occurred. the time frame for providing notices may be extended beyond the 14. termination.and 30-day requirements if allowed by plan rules.External Agents ___________________________________________________________________ determine the specific rights of beneficiaries with respect to election. Employers must notify plan administrators within 30 days after an employee's death. This period is measured from the later of the coverage loss date or the date the notice to elect COBRA coverage is sent. ERISA requires employers to furnish modified and updated SPDs containing certain plan information and summaries of material changes in plan requirements.doc Ver 0. Disabled beneficiaries must notify plan administrators of Social Security disability determinations. employers are relieved of the obligation to notify plan administrators when employees terminate or reduce their work hours. COBRA information also is required to be contained in the summary plan description (SPD) which participants receive. Multi-employer plans may provide for a longer period of time. their spouses and newly hired employees informing them of their rights under COBRA and describing provisions of the law. upon notification of a qualifying event. Qualified beneficiaries have a 60-day period to elect whether to continue coverage. reduced hours of employment or entitlement to Medicare. These beneficiaries also must notify the plan administrator within 30 days of a final determination that they are no longer disabled. There are two special exceptions to the notice requirements for multi-employer plans. First. qualified beneficiaries and plan administrators when a qualifying event occurs. Second.00a Page 109 of 150 . Notice Procedures General Notices An initial general notice must be furnished to covered employees. COBRA coverage is retroactive if elected and paid for by the qualified beneficiary. Election The election period is the time frame during which each qualified beneficiary may choose whether to continue health care coverage under an employer's group health plan. Plan administrators must automatically furnish the SPD booklet 90 days after a person becomes a participant or a beneficiary begins receiving benefits or within 120 days after the plan is subject to the reporting and disclosure provisions of the law. Specific Notices Specific notice requirements are triggered for employers. must automatically provide a notice to employees and family members of their right to elect COBRA coverage. notification and type of coverage options. 65736839.

. Assuming a qualified beneficiary had been covered by three separate health plans of his former employer on the day preceding the qualifying event. vision and prescription benefits under single or multiple plans maintained by the employer. Inc. Example 4: Jane W. Then. which maintained an insured group health plan for its 10 employees in 1987 and 1988. She is not entitled to COBRA coverage with the plan of RST. dental. may independently elect COBRA coverage. since the firm had fewer than 20 employees in 1987 and is not subject to COBRA requirements. the plan need only provide continuation coverage beginning on the date the waiver is revoked. Covered Benefits Qualified beneficiaries must be offered coverage identical to those received immediately before qualifying for continuation coverage. except where they are mandated by law in which case they become core benefits. 65736839. leaves in June 1988 to take a position with a competing firm.. left brokerages firm in May 1990 to take a position with a chemical company. hospitalization. Even though Jane signs up for the new employer's plan.doc Ver 0. A beneficiary may then reinstate coverage. She was five months pregnant at the time. A waiver of coverage may be revoked by or on behalf of a qualified beneficiary before the end of the election period. John may elect and pay for a maximum of 18 months of coverage by the employer's group health plan at the group rate. Example 2: Day laborer David P. Each qualified beneficiary. a beneficiary may have had medical.External Agents ___________________________________________________________________ A covered employee or the covered employee's spouse may elect COBRA coverage on behalf of any other qualified beneficiary. that individual has the right to elect to continue coverage in any of the three health plans. For example. David loses his health coverage when he and his wife become divorced. David is entitled to a maximum of 36 months of COBRA coverage. a secretary with six years of service. John is fired for a reason other than gross misconduct and his health coverage is terminated. Core benefits include all other benefits received by a beneficiary immediately before qualifying for COBRA coverage. Mary H. a stockbroker. participates in the group health plan maintained by the ABC Co. individuals may generally elect either the entire package or just core benefits. however. Example 3: RST. which has no health plan.00a Page 110 of 150 . has health coverage through his wife's plan sponsored by the XYZ Co. Individuals do not have to be given the option to elect just the non-core benefits unless those were the only benefits carried under that particular plan before a qualifying event. David may purchase health coverage with the plan of his former wife's employer. she has the right to elect and receive coverage under the old plan for COBRA purposes because the new plan limits benefits for pre-existing conditions. Since in this case divorce is the qualifying event under COBRA. Non-core benefits are vision and dental services. Inc. A parent or legal guardian may elect on behalf of a minor child. is a small business. The health plan of the chemical company has a pre-existing condition clause for maternity benefits. How COBRA Coverage Works Example 1: John Q. If a plan provides both core and non-core benefits.

A plan. the option must be given for the beneficiary to enroll in a conversion health plan within 180 days before COBRA coverage ends.External Agents ___________________________________________________________________ A change in the benefits under the plan for active employees may apply to qualified beneficiaries. the 18-month period is expanded to 29 months. Paying for COBRA Coverage Beneficiaries may be required to pay the entire premium for coverage. Certain qualifying events. including both the portion paid by employees and any portion paid by the employer before the qualifying event. or a second qualifying event during the initial period of coverage. Duration of Coverage COBRA establishes required periods of coverage for continuation health benefits. however. If this option is available from the plan under COBRA. Premiums due may be increased if the costs to the plan increase but generally must be fixed in advance of each 12-month premium cycle. the premium for those additional months may be increased to 150% of the plan's total cost of coverage. COBRA beneficiaries generally are eligible to pay for group coverage during a maximum of 18 months for qualifying events due to employment termination or reduction of hours of work.00a Page 111 of 150 .doc Ver 0. 65736839. plus two percent for administrative costs. Coverage begins on the date that coverage would otherwise have been lost by reason of a qualifying event and can end when: The last day of maximum coverage is reached Premiums are not paid on a timely basis The employer ceases to maintain any group health plan Coverage is obtained with another employer group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition of such beneficiary A beneficiary is entitled to Medicare benefits Special rules for disabled individuals may extend the maximum periods of coverage. The plan must allow you to pay premiums on a monthly basis if you ask to do so. may provide longer periods of coverage beyond those required by COBRA. may permit a beneficiary to receive a maximum of 36 months of coverage. Some plans allow beneficiaries to convert group health coverage to an individual policy. Beneficiaries also may change coverage during periods of open enrollment by the plan. is not available if the beneficiary ends COBRA coverage before reaching the maximum period of entitlement. Premiums reflect the total cost of group health coverage. In this case. however. COBRA does not prohibit plans from offering continuation health coverage that goes beyond the COBRA periods. The premium is generally not at a group rate. The conversion option. The premium cannot exceed 102 percent of the cost to the plan for similarly situated individuals who have not incurred a qualifying event. If a qualified beneficiary is determined under Title II or XVI of the Social Security Act to have been disabled at the time of a termination of employment or reduction in hours of employment and the qualified beneficiary properly notifies the plan administrator of the disability determination. it must be offered to you. Although COBRA specifies certain maximum required periods of time that continued health coverage must be offered to qualified beneficiaries. For disabled beneficiaries receiving an additional 11 months of coverage after the initial 18 months.

). Coordination with Other Benefits The Family and Medical Leave Act (FMLA). which meets. Government.S. Premiums for the rest of the COBRA period must be made within 30 days after the due date for each such premium or such longer period as provided by the plan. any additional information needed to support the claim and procedures for appealing the denial. Contact the plan administrator for more information on filing a claim for benefits. The Departments of Labor and Treasury have jurisdiction over private sector health plans. only on a periodic basis. such as when an employee notifies an employer of his or her intent not to return to work. COBRA beneficiaries remain subject to the rules of the plan and therefore must satisfy all costs related to deductibles. Complete plan rules are available from employers or benefits offices. Coverage provided under the FMLA is not COBRA coverage. 1993. Claims Procedures Health plan rules must explain how to obtain benefits and must include written procedures for processing claims. plan administrator. the due date for the month of January could not be prior to January 1 and coverage for January could not be cancelled if payment is made by January 31. listed in most telephone directories under U. You have 60 days to appeal a denial and must receive a decision on the appeal within 60 days after that unless the plan provides for a special hearing. catastrophic and other benefit limits. Claims procedures are to be included in the SPD booklet. A COBRA qualifying event may occur. must make the decision. and FMLA leave is not a qualifying event under COBRA. Further information on FMLA is available from the nearest office of the Wage and Hour Division. Premiums for successive periods of coverage are due on the date stated in the plan with a minimum 30-day grace period for payments.External Agents ___________________________________________________________________ The initial premium payment must be made within 45 days after the date of the COBRA election by the qualified beneficiary. Employment Standards Administration. For example. The notice should state the reasons for the denial. The due date may not be prior to the first day of the period of coverage. The United States Public Health Service administers the continuation coverage law as it affects public sector health plans. Department of Labor. is not obligated to send monthly premium notices. however. however. when an employer's obligation to maintain health benefits under FMLA ceases. You should submit a written claim for benefits to whomever is designated to operate the health plan (employer. Role of the Federal Government Continuation coverage laws are administered by several agencies.doc Ver 0. Payment generally must cover the period of coverage from the date of COBRA election retroactive to the date of the loss of coverage due to the qualifying event. There can be charges up to 25 cents a page for copies of plan rules. effective August 5. The plan.00a Page 112 of 150 . If the claim is denied notice of denial must be in writing and furnished generally within 90 days after the claim is filed. etc. 65736839. requires an employer to maintain coverage under any "group health plan" for an employee on FMLA leave under the same conditions coverage would have been provided if the employee had continued working. or a group.

If a claim is determined to be free of typographical. This is a service that is continually under development. it is forwarded to the insurance company responsible for payment. This process may be repeated until the claim passes the inspection. We will make an effort to correct errors brought to our attention.doc Ver 0. Improved efficiency in healthcare delivery by standardizing electronic data interchange is a main feature in HIPAA. we make no guarantees. COBRA 3. False 2.External Agents ___________________________________________________________________ Conclusion Rising medical costs have transformed health benefits from a privilege to a household necessity for most Americans. While we try to keep the information timely and accurate. A good starting point is reading your plan booklet. If errors are detected.1 Benefits Of A Clearinghouse  Cash Flow If a HealthCare Provider were to send claims through the mail. The HealthCare Provider may then correct the related errors and resubmit for another pass. and logistical content errors. ______ Contains provisions giving certain former employees the right to temporary continuation of health coverage at group rates. Workers need to be aware of changes in health care laws to preserve their benefit rights. Net result: Improved cash flow. many weeks would pass before he would receive mail notification that errors were holding up payment release on his submitted claims. Say True or False.4. 3. Exercise HIPAA Means Health Insurance Portability & Affordability Act. syntax. Most of the specific rules on COBRA benefits can be found there or with the person who manages your health benefits plan. 8. Be sure to periodically contact the health plan to find out about any changes in the type or level of benefits offered by the plan.00a Page 113 of 150 . 2.3 1. 8. Say True or False. True 8. A Clearinghouse collapses the wait cycle into an average of 5-21 days. Answers: 1. The Department of Labor maintains this article to enhance public access to the Department's information. down from 4-8 weeks on paper claims.5 Clearing Houses A HealthCare Transaction Clearinghouse performs auditing services on insurance claims. 65736839. COBRA creates an opportunity for persons to retain this important benefit.5. it is returned to the HealthCare Provider along with an explanation of what was wrong.

But clearinghouses can typically access hundreds of insurance companies through a single port of entry from the office of the HealthCare Provider.00a Page 114 of 150 .000 combinations of errors. Topic Audit Logic Unbiased Processing Clearly. Today's HealthCare Clearinghouse market is very confusing. HealthCare Providers using the free or low cost software distributed by some insurance companies are subject to biased auditing without knowing so. 65736839. others nothing. Direct Filing Same. have strong ties with insurance companies that result in biased editing.  Connectivity Some insurance companies offer direct filing software. The industry is riddled with organizations that are exceptionally difficult to decipher. since the software may reject certain coding combinations during data entry.50 per claim.5. Filing a claim to an insurance company direct is almost reminiscent of allowing the IRS to file your tax return. 8.doc Ver 0. a clearinghouse has nothing to gain by delaying submissions or other operational errors.S. Insurance companies have everything to gain by delaying payment to HealthCare Providers. but most are not reported back to the HealthCare Provider. Instant notification back to the Provider. direct filing to insurance companies offers potentially hard to detect disadvantages to U. Some clearinghouses though. Insurance companies tend to "pick" on some HealthCare Providers and not on others. A clearinghouse has everything to gain by HealthCare Providers getting paid quickly and collecting as much of a submitted claim value as possible.2 Clearinghouse versus Direct Filing Using A Clearinghouse Routinely check for as many as 10. Typically. Coding is crucial in determining the income of a HealthCare Provider. When the claim travels electronically through a clearinghouse. and yet others in-between somewhere. Some clearinghouses charge $0. In many cases claims just "sit there" until a tracer or formal complaint is received. This may go unnoticed by incompetent or negligent staff inside the office of the HealthCare Provider. HealthCare Providers. A clearinghouse serves as a liaison to the HealthCare Provider.000 .30.External Agents ___________________________________________________________________  Guaranteed Delivery Insurance Companies often claim not having received claims that HealthCare Providers send through the mail. Audits performed on claims are not critiqued in favor of the insurance company with regard to how claims are coded. Then rejection occurs. these instances are greatly reduced.

A HealthCare Transaction Clearinghouse performs auditing services on ___________ _______. Cash Flow. standard working relationship with insurance companies Unbiased. to understand how clearinghouses make their money. residents of this state in connection with life. 8. to whom services are rendered. most income derives from insurance companies and is formally referred to as "rebates". Type 3 clearinghouses "lease" Type 2 gateways to insurance companies at volume driven rates. but render unique and superior audits resulting in improved services at a lower cost to the HealthCare Provider. 2. close affiliation with insurance companies Unbiased. Insurance companies typically do not charge anything to receive claims.6 Third Party Administrators Third Party Administrator is an entity required to make or responsible for making payment on behalf of a group health plan.4 1. Rebates. Type 3 clearinghouses utilize Type 2 gateways for transporting claims. close affiliation with leading Type 2 clearinghouses.3 Clearinghouse Income  Type 1 Biased. "Administrator" does not include any of the following: 65736839. imply that something was initially received. or disability insurance or self-insurance programs. Unbiased and "rebate" free. The following chart will illustrate all the groups Clearinghouse Types  Type 1 Type 2 Type 3 Biased processing.External Agents ___________________________________________________________________ As indicated. Exercise List down the Benefits of a Clearinghouse. As Type 1 clearinghouses developed "rebate" income.00a Page 115 of 150 .5.doc Ver 0.   It may be helpful. health. thus avoiding the typical enormous overhead of Type 2 clearinghouses. Type 2 clearinghouses followed up by negotiating rebates as well. 8. "Administrator" means any person who adjusts or settles claims on. Typically competitive in cost and superior in service. however.5.  Type 2  Type 3 8. Insurance Claims. dental. Answers: 1. 2. Guaranteed Delivery & Connectivity. all clearinghouses are not created equal. They typically fall into one of three possible group types. Primary income is derived from the submitting HealthCare Provider.

  Administrators may be tested and shall be licensed by the superintendent of insurance in accordance with rules adopted by the superintendent. or provide administrative services to. be licensed without testing. a plan or sponsor of a plan that is either domiciled in this state or has its principal headquarters or principal administrative office in this state unless the person is duly licensed under sections 3959. that enables to conquer the mysticism of Claims Adjudication. Any health-insuring corporation holding a certificate of authority of the Revised Code or an insurance company that is authorized to write life or sickness and accident insurance in this state. upon application.00a Page 116 of 150 .External Agents ___________________________________________________________________    An insurance agent or solicitor licensed in this state whose activities are limited exclusively to the sale of insurance and who does not provide any administrative services. Features: Repricing 65736839. at least once annually. Any person who administers or operates the workers' compensation program of a selfinsuring employer under of the Revised Code. Levels of the specific excess insurance stop-loss deductible. and any ownership relationship of five per cent or more between the administrator and such insurance payers. including any minimum attachment point factors.  Fail to disclose in written form the method of collecting and holding any plan sponsor's funds.  Fail to disclose in written solicitation material and on an on-going basis. dental. 8. The aggregate excess insurance stop-loss attachment point factors.7 Specialized Adjudication Engines/Companies Adjudicator A powerful engine that links to the existing software equipped with simple Boolean rules. Any person that administers an insured plan or a self-insured plan that provides life. identifying what each fixed cost includes. An administrator who has been licensed or certified by the state of the administrator's domicile under a statute or rule of the Revised Code shall. The names of all insurance payers providing protection for the plan sponsor's plans. health. provided the state of domicile recognizes and grants licenses to administrators of this state who have obtained licenses under such sections. No administrator shall do any of the following:  Use plan sponsor funds for any purpose or purposes not specifically set forth in written form by the administrator. No person shall solicit a plan or sponsor of a plan to act as an administrator for.  Fail to remit insurance company premiums within the policy period or within the time period agreed to in writing between the insurance company and the administrator.16 of the Revised Code. or disability benefits exclusively for the person's own members or employees. Any person who administers pension plans for the benefit of the person's own members or employees or administers pension plans for the benefit of the members or employees of any other person. to the plan sponsor all of the following: All fixed plan costs.01 to 3959.doc Ver 0. The system contains the most commonly used routines to analyze a healthcare claim and one can also write specific rules required for adjudicating the claims.

a comprehensive database that contains procedures. organizational charts. but is not limited to. enroll. position descriptions.00a Page 117 of 150 . procedures. sample template letters. the applicant usually must provide additional documentation clarifying any pending issues.9. one or more full-time URAC reviewers analyze the applicant's documentation in relation to the URAC standards. and preserve the integrity of brokerclient relationships. These phases include the following: 8. the remaining three phases of the accreditation process cover a period of approximately three to six months.1 Accreditation Agencies The Accreditation Process Organizations applying for accreditation participate in a process that entails a rigorous review occurring in four phases. If you process claims that require different fee schedules. in an effort to maximize cost containment and fairness in adjudicating claims. Once the application and base fee are received by URAC (The American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC). formal policies and procedures. As a full-service agency.8 General Agents They provide end-to-end connectivity that allows brokers and their clients to shop. modifiers and diagnoses Detects unbundling and upcoding Allows you to reduce levels of service Alerts of potential fraudulent billing Prepares an explanation of benefits with messages specific to your operation. including licensing and appointment with insurance payer. diagnoses and the Medicare fee schedule. usually takes several months. the leading accreditation organization for traditional health insurers). they provide valuable services. purchase. also uses the HFCA published guidelines for medical procedures. which consists of completing the application forms and supplying supporting documentation. "AccuChecker for Windows" has the 2001 tables of procedures and ICD-9 codes. supporting brokers in plan development. negotiation. serve and renew policies. computing the amount approved according to established fee Schedules and provider's contractual agreement Gives you the tools to automate correspondence with patients and providers AccuChecker is one such Adjudication Engine. This system comes equipped with "AccuChecker for Windows".doc Ver 0. The applicant's documentation usually consists of. 8. 8. The initial phase "Building the Application". case installation and communication. 65736839. the system allows you to insert additional files with the information needed.External Agents ___________________________________________________________________ Validates eligibility of patients. like for example Workers Compensation cases. contracts. as well as plan management and customer service.9.9 8. After receiving a desktop review summary.1.1 Desktop Review In the desktop review process. They are the people who work behind the scenes to reduce administrative hassles. resolve complex service issues. and program descriptions and plans for departments such as quality management and credentialing. consultation.

its accreditation will likely be rescinded. Conditional accreditation may be awarded to applicants who have appropriate documentation.3 Committee Review The last phase in the accreditation process is a review by two URAC committees that include professionals from a variety of areas in health care as well as industry experts selected from or chosen by URAC's member organizations. Ongoing Compliance with the Standards Accredited organizations must continue to remain in compliance with the applicable standards throughout the accreditation cycle. Follow-up activities for organizations receiving conditional accreditation or corrective action may include submission of additional or revised documentation and another onsite review. An accreditation recommendation is then forwarded to URAC's Executive Committee.9. Accredited organizations also provide copies of accreditation certificates to regulators in states where URAC accreditation is deemed. This summary is submitted to URAC's Accreditation Committee for evaluation with discussion with the review team as needed. In addition. The committee review process begins with a written summary documenting the findings of the desktop and onsite reviews. During this review.4 Accreditation Status Applicants who successfully meet all requirements are awarded a full two-year accreditation. During the onsite visit. After reviewing the summary and considering the Accreditation Committee's recommendation. 8. When these follow-up activities are complete. the accreditation review team conducts an onsite review to verify compliance with the standards. Education and quality management programs are reviewed in detail as well. If an accredited company is unable to comply with URAC Standards.g. Accreditation Certificates A certificate of accreditation is awarded to accredited organizations. URAC reviewers also share "best practices" and provide other helpful guidance.00a Page 118 of 150 . or choose to withdraw.doc Ver 0.External Agents ___________________________________________________________________ 8.2 Onsite Review After the desktop review is complete.1. the Executive Committee makes a final accreditation determination. which has the authority to grant accreditation. Each accredited site is given its own certificate. those that have not yet implemented their program or have not had at least six months of operational experience at the time of the onsite review. audits are conducted and personnel and credentialing files analyzed.9. denied accreditation. This will help the applicant differentiate its various products in the health care market and target a variety of current and potential clients.9. Complaints against an Accredited Company 65736839. attesting to the program the organization is accredited for. Conditional accreditation may also be awarded to companies determined to be "start-ups". and an accreditation certificate is issued to each company site that participated in the accreditation review. carried out by the same team that performed the desktop review..1. a follow-up executive summary is submitted to URAC's committees for a possible change to full accreditation. management is interviewed about the organization's programs and staff is observed performing its duties. Organizations that are unable to meet URAC standards may be placed on corrective action status.1. 8. e. but incomplete implementation of certain policies and procedures.

Once the pre-pay is processed. Sanctions may range from a letter of reprimand to revocation of accreditation. they are evaluated in terms of how much risk they present to the insurance company. URAC reserves the right to conduct an onsite review if the telephone interview and formal application are inconclusive. onsite visits are not "required" during the application process and a telephone interview of corporate officials is conducted instead. Web Site Accreditation Process The Web site accreditation process has some notable differences from the other accreditation programs. Employer-sponsored plans and associations are among the most common sources of group health insurance. URAC may sanction an accredited company. When they apply for individual insurance. Individual insurance is somewhat more risky for insurers than group insurance. This is generally done through a series of medical questions and/or a physical exam. 65736839. because group insurance allows the insurer to spread the risk over a larger number of people. Once completed. the formal application will be assigned to an Accreditation Reviewer. with the sponsoring employer or association paying all or part of the premium. Individual health insurance is a type of policy that covers the medical expenses of only one person. and presentation of the application to the URAC committees. The Accreditation Reviewer will follow the formal application through the accreditation process and is the same reviewer who will conduct all activities associated with the review process -desktop review. members purchase individual insurance directly from an insurance company. URAC first requires applicants to submit a “pre-applications” including payment information and general information about the company and it’s Web site. Unlike group insurance. Member’s risk potential will determine whether he qualifies for insurance and how much the insurance will cost. The letter of receipt will include confidential access codes assigned to the applicant that are used to access the secure.External Agents ___________________________________________________________________ URAC has a grievance procedure for investigation of complaints about an accredited company. individual insurance is generally more difficult to obtain and more costly than group insurance. Because only one policy is issued for the entire group.doc Ver 0. online formal application which contains questions specifically related to the Standards. Accredited companies seeking reaccreditation must submit the reaccreditation application to URAC at least four months before the accreditation expiration date or six months prior to expiration if the accredited company is a network reapplying for Health Plan or Health Network accreditation. URAC will initiate the formal application process. URAC's model of performing accreditation reviews allows the Accreditation Reviewers to develop an in-depth knowledge of the organization under review and provides a mechanism for the applicant to receive on-going feedback regarding the application and review findings. depending on the nature and frequency of the violations. After an investigation of each complaint. With group health insurance. The application process is divided into two distinct phases: 1) the pre-application. Unlike other URAC accreditation programs. Accreditation Cycle and Reaccreditation URAC accreditation is granted for two years starting the first day of the month following URAC's Executive Committee approval. Complaints may originate from consumers. the initial cost of establishing group coverage is lower than the cost of issuing a separate policy to each person. which may or may not include an onsite visit. providers or regulators.00a Page 119 of 150 . For this reason. a single policy covers the medical expenses of many different people (a group) instead of covering just one person. onsite review. URAC will send the primary contact person a letter and/or email confirming receipt of the preapplication. In certain circumstances. and 2) the formal application.

The contract details of every manufacturer are set up through some process like Volume Discount on-line processes. based on the manufacturer. such as average age and degree of occupational hazard. which is an independently managed US wide database for drugs. Whenever a member goes to buy a drug from a pharmacy. In the invoicing stage. all eligible people can be covered by a group policy regardless of age or physical condition. These limits are decided at the contract level and can be directly proportional to the number of drugs sold or can be based upon the market-share value for that drug across all the competitor drugs.00a Page 120 of 150 . Once the rebate checks arrive. product indicator etc. Any drug on the NDC list can be covered under the contract (but usually very costly and very rarely used drugs are not part of rebate contract). Health Insurance sets up a contract with each of them. he has to pay higher Co-pay. An extraction job runs on this database every quarter and pulls out those claims for which there are rebate contracts set up. Actual rebate value is decided when the contract is set up and varies over a wide range depending on the contract and manufacturer. Formulary and Cost Management Group using VDS on-line transactions only enter all these information. his claim is adjudicated online by the Real time Adjudication System. but this plan attracts higher premium. where each person's risk potential is evaluated and used to determine insurability. the relevant details are entered through Volume Discount Allocation system. Various inclusion/exclusion rules are applied. The premium for group insurance is calculated based on characteristics of the group as a whole. A member has to pay standard Co-pay when he buys a preferred drug. a set of jobs does the actual rebate amount calculations. which allows him to buy outside the preferred network for same Co-pay. along with the business rules from the contracts and summary files are obtained which form the input to the invoicing stage. want to put their products on preferred drug list/network. group. The drug information is obtained from First Data Bank. it is entered in the database. 8. regarding rebates that can be obtained from the individual manufacturers when drugs bought under health insurance policies cross pre-defined limits. Doctors can prescribe a drug outside this preferred list. The invoice amounts and the details are communicated to the manufacturing companies. for all the products they wish to add to preferred drug list. The policy is typically negotiated between the insurer and the "master" policy owner (employer or association) without any input from the member. 65736839.doc Ver 0.External Agents ___________________________________________________________________ Unlike individual insurance. as are the deductible amount and co-payment percentage. who to promote the sales. but if he buys drug outside the preferred drug network. client.10 Drug Manufacturers Health Insurance group identifies potential drug manufactures. A member can take a plan. Invoices for the dollar amounts payable by each manufacturer is prepared. The on-line screens are also used to enter the business rules (exclusion & inclusion) that determine the actual set of already adjudicated claims that can be considered for the rebates as defined in the contracts. The specific policy provisions are all determined in advance. Once the claim is adjudicated. This process also generates detailed utilization information to support rebates invoiced. contract. Doctors as well as pharmacies are provided with the preferred drug list (usually on-line). The Volume Discount System runs on a quarterly basis. In general. either electronically or through postal mails. the only real disadvantage of group insurance is limited or no freedom to customize the policy to member’s individual needs.

8.com http://www.yourhealthplans.com http://www.dhhs. 16.healtheon. 18. http://www.com http://www.com http://www.com http://www. 11.12 References 5.com http://www. 24. 13.gov/ http://www.hipaadvisory.com http://www. 22.com http://www. 4.insurance. 23.accuchecker.11 Review Questions 1. yourhealthplanonline. 3.os. 17.gov/ http://www.horizon-healthcare.nlm.External Agents ___________________________________________________________________ 8.com http://www. What is the role of Drug Manufacturers in a Healthcare Industry? What are the four parts of Administrative Simplification in HIPAA? 8.iix. 10. 2.hcfa.com 65736839.hrsa. 15.gov/nichsr/nichsr.00a Page 121 of 150 .alliance-edi. 25. 20. 12.com http://www. Explain the role of Third party Administrators. 19.horizon-healthcare. 7. 6.nih.insurance.accuchecker. 14.iix.yourhealthplans.com http://www. 21.gov http://www.doc Ver 0.alliance-edi.dhhs.com http://www.com http://www. 9.gov/ http://www.html http://www.com http://www.cdc.com http://www. List down some of the features of Adjudicators.healthinsurance.

dhhs.com http://www. 27. http://www.cdc.healtheon.hcfa.gov/ r. 29. 31. 33.External Agents ___________________________________________________________________ 26.nih.com http://www.gov/nichsr/nichs http://www.com http://www.os.gov http://www.00a Page 122 of 150 .com http://www. 32. 28.doc Ver 0.nlm.html 65736839.healthinsurance.gov/ http://www. 34.gov/ http://www.dhhs. 30. yourhealthplanonline.hipaadvisory.hrsa.

1 Unit Objectives This unit will summarize the contents of this course material by presenting a detailed description of healthcare industry workflow.IX 9 Summary 9. Figure 4: Detailed Workflow This diagram can be broken down into following stages – 65736839.2 Workflow The detailed workflow for the healthcare industry can be represented as shown in the Following figure.doc Ver 0.Summary ___________________________________________________________________ UNIT .00a Page 123 of 150 . 9.

Usually. which is submitted. They collect the required information such as number of members. the marketing department of the company creates a quote and presents it to the plan sponsor. He can go to any provider of his choice. to the quote requester. the PCP will provide a referral to the member.2. it is necessary that he should have satisfied his deductible for that particular year.3 An Enrolled member wants to seek medical services. Hospitals and pharmacies are usually contracted on a volume-for-rebate basis. payment details. Based on their judgment and experience they tailor the rates and prepare the details of plan coverage and commercial agreements. This is the flow in case of HMO and EPO plans.Summary ___________________________________________________________________ 9. the underwriters validate the rates offered by the marketing department. The insurance company guarantees an increased patient volume and they in turn give rate discounts to the members. network they need to get accreditation 9. Based on these rates. If there was any broker involved in the deal. If this is accepted by the quote requester. But before the providers can become a part of the from the relevant accreditation agencies. If this quote is accepted. In case of managed care plans. etc to prepare a quote. as in the staff model. PCP information (in case of managed care plans). they will have to meet a deductible before they can avail this facility.doc Ver 0. But. 9. their age. it needs to have an agreement with healthcare providers such as doctors. the flow is a bit more complicated. The PCP will also file a claim on behalf of the member. This data goes into an offer presentation. However.00a Page 124 of 150 . then the insurance company pays him a commission based on the size and nature of the deal. 65736839. income data. Now the member is formally enrolled with the insurance company. member number. then the policy department of the insurance company prepares a policy which has details such as policy number. The actuaries calculate the rates for the various services to be offered by the insurance company. doctors are contracted by paying them a fixed capitation fee (this is the case for most individual doctors). The PCP will try to provide as many services as he can.2.1 The Beginning: Member wants to purchase insurance The sales and marketing department approaches potential member(s). He pays the provider then and there and files a claim with the insurance company. In case of POS and PPO plans. They can also be contracted in the form of an IPA or may be put on the payroll of the insurance company. claim posting address amongst other things. hospitals and pharmacies. The member only has to pay fixed copay to both the PCP and the specialist.2. The member first has to visit his PCP. the member can seek services from out of network providers. This referral authorizes the member to seek medical services of a specialist provider. if a medical condition arises which requires treatment from a specialist. Also the concept of coinsurance will come into picture. type of plan. previous medical history. then things are very simple. If the member is enrolled in an Indemnity plan.2 Getting a provider For an insurance company to deliver healthcare services to its members. However. In case of PPO plans the member has the added advantage that he does need to have a PCP for In-network care.

NA 9. If the claim is found to be a valid one. as otherwise these claims would have to be adjudicated manually. The information about the entire processing is usually stored in a database for further reference. 65736839. the primary payer takes care of the COB or coordination of benefits. There are several government agencies that help in regulation of the healthcare industry.3 Review Questions. The government controlled Medicare and Medicaid are amongst the most important healthcare plans available. As a matter of fact. they are sent to the insurance company. Incorrect claims are returned back to the member (or his PCP whoever has file the claim). In case of the member having coverage with multiple carries. Claims adjudication requires a lot of information about various entities such as members.5 Effect of external agencies Health insurance is a highly regulated area in the U.S. In addition there are several other agencies such as clearinghouses and third party administrators who help the insurance companies deliver better services to the members. 9. The turn around time take to process the claims is also an important consideration for members and providers.Summary ___________________________________________________________________ 9. He is also sent an EOB detailing the payments made and the reasons for those. The company validates the claims based on various factors (as were detailed out in the unit on claims). If the claim requires very specialized processing (and if the rule engine for that is not available with the insurance company).4 Member has filed a claim In most cases the claim is first validated for typographical and information errors by clearinghouses. There is usually a rule engine (a software) in place for adjudication. plays an important role in shaping the way the industry functions. policy that are stored in their respective databases. The federal government too. which has since then dominated the market.doc Ver 0.2.2. This helps reduce the burden on the insurance company and speeds up the process. If the claims are found to be free of such errors.A. it was the path breaking HMO act of 1973. Accreditation agencies such as URAC (The American Accreditation Healthcare Commission/Utilization Review Accreditation Commission) play an important role in ensuring that only qualified providers are able to sell their services in the market. which paved the way for the managed care model. 9. In case the claims have incomplete information or the information is ambiguous. then the member is paid for his expenses.4 References. Hence the insurance companies try to reduce the time for adjudication by going automatic claim adjudication systems. then the claim adjudication is outsourced to a company specializing in adjudication of such claims. providers. the claim examiners do the adjudication manually. The federal spending on healthcare also has been on a steady rise. In short claims adjudication requires lot of database interaction and is the most complex of all processes.00a Page 125 of 150 .

00a Page 126 of 150 .doc Ver 0.Summary ___________________________________________________________________ 65736839.

090.408 69.8 Asia/Pacific Canada Europe Japan Latin America Rest of World United States Total Healthcare Worldwide 42. 1998-2003 (Millions of U.00a Page 127 of 150 .477 141.146 592.829 31.479 9.402 66.403 1.682 258.612 1.3 Source: Dataquest (January 2000) 10.834 10.867 161.393 411.741.1 1.674 32.877 1.113 500.268. there are Insurance-based systems in which providers are subcontracted by the government.505 54.749 5.8 46.5% in Europe.606.819. Dollars) Healthcare 1998 1999 2000 2001 2002 2003 CAGR (%) 53. Whereas they are Tax based systems (all providers are government owned) are in vogue in UK/Australia.668 44.2 835. Other countries spend less on IT as a % of revenues. Japan and Australia.437 266.doc Ver 0.Appendix ___________________________________________________________________ 10 Appendices 10.1 Appendix A: Total E-Business Services Forecast for Healthcare Total E-Business Services Forecast for Healthcare.800 20.187 40.020 293.164 417.628 289.931 1.081 81. In Germany/ France.917 29.140 5.S.314 25.850 48.201 2.756 50.285 816.6 43.1.979 363.018 91.551 45. by Region.964 151.5 45.444 184.805 646.086 14.5 515.843.259 194.523 442.752 140.979 3.050. 65736839.988 210.122 17.2 Appendix B: The world Healthcare market and Healthcare IT spending The US healthcare market is predominantly privately run.804 109.144 13.

00a Page 128 of 150 . Proteomics and Bio technology) revolutionize health care. (Source: Gartner Research. (Source: Gartner Research. Inc) 10.3 Appendix C: The Cash Flux of the US Healthcare Industry Healthcare started in a “not for profit” mindset and that still has influence in decisions made in this sector. less choice to patients and administration efficiencies. but the profit angle is increasingly focused on. Healthcare market.doc Ver 0. investment in IT in healthcare is at a low of 3% as compared to an overall average of 6% and 12% for Financial services. Other countries spend less on healthcare than the US does because single payer systems tend to have efficiencies in purchasing.Appendix ___________________________________________________________________ Worldwide. Inc) 65736839. a core focus for most governments around the world will continue to grow as newer technologies and sciences (Genomics.

doc Ver 0.4 Appendix C: Sample Quote Sheet Page 1 XXXX Proposal For July 26.60 $227.00 $264. Service Area is determined by the location of the subscriber's primary care doctor.00a Page 129 of 150 . Rates will vary for other service areas.Central Benefits For ZZZZ Plan Primary Office Visit Copay: ($5) Specialist Copay: ($5) SPU Surgery Copay: ($0) Hospitalization Copay/A: ($0) Emergency Room Copay: ($35) MH O/P Copay: ($25) 20v/cal Routine Eye Exam Copay: ($5) Routine GYN Exam Copay: ($5) 1v/yr Pediatric Preventive Dental Copay: ($5) Quote ID 7011968 Colorado Composite Rates Single Parent and Child(ren) Couple Family $114.70 $413.Appendix ___________________________________________________________________ US is the largest spender in this market.3 Trillion. account for 43% of the world spending. (Source: Gartner Research. 70% of the Federal budget of the US. 65736839.30 The foregoing rates apply in the Service Area specified above. The total health care spending (by private and public in the US) is 1.a whopping number by any standards. 2001 ABCDEF Inc Effective Date 10/01/2001 Renewal Date 10/01/2001 Service Area Colorado . Inc) 10.US also leads in the IT development of this market.

spouse or children and employee/family and (c) 4 tier which is an average rate for employee only.employee.The carrier also must provide the form. This proposal is subject to change at any time prior to the acceptance by AUSHC of Employer's offer.Groups with under 10 employees may only elect an age banded rate structure. Benefit Waiting Period (BWP) Standard BWP is 3 months minimum. There are two different rate structures available depending on the employer case size. Any changes in benefit level or conditions stated above may require a change in rates.Groups with 10 or more eligible employees have the right to see what the premium would be quoted either of two ways. a composite rate structure (an average rate based upon employee enrollment which vary by family status)or an age banded rate structure (a rate based on the age of the enrolledemployee).00a Page 130 of 150 . There are three different rate tiers available when electing the composite rate structure. to any person who is interested in coverage under or who is covered by a health benefit plan of the carrier. an unmarried child who is a full-time student under twenty-four (24) years of age and who is financially dependent upon the parent. These monthly quoted rates are valid as of the Effective Date and apply only to the benefit level and conditions stated above and are subject to the terms and conditions set forth in the HMO's Group Master Contract. Rates are pending approval by state regulators and are subject to adjustment based on regulatory determinations.(b) 3 tier whichis an average rate for employee only. upon oral or written request. employee/children and employee/family. an unmarried child under nineteen (19) years of age.The form must be provided automatically within three (3) business days to a potential policyholder who has expressed interest in a particular plan. (a) 2 tier which is average rate for employee only and employee/family. i. 6 months maximum or match the incumbent carrier's BWP up to 6 months maximum. Employer Authorization ___________________________________ Date ______________________ CC: AAAAA BBBBBB For office use only Grp Type 10 Code P RA TR X Val'd Seq#/Grp# 058963532205 Quote ID Customer ID 7011968 Calc 2254643 U PPID Rate Colorado law requires carriers to make available a Colorado Health Plan Description Form..Appendix ___________________________________________________________________ Quote Conditions Assumed Dependent Eligibility Dependent means a spouse.within three(3) business days.doc Ver 0. and an unmarried child of any age who is medically certified as disabled and dependent upon the parent.e. 07/26/2001 1:48:14 PM 7011882 LIFRAM12 65736839.which is intended to facilitate comparison of health plans.employee/spouse.

Provider: The person or group that provides medical services.doc Ver 0.e.: A member has to pay $5 every time he visits his PCP. doctors. Life. Member: The person or group who seeks insurance. Deductible: The minimum amount. Network: A group of providers in designated areas who are contracted by the insurance company to provide healthcare services to its members. the member. Benefit Code : Code assigned to Benefits. benefits meaning Medical Services (Service Types . pharmacies all can be providers. Co-Pay: The fixed amount. which the member has to pay for service availed from a provider.00a Page 131 of 150 . o What are the payments that the member makes? Policy: The legal document or contract issued by the insurance company to the member that sets forth the terms and conditions of the insurance. his co-pay is $5. Referral: An authorization from a PCP permitting a member to visit a specialist doctor for further treatment.Glossary ___________________________________________________________________ 11 Glossary  Benefit: (1) Right of the insured to receive either cash or services promised under the terms of an insurance policy. For e.               65736839. For e.) Co-insurance: A specific percentage of the cost of treatment the member has to pay for all covered medical expenses remaining after the deductible has been met. Plan: An agreement between the Insurance Company and the member that details the services that can be provided to the plan holders i. Dental. Insurer: The organization that provides insurance.e. Medical. (2) A major line of coverage provided by an insurance company (i. which has to be paid by the member to the insurance company before he can claim for benefits. etc.g. o What types of medical services will be covered. which the member has to pay to the insurance company on a timely basis (annually/quarterly/monthly) as a fee for providing insurance coverage. Premium: A fixed amount. It covers aspects like – o Policy agreements. Diagnosis Code : Code used for diagnosis that the patient has undergone. o What will be the maximum amount for which the member is covered. Long Term Disability.g.say Surgery) Insurance company will pay for. hospitals. A plan document identifies the benefits the members are to receive and the requirements they must meet to become entitled to those benefits. PCP: Or the primary care physician is a doctor contracted by the insurance company to manage the healthcare of a member. fully or partially.

      65736839.for full medical care of an individual. on monthly basis and/or per member basis . Proc/Service Code : Code for particular service coming under particular service type. The member is expected to consult its PCP first for any kind of health service for HMO care .00a Page 132 of 150 . Primary care Physician : The physicians/doctors providing full range of basic health services to patients. Capitation : Fixed amount of money paid to provider. Drug Code : Code for medication provided as a part of treatment. The service is specific whereas service type is generic. AT&T) makes contrat with healthcare companies for adjudicating claims for a fixed sum of money. Self Insured Groups : Some companies like (Eg.doc Ver 0.e. AT&T ) provides insurance for its employees by collecting money from them annually ( funding or contribution) . where in the company (i. Generally observed for Indemnity Plans.Glossary ___________________________________________________________________ Rider : These are add-ons to basic plan at some extra cost and will cover additional benefits.

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->