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 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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

........................................102 8...1 Benefits Of A Clearinghouse.....................113 8....................12 References.................................................115 8..............................103 8...................................127 10...........3......................................121 9 Summary.........................124 9.......................................3 Exercise...2 CORBA...9..........5......................................................................................................7 Exercise..............2........................2 Clearinghouse versus Direct Filing................................................................................124 9............6 Health Resources and Services Administration (HRSA)...127 10.......................128 10.....125 9.............103 8...7 Specialized Adjudication Engines/Companies........4.......................................................8 General Agents.........................4 Member has filed a claim..........115 8...............4 Appendix C: Sample Quote Sheet.........................2 DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHSS)..........Healthcare Market Overview ___________________________________________________________________ 8..............................................................................................................................113 8.............4......................2.....................................129 11 Glossary........................................ Inc).......................114 8........127 10........113 8....6 Third Party Administrators........................... 1.....................5...125 10 Appendices...doc Ver....................................105 8.......................................................117 8.....................................................3.........................................116 8..4 Government Acts and Regulations........................2 Getting a provider..125 9................................................................................3 Review Questions..........10 Drug Manufacturers...........................5................117 8......103 ELECTRONIC HEALTH TRANSACTIONS STANDARDS ..........................103 8..................5...............................................................................3 Centers for Disease Control and Prevention (CDC)..................121 8.........................................124 9......................................125 9........123 9.........128 (Source: Gartner Research..........................................................103 8.........................................117 8........................................................................3......................11 Review Questions................1 The Accreditation Process..................5 Effect of external agencies.................115 8...................1 Unit Objectives ...........................................101 8.....................................2.............................................................1 HIPAA..........................5 National Information Center on Health Services Research and Health Care Technology (NICHSR).......131 __________________________________________________________________________________ 65736839.......................3........................4 Agency for Health Care Research and Quality (AHRQ) .............3..........................4.........3 An Enrolled member wants to seek medical services...........106 8.2 Workflow ...4 Exercise..............................5 Clearing Houses...............................................................0 Page 4 of 132 ........................3 Appendix C: The Cash Flux of the US Healthcare Industry............123 9.......102 8......................................................1 The Beginning: Member wants to purchase insurance.2............................................................3 Clearinghouse Income...2.......................................9 Accreditation Agencies.......................................................................................4 References............3.........120 8..........................2 Appendix B: The world Healthcare market and Healthcare IT spending...123 9............................1 Appendix A: Total E-Business Services Forecast for Healthcare...................

there is a Deductible. since these companies are service oriented. It aims in providing the brief idea of the Industry and it’s the key players. The HMO concept has evolved over the last 15 years as a way to provide less expensive health coverage. Traditionally insurance has been one of the largest users of Information Technology.doc Ver.I 1 Healthcare Market Overview 1. a certain percentage will be paid by the Member and the rest by the Insurance Company (co-insurance). The “For-profit” companies control 60% of the Managed Health Care __________________________________________________________________________________ 65736839. HMOs typically interact with two types of customers: Employer Groups – These are companies that provide health coverage for their employees and dependents. violating this rule will make the member liable for the full amount. Managed Health Care is provided by HMOs (Health Maintenance Organizations). Any amount over the Deductible and the Co-insurance will be fully paid by the Insurance Company. This Industry is highly regulated and captures high volume of data. 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. 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. Their primary function is to provide Health Insurance to Employer Groups and Individuals. When a member follows this rule. After that. The concept has gained in popularity mainly from employers who provide health insurance to their employees in the 1990s. In case of Indemnity Plans. Health Insurance in the United States was through Indemnity Plans.1 Introduction This unit provides a brief idea of the Health Care Industry in the United States. the Imaging system that scans all incoming documents for storage and retrieval. All visits to any Doctor or Hospital have to be authorized by the HMO. To process this high volume of data collected and maintain them for stipulated time. Though the primary information system is the OLTP system that runs the daily business. In these plans.0 Page 5 of 132 . 1. the member is free to visit any Provider. he ends up paying a small fixed payment. Also. Historically. 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. 1.Healthcare Market Overview ___________________________________________________________________ UNIT . there are also support systems like the Data Warehousing System that helps in decision support. On the other hand. Also state mandated programs like Medicare and Medicaid also allow the recipients to be enrolled in HMOs. The industry has grown quickly and at present about 25% of all health insurance members are in some sort of Managed Health Care program. which means the first few hundred or so dollars is fully paid by the Member. and Individuals who look for coverage for themselves and their dependents.2 What is an HMO? HMO stands for “Health Maintenance Organization”.3 The Industry Outlook The concept of Managed Health Care gained popularity in the last 80s and the early 90s. response times become a crucial factor both to reduce cost and improve performance 1. The member should always visit the chosen PCP and on his referral can visit other doctors. for the next few thousand dollars. a high computing power becomes imminent.

US also leads in the IT development of this market. Cap on spending by government (BBA) is focusing efforts on cost cutting in this space. there has been a tremendous pressure on the bottom line of these companies. Initially small players focused on local markets dominated the Industry. the members participating in these plans feel that the HMOs squeeze the patients to maximize their profit.6 million) represents the largest number of users of long-term healthcare services. (Refer Appendix C). privacy and security. At present. __________________________________________________________________________________ 65736839. The past few years has seen a consolidation in the hospital and health sectors. See Appendix A). But the Healthcare market. However. also the fastest-growing segment of the U. Furthermore. Individuals aged 85 and older (3. 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. struggling independent facilities in rural markets. The last few years have seen smaller provider sub segments face financial challenges. population. will continue to grow as newer technologies and sciences (Genomics. accounting for 43% of the world spending. a decrease of about 11%. The US Congress is currently debating on a “Patients bill of rights” that will allow the patient to get better care under this system. 1. As a reciprocative step.but low activity expected. Large corporations want see employee health insurance costs to reduce overheads. which are coming into place.0 Page 6 of 132 . 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. it is estimated that about 13% of the overall industry bed capacity are operating in bankruptcy. they will now receive $74 billion over the same period. due to increasing health care costs.310 Billion annually (2001) and is growing at 7%.3 Trillion. (Refer Appendix B). reaching $30 billion by 2005. however as a result of the BBA. Before BBA.  HIPAA (Health Insurance Portability and Accountability Act) This act impacts all segments of healthcare industry with focus on standardization. which is a core focus for most governments around the world. The last major merger happened in Feb 1. 70% of the Federal budget of the US.Healthcare Market Overview ___________________________________________________________________ Industry. US is the largest spender in this market. will seek acquisition by larger chains.1 Trends in Healthcare – Provider Space There are two major regulations. and is estimated to grow to a huge USD 4 Trillion by the end of 2003 (Dataquest.doc Ver. Provider Organizations are adopting some Cost Cutting measures.S.when CHRISTUS Health was formed. The world market for Healthcare is USD 3 Trillion presently. Proteomics and Bio technology) revolutionize health care. However. In the last few years. The total health care spending (by private and public in the US) is 1. This trend has slowed considerably and can be considered to be over for now. 1. 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. The last few years have seen a rise in the Assisted Living Centers. Also. Furthermore.a whopping number by any standards. The US is the largest player in the Healthcare market and is worth $ 1. Industry sources project expenditures for senior living of $18 billion in 2000. which are going to have a major impact in the way healthcare providers operate presently. The trend is still continuing and the growth is expected to continue. 1999 .3. skilled nursing providers were slated to receive $83 billion during 9802. In the last few years there has been an increasing number of acquisitions and the industry is moving into the consolidation phase.

1. Ongoing pressure to reduce healthcare costs will prolong the merger trend in coming years. 10. Large HMOs are notifying the HCFA of their intent to exit Medicare + Choice market in 2001.g. which collectively serves 21. Managed Care Market Still Top-Heavy in the sense the managed care sector is fairly concentrated. resulting in more people covered.6 million Americans. 1. E. HMOs cut 400. Aging of the baby boom generation (born between 1946-1964). Plans available across the country United Health Care Minneapolis.com Into Health Care. CT www. People older than 65 years (currently 14%) are estimated to rise to 18. The largest privately held chain is the Blue Cross/Blue Shield Association. Individuals. Provides both Indemnity and HMO based Health insurance plans 21 million subscribed members in various health plans.aetna.3 members of Prudential Health Care recently acquired. Hartford. Cigna. MN www.5% in 2025. Prescription drug coverage has increased (95% of all members). Group Insurance etc. Retirement and Investment Services.000 members). More than 35 class-action suits have been filed against managed care companies to date.Healthcare Market Overview ___________________________________________________________________ labor costs (typically 40 -50 % of hospital operating costs) are steadily rising (specialized skills shortage). the rapid expansion of the elderly segment of the population is presenting HMOs with a new set of challenges.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. the number continues to climb. which requires them to re-look at their transactions.com Leading provider of health and retirement benefit plans. including Aetna (affecting 355. Recent times have seen HMOs exiting Medicare Choice plans. Pharmaceutical costs are rising about 15 %. Aging Population Poses New Challenge for the Healthcare organizations. Aetna. These companies cater to small and large Employer Groups. and also provide coverage for members participating in government programs like Medicare and Medicare.unitedhealthgroup. The last few years have seen Rising Costs for the MCO (Managed Care Organization). Provides both Indemnity and HMO based Health insurance plans 6. CT www. Property and Casualty. undercapitalized players. among others.5 Million members enrolled in Medical HMO Plans. HIPAA is going to have sweeping effect on HMO. Furthermore Managed Care Consolidation has seen larger companies acquiring smaller. Numerous companies have exited Medicare Choice markets following implementation of the BBA in 1997.000 members in 1999 and another 327.com __________________________________________________________________________________ 65736839. 1.5% in 1999. And this has resulted in higher costs. on average.cigna. Hartford.2 Trends in Healthcare – Payer Space There has been a rise in Regulations & Lawsuits against payers.000 in 2000.0 Page 7 of 132 . with the top 10 HMO chains accounting for close to 2/3 of total HMO enrollment in the US.3 million of those are Managed Health Care Members includes 5. Medical costs rose 7.3.doc Ver.

Healthcare Market Overview ___________________________________________________________________ Primarily into Managed Health Care.gartner.8 million Fully Insured Managed Care Members.com/ __________________________________________________________________________________ 65736839.000 Medicare members and 530.com/ http://www. 1.5 References AETNA Intranet http://www.gartnerg2.com/ http://www. 445.doc Ver.com/ http://www.com/ http://www. 1. no risk).jup. operates in many markets.aetna.8 million self-insured members (fee basis.gigaweb. About 5.0 Page 8 of 132 . 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.

In 1971. In the 1930s. Blue Shield) did not try to tell physicians how to practice medicine. who argued that the structural incentives of traditional fee-for-service medicine had to be reversed in order to achieve positive reform. and the Blues would simply pay the bills on a fee-for-service basis. During World War II. When the war ended. In the late 1960s and early 1970s. Kaiser believed he could reorganize medical care to provide millions of Americans with prepaid and comprehensive services at prices they could afford. the Administration was influenced by Dr. Physicians were free to practice as they saw fit. Ten years after the war. Paul Ellwood of Minneapolis. were all on the agenda. physicians in private practice almost always billed patients directly on a fee-for-service basis. politicians and interest groups promoted various proposals for reforming the healthcare system. 1.0 Page 9 of 132 . the Kaiser Permanente health plan had a growing network of hospitals and clinics and a half million people enrolled. However. developed peer review procedures. coverage for the uninsured. These members paid a predetermined fee and Dr. hospitals began to suffer from patients’ inability to pay their bills. The foundation heard grievances against physicians. This plan is considered the earliest example of an independent practice association (IPA) model prepaid health plan. Dr. and it paid the affiliated independent physicians and hospitals according to a relative value-based fee schedule. financially stressed hospitals prevailed on state legislatures to legalize the insurance schemes that became known as Blue Cross which were created as non-profit. Blue Cross (and later. Other local physicians became concerned about their own patient base.II 2 Healthcare Overview 2. prepaid health care remained a minor phenomenon until the 1970s. 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. Shadid rendered care to his patients. Kaiser opened his plans to the public. Michael Shadid started a rural farmers' cooperative health plan in Elk City. during the Great Depression. President Nixon’s Administration announced a new national health strategy. “Provider-oriented” meant that. The HMO Act of 1973 authorized $375 million in federal funds to help develop HMOs.1 Unit Objectives This unit will present an overview of the healthcare industry to the reader. Oklahoma 1929. In some locations prepaid group practice plans were quite successful at attracting members. provider-oriented insurance organizations. the development of health maintenance organizations (HMOs). In 1929 Dr. and monitored quality of care. 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.2 Genesis Of Healthcare Until the early 20th Century. efficient delivery systems and more. In adopting this policy. Issues of cost containment.Healthcare Overview ___________________________________________________________________ UNIT . __________________________________________________________________________________ 65736839. In 1954. 2. The foundation accepted capitation (fixed) payments from subscribers. Thus early insurance was restricted to Indemnity insurance. the San Joaquin County (California) Medical Society formed the San Joaquin Medical Foundation in response to competition from Kaiser. Over the initial objections of physicians.doc Ver. consumer rights. access to services for the poor and minorities.

and the federal government implemented Medicare. the figure can be said to portray the actual workflow for any managed care organization. enrolling about 65 million members (close to a quarter of the population of U. __________________________________________________________________________________ 65736839. (HMO is a subset of managed care) continued to grow throughout the 1970s. we will be better equipped to understand the workflow as depicted in the following figure. 2. The workflow for this model can be depicted as shown in the following figure. By the end of 20th century. or. Overall. The major players in this flow. 1980s and 1990s. however. 1. there were over 600 HMOs in operation. Employers came to look upon managed care as a less expensive yet comprehensive and high quality form of insurance to offer to their employees. thereby dominating the healthcare market.3 How the industry Works? Managed care market dominates the healthcare industry.doc Ver. This workflow is specific to Aetna-USHC (a leading provider of healthcare services).A). as it came to be called.Healthcare Overview ___________________________________________________________________ Managed care. 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. State governments turned to managed care to help with the Medicaid program. the managed care segment had 181 million members. We will see each of these in greater details in the next section. After the five pillars have been introduced.S.0 Page 10 of 132 . the nature of this information being very generic.

doc Ver.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. 1.0 Page 11 of 132 .

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

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

Claims adjudication is a very complex process and requires information of almost all the entities associated with health care such as members. a Claim is a request filed by the member (or his PCP) for the refund of medical expense incurred by him. As explained earlier. 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. Claim is either filed on paper or sent electronically . validated for necessary information and then loaded into a database. Apart from speeding up the process. The claim is then adjudicated (or tested for authenticity) as per the company’s business rules and policies. 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. Members cannot avail services from a provider not contracted with the insurance company. This is known as coordination of benefits (COB). also know as Claim Examiners. POS provides the member with the option of having HMO type coverage at a lower fee. 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.Healthcare Overview ___________________________________________________________________ The model of managed care as described above is known as a HMO or a health maintenance organization. policy etc. is a recent addition to the stable of managed care plans. The checks can include. On completion of claims adjudication. members may be enrolled with multiple carriers (insurance companies). It also gives the amounts applicable to him. while having the option of Indemnity type coverage at a higher fee.4 Claims. The recent trend has been to go for PPO plans. Hence.4.0 Page 14 of 132 . benefits. 2. The member is also sent a letter called the explanation of benefits (EOB). It has a major disadvantage that it limits the choice of providers to a network. providers. it also reduces the necessity for claim examiners. 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. a hybrid of HMO and POS plans. 1. referrals. as it offers the best of both Indemnity and Managed care plans. thereby making the process more cost effective. member receives a check for payment of the expenses. 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. 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. nowadays there is a major emphasis on automated claims adjudication.The claim is received by the insurance company. Sometimes. also claims with any missing information are resolved manually by Adjudication experts.EPO or exclusive provider organization. Complex or ambiguous claims.doc Ver. __________________________________________________________________________________ 65736839.

2. Apart from these regulating agencies. 2.doc Ver. claims which require very specific processing are sent to these specialized adjudication companies.A. 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.S. Clearinghouses perform auditing services on insurance claims. __________________________________________________________________________________ 65736839. So in case of very specific claims (such as processing of vision claims). it is returned to the Provider/Member along with an explanation of what was wrong. Following are some examples of such agencies. This helps reduce the cycle time for claims adjudication. 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. If a claim is determined to be free of typographical. These rates are based on a variety of factors and involve statistical and mathematical computations. Usually.In addition. 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. Meanwhile. All the services and management activities cannot be carried by the insurance company itself on it's own.5 Sales.0 Page 15 of 132 . the process of adjudication may be outsourced to another organization that has the necessary rule engine in place.6 External Agents. 1. Center for Disease Control and Prevention (CDC). 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). These organizations are known as specialized adjudication companies (Magellan and ADESSO are two such organizations). It requires some help from some external sources or agencies. If errors are detected. Since claim adjudication is a complex process. there are agencies that aid the insurance company on various other fronts. The role of the actuary is to decide the rates for the various services offered by the insurance company. Center for Medicare & Medicaid Services (CMS).Healthcare Overview ___________________________________________________________________ Also. Health care is a highly regulated area in U. Agency for Health Care Research and Quality (AHRQ). Sales and Marketing form an important activity in the health insurance industry. as there is stiff competition in the market. Together they use various methods and strategies to sell the plans to as many customers as possible. it is not possible for an insurance company to have a rule engine for adjudication of every type of claim.4. syntax. 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. After that come the Specialized Adjudication Engines/Companies who offer help on adjudication of claims. Government agencies such as Department Of Health And Human Services (DHSS).4. and logistical content errors. it is forwarded to the insurance company responsible for payment. An insurance company has its own marketing workforce and also a pool of agents (brokers). Health Care Financing Administration (HCFA) along with others are responsible for regulating the healthcare industry. the nature of claims processing being highly situation specific.

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

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

8 References. 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.doc Ver. __________________________________________________________________________________ 65736839.yourdoctorinthefamily.cornell.0 Page 18 of 132 . Review Questions.      www. 4.com http://trochim.com www. 1.human. “Future of managed care” by Tufts managed care institute.Healthcare Overview ___________________________________________________________________ Figure 2: Detailed Workflow 2.edu/ “History of managed care” by Tufts managed care institute.insurance. 2. 2.7 1. 3.

Healthcare Overview ___________________________________________________________________  “Managed care overview” by Amit Shukla __________________________________________________________________________________ 65736839. 1.doc Ver.0 Page 19 of 132 .

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

0 Page 21 of 132 . an insurer provides ID cards to its members. Provider will check the eligibility of the member for that service. Member can go to a service provider (hospital.1 Insurance Business: An Overview.2.2 Introduction Member is a person who is the actual beneficiary of the healthcare plan. 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. doctor) to avail the service.Members ___________________________________________________________________ UNIT . Some employers sponsor healthcare plans to its employees and its dependents.doc Ver.1 Unit Objective This unit will acquaint the reader with the role played by the member in the Healthcare Industry. These will be used to show the validity of the policy taken. 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"). The provider/ member then will file a claim to insurance company.III 3 Members 3. The pictorial view of the process is as shown in figure 1. Once enrolled. 1. __________________________________________________________________________________ 65736839. 3. Claim will be validated and the insurer will reimburse the amount to the provider/member.

1. Fig 2.Members ___________________________________________________________________ For the pictorial representation of insurance business and the member's interaction with other systems please refer to figure 2. __________________________________________________________________________________ 65736839.0 Page 22 of 132 .doc Ver. Insurance: An Overall Picture.

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

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

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

he/she can cut his/her insurance premiums dramatically. High lifetime payout Find a policy with the highest lifetime payout possible. Since group insurance costs less for the insurance companies to establish and administer. Anything less than $1 million may be insufficient to cover in the event of a catastrophic illness. A waiver-of-premium provision This allows one to skip the premium payments if he/she becomes ill. This can make group insurance even more affordable. In a group insurance situation. In the increasingly tight labor market conditions prevailing in Ireland at the moment. he/she may be able to choose between two or more insurance plans. the employer or association will pick up some or the entire group insurance premium. 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. And as long as he/she retains a reasonable out-of-pocket maximum. Choosing an out-of-pocket maximum is a personal matter. the companypaid group healthcare scheme offers benefits for employer and employee alike. however. Disadvantages of group insurance One can't customize the policy. Within a fairly large group. one shouldn't have to worry about medical costs getting out of hand. or Standard & Poor's. 1.3. What to look for in a group policy?  Financial stability Look for an insurer with an "A" or "A+" rating from A. Lower out-of-pocket maximums can mean substantially higher premiums. but he/she pays dearly for this protection. In some situations.M. Company Paid Groups     3. An increasingly powerful "perk" useful for both attracting and keeping good staff.4 In these groups.doc Ver. The provision can be very important if he/she is unable to work for an extended period of time. it is almost certain that the good insurance risks will equal or exceed the bad insurance risks. Moody's. the provisions of the policy are negotiated between the insurer and master policy owner (usually an employer or association). 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. Break on premiums In many cases. since the risk is spread out among a larger number of people. company-paid schemes are the fastest-growing segment of the market at present. 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.0 Page 26 of 132 . A "stop-loss" provision This limits the out-of-pocket costs.Members ___________________________________________________________________ insurance is somewhat less risky for insurers than individual insurance. it generally costs less to purchase. employers pay Healthcare subscriptions for some or all of their staff. An individual member does not have the freedom to have provisions included or excluded. Best. By agreeing to a higher deductible and/or co-payment. __________________________________________________________________________________ 65736839.

thereby reducing their effective rate of BIK to the standard rate of income tax. In a company-paid scheme. retention and goodwill. staff members can select a higher plan and simply have the balance deducted from their salary. __________________________________________________________________________________ 65736839. as it is helpful in growing their relationship.  Risk is moved to the Insurance Company. 1. The SI group also has to maintain certain bank balance at all times to ensure the continuance of medical benefits to their employees. (Examples are the Irish Farmers’ Association.) 3. Tax Relief for employees Employees are liable for Benefit-in-Kind (BIK) taxation on the paid Healthcare premium at their top rate of tax. a payment can be made directly on a yearly. Plan Sponsor is profited by:  They get the Health Insurance plan at a cheaper rate.3. professional bodies. one can provide his/her company with significant benefits in terms of employee recruitment. 3.Members ___________________________________________________________________ Fast access to the best in modern healthcare Members can choose admission dates to fit in with work and family commitments. Benefits to the company Introducing a Healthcare group scheme for employees. leading to less stress for them and their employees. Ease of Payment Payments can be made by direct debit through company bank account. quarterly or monthly basis. half-yearly.  They will be given more priority for processing of their claims then others get.) for their employees. SI Groups pay "Service Charges" to insurer for administration / management of medical insurance (adjudicating claims etc. Insurance Company is profited by:  Getting a fixed sum of money for adjudication of claims. Benefit in the premium amount Some group schemes qualify reduction in the premium amount. the company can claim healthcare payments under the Corporation Tax shelter.0 Page 27 of 132 . Flexible cover options Once employer chooses a particular level of cover. Alternatively.5 Affinity Groups An Affinity scheme is appropriate for members of business organizations.6 Self Insured Group Plan Sponsors / Companies who pay the Claims' amount of their employees themselves are called SI (Self Insured) Groups. sports clubs and interest groups. The financial risk is borne by the Plan Sponsor. But these figures are much lower than paying premium to cover all the employees. they are entitled to claim tax relief on the full premium. the Credit Unions and the Small Firms Association. 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.  Their Work will be given higher priority by the insurance company.doc Ver.3.

5 percent of AGI as are medical expense deductions. The definition of self-employed individuals includes partners and 2 percent S corporation shareholders.5 percent of his/her adjusted gross income (AGI) in any tax year.doc Ver.e. and physician's expense insurance.0 Page 28 of 132 . surgical. hospital. 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.. his/her spouse. trade group. These deductions aren't limited to amounts over 7.7 Self-Employed Members Health insurance need of a self-insured person is probably greater than the average person. 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. Un-reimbursed medical expenses include premiums paid for major medical. This option is not available to self-employed. then health insurance costs paid during that time cannot be used to calculate this deduction. __________________________________________________________________________________ 65736839. if the spouse of a self employed person. Special rules for the self-employed In addition to the general rule of deducting premiums as medical expenses. self-employed individuals can deduct a percentage of their health insurance premiums as business expenses. 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. he/she may deduct the amount by which his/her un-reimbursed medical expenses exceed this 7.5 percent threshold.3. he/she can deduct the following percentages of premiums for insuring himself/herself. were eligible for an employer-sponsored health plan for any part of the tax year. In terms of health insurance. chamber of commerce) Deductibility of un-reimbursed medical expenses In general If someone itemizes deductions and his/her un-reimbursed medical expenses exceed 7. and amounts paid out of his/her pocket for treatment not covered by his/her health insurance. Also. instead of saving for retirement.Members ___________________________________________________________________ 3. because an extended illness or hospitalization could easily deplete his/her personal assets and endanger his/her business. If someone meets the definition of a self-employed individual. Most people get their health insurance through their employers. However. funds in an Archer MSA are used to cover healthcare expenses. 1.

The biggest challenge in setting up an Archer MSA may be finding a company that offers them. Enlist advantages and disadvantages of individual and group insurance. are those who purchase insurance directly from an insurance company in case of an individual insurance.3. Answers: 1.  Someone. having additional coverage under a health plan that is not a high deductible. Many financial institutions are also still in the development stage with their Archer MSA account products. 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. 5. 3. __________________________________________________________________________________ 65736839. and The annual out-of-pocket expenses do not exceed $3.200 for individuals ($5. is not eligible to open an MSA. Employers 3. For Self-insured groups insurance company may provide the services. insurers are running into problems with state laws that prohibit such high-deductible plans. are those who purchase insurance in an employer sponsored insurance. in some states. In fact. 3.850 for families). A highdeductible plan is defined as one in which:  The deductible is between $1.200 to $4. Many insurance companies are still developing qualified high-deductible insurance plans and products with a savings component.400 for individuals ($3. 1. are those who pay the Claims' amount of their employees are Self Insured Groups. Individual Members 2.doc Ver.600 and $2.0 Page 29 of 132 .800 for families). 4. 2. This includes Medicare coverage. Plan sponsors/ Employers 4. However. Administrative /Management of medical insurance 5.8 Exercise 1.

Enrollment through the employer based systems Employers do have employees data maintenance systems. a member can start filling up the claims. verifying. Required data will be captured and sent to the insurance company electronically.Members ___________________________________________________________________ 3. Member will provide all necessary data to the insurance company that will include personal information. Member has to approach the office. Membership letters and other details will be sent to the member once the process is over.4 3. billing.doc Ver. Data entry operators will make you enroll online. For an employer ID numbers and passwords for its employees will be provided.4. Web-based applications For an individual web based application will facilitate online registration/ enrollment to get enrolled. Employees are allowed to select the benefits they wanted to opt for. Member will receive membership letter once the enrollment is over. and making available all necessary eligibility information for enrollee membership. This is most commonly used methodology for large employers having more than 300 employees.    __________________________________________________________________________________ 65736839.2  How is enrollment carried out? Traditional Paper Enrollment Enrollment forms would be available on the web sites or situated office outlets of the company.4. product issuance. The enrollment process will then be automated. Member can fill up the forms and send it to the respective postal addresses. 3. benefit information that he/she has opted for. Once the enrollment is over. The data will be received and formatted fed to the systems.0 Page 30 of 132 . This is the most commonly used approach. and claim adjudication. 1.1 Member’s enrollment What is Enrollment? The enrollment process comprises of collecting. Collecting and updating the systems with the data completes the enrollment process. Employer then validates and sends the information to the insurance companies electronically. Enrollment in the office outlets of the insurance company There will be city-based office outlets set up by the company. There will be online systems set up there.

doc Ver.4. Provider Report Providers are made aware of the new members enrolled under his/her name. Member has to show his/her identity card when he/she approaches a service provider (doctor. Member Member Member Employer Associations Insurance Company Fig 3: Enrollment Data Flow 3. hospital. Membership letters Once the enrollment process is complete. Name. membership number and other details. ID card would have details about the member's SSN. eligibility information. 1. Employer Report A report will be sent to the employer giving the details of its employees enrolled and their details.Members ___________________________________________________________________ Enrollment Data Flow is shown in figure 3. pharmacist).0 Page 31 of 132 . 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.

3.doc Ver. Direct enrollment in the field offices c. Fig. Web-based applications. Answers 1.4.5 Exercise 1. Electronic data transfer. 3. 1. Member needs to show _______ as a token of its membership in the insurance company. Employers having own member's database provide data to the insurer via _________. Enlist the means of enrollment.Members ___________________________________________________________________ 3.0 Page 32 of 132 .4. 4 Enrollment Process 3.4 Enrollment: Overall Picture Please refer to figure 4 for the pictorial view of enrollment process. 2. Electronic data transfer from employers d. 2. Traditional Paper transfer b. ID card __________________________________________________________________________________ 65736839. Means of enrollment are a.

 Service related information.  Subscriber's information. termination date will be sent back to the provider. member number (Identification number given by insurer). So the policy effective date.1 Member’s and Dependent’s eligibility Eligibility Eligibility is the ability of a person to use any kind of service. Last name will be fed to the online system as input. Identification number etc. These validations are also carried away when the eligibility is validated. Provider will send subscriber's information only if the member is a dependent. Every service-provider is bound to check the eligibility when a member asks for any kind of service except for indemnity plans. The system will run eligibility checks and returns the data to the provider. If member is eligible. Taking insurance business into consideration. Subscriber's name. Member when purchases a policy selects the services that we would want to be covered. Provider will also provide employer's data if the plan is sponsored by member's employer.  Employers Information. Again this will be validated against the insurer's database to make sure that the subscriber is a valid member. ID number is validated with the insurer's database. Social Security Number) along with service he/she is asking for. a member’s eligibility for a service will be decided upon the benefits that he/she has opted for. will be given to the system.  Policy Dates. Every employer when signs a contract with the insurer are given identification number.5 3. 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. Provider need not do any eligibility checks when member is having indemnity plans. 3.2 Eligibility Process Provider will query on a member for getting a particular service. __________________________________________________________________________________ 65736839.0 Page 33 of 132 . There are different services that could be covered by the insurer. The system will crosscheck the eligibility for the service and inform the provider back. 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). This data will be validated with the database of the insurer to make sure that the person is a valid member.5.Members ___________________________________________________________________ 3. If the member is not eligible to avail the service the service provided will not be insured. Insurers will set-up systems by which eligibility information will be available to the provider. Employer Name. 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. So every time a service is given a provider asks the system if member is eligible to get that service or not. Depending on that various terms like rates.doc Ver. the service will be provided and provider will file the claim for the payment of the service.5. premium will be decided. Not all could be applicable for a member. Provider gives basic information about the member (Member's identification number.

 Member having HMO plan __________________________________________________________________________________ 65736839. Even an employer is given access to this data so that it can monitor eligibility status of its employees. the information needs to be validated before giving any kind of service. By permitting healthcare providers to access this information directly.3 How a member should approach right provider? Eligibility also talks about the member getting service from a particular provider is valid or not.Members ___________________________________________________________________ A member is also allowed to monitor its own/ dependent's eligibility status. The Employer Eligibility information will be maintained and accessed by the employers. Employer groups normally use online administrative system that will provide eligibility status of a member. Some employers provide an online eligibility status inquiry similar to that given for employers.5. the deductible and all other information. 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. Insurance companies set online systems through which providers can query for the eligibility data for the member approached to him. The Member Member may be interested in looking for their benefit data. 1.doc Ver. Every time a member visits a provider. provider will give service to the member. employers and to its members. 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. 3. After getting confirmation from the insurer. The Provider Healthcare providers need vital information related to member eligibility and claim status. Eligibility data flows as shown in the figure 5.0 Page 34 of 132 .

If goes to in-network provider the co-pay will be less. 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. or a physical disability. Exercise 1.0 Page 35 of 132 . moves out of the household.Members ___________________________________________________________________ Every member has associated Primary Care Physician (PCP) for medical services and Primary Care Dentist (PCD). But there is no restriction on the choice of the provider.6 Answers __________________________________________________________________________________ 65736839. These are generally unattended.  Member having indemnity plan Member is free to go to any provider. Coverage for an enrolled child will end when the child marries.doc Ver. 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. 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. 1. Affidavits of Dependency and legal documentation are required with enrollment forms for these cases. Providers need not validate the member eligibility before catering any kind of service. mental retardation. automated transmissions that include security features like encryption technology and unique IDs and passwords for user verification and system access. 3.5. 4.  Member having POS plan Member is free to go to any provider.5. (Y/N) Son Bill of age 21 got married and moved out will be a valid dependent of Joe.5. 2.4 Eligibility Data Transfer Most of the insurance companies transfer the eligibility data electronically.  Member having PPO plan A member will fall under a network and can get service from any provider falling in that network. This methodology eliminates the need to submit paper forms or produce and send cumbersome tapes. Provider validates the eligibility of the member for the service asked. (Y/N)    3. legally adopted children. 3. 3. coverage may be continued. or turns age 23. So eligibility checks would be carried away but will not hold back the member from getting the service. (Y/N) Providing member's eligibility data to the providers is a responsibility of the insurer. This includes children who are away at school as well as divorced children living at home and dependent upon member for support. (Y/N) Daughter July aging 26 passing through a phase of mental illness is treated as a valid dependent. cartridges and diskettes. If member is divorced. foster children. Stepchildren.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. children who do not live with the member are eligible if member is legally required to support those children. which can get lost or damaged.

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

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

web-based applications or the walk in offices situated.  Update information These services are catered through phone calls. Log issues and complaints: o Logging provider complaint Member is free to log in any complaint about the service or the provider.Members ___________________________________________________________________ o Provider directory Provider directory is that enlists the providers those are in the network of the insurer/in contract with the insurer. proposed adoption. o Add or delete family members at open enrollment. 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. 1.doc Ver. Some of the cases are:    A marriage or divorce of the employee The death of the employee's spouse or a dependent The birth. o Updating personal information Member may wish to update the personal information such as address or contact number etc. booklets:  __________________________________________________________________________________ 65736839. Some times the employers update the insurer about these changes. Internet also helps out by providing enough data on the site.  Distribution of ID cards. o Clarification about the benefits Member can get the doubts about the benefits at any point of time. 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. are made available on the web-sites/applications that might be needed by the member. 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. 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. can walk in the offices set up by the insurer and do the changes.0 Page 38 of 132 .

  Some insurance companies also send the premium statements through email. claim payments.8. policy number etc. The member tears of the lower part of invoice. __________________________________________________________________________________ 65736839. cheque number. The member receives the acknowledgement letter from insurer giving detail about the premium received.doc Ver.Members ___________________________________________________________________ o Issue ID Card Member may need to issue a new ID card if misplaced/lost. moth. Can print as many copies as needed. Charging to the member’s credit card Some times member authorizes the insurer to charge the premium to his/her credit card.) and sends it along with the cheque in the envelope received with the invoice.1 Member Group Maintenance What are Groups? Groups are the frameworks used to organize billing. facilities: There are many upcoming services/ benefits newly provided by the insurance company. 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 acknowledgement letter contains the detail about the payment such as premium amount. fills in the detail (name. New facilities information About products and programs that are available in the state.8 3.   3. Payment by cheque If the member is willing to make a payment through cheque. 3.  Updating member with new products. Monthly statements are emailed to the member portable document format (.0 Page 39 of 132 . Address of the insurer is preprinted on the envelope. policy number etc. o o o New benefits information. The facility to replace the ID card would be provided. he/she receives a premium statement through post. Can be stored electronically on computer for easy retrieval. A new card will be sent to the address we have on file for you. 1. Sending statements through email has many advantages. 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. recording. The member has to fill a form for the ID card issuance. statements:   Can be viewed on computer.pdf) attachment. accounting and reporting of data to the plan sponsors (employers/ associations). Member is kept updated with the information by weekly/ monthly reports or news on the websites. Once the money is transferred to insurer’s account. The premium statement is sent to the member along with an envelope.

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

Guaranteed renewable means that the policy can't be canceled as long as member pays premiums. so may be premium will be raised only every few years. Employers can provide coverage for employees too. noncancelable policies are offered only to low-risk occupational groups at a high premium. 5. 5. they must have the permission of state's insurance department. which would apply to all individuals in the same insurance classification).0 Page 41 of 132 . What types of services does the insurer provide? 2.2 Exercise Questions 1. For a guaranteed renewable contract company cannot raise your premium on an individual basis. but the premium can be raised under certain circumstances (the state insurance department must approve the change. A non-cancelable contract is preferable to a guaranteed renewable contract.doc Ver. Often. Disability benefits contracts in which policy cannot be canceled but premiums can be raised are _________. Opting for the guaranteed renewable provision may save as much as 30 percent of the premium cost. pay attention to whether the contract is non-cancelable or guaranteed renewable.9. 3. 3. Answers: 4. When the groups are formed in case of a group insurance? 3.9. Enlist the services offered for group maintenance.they can be used in any way the member wishes them to use. __________________________________________________________________________________ 65736839. 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.1 Member’s concern When a member buys an individual disability insurance policy. 4. Disability benefits contracts in which policy cannot be canceled and premium cannot be raised are _________. 1. The funds paid are not specified for medical expenses .9 Disability Benefits Disability income insurance provides members with an income if they become sick or injured and are unable to work. Guaranteed renewable. Non-cancelable.Members ___________________________________________________________________ 3.

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

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

doc Ver.g.e. 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.   SPECIALIST: A specialist is one who has one or more areas of specialization in medical field. the members.Providers ___________________________________________________________________ UNIT .IV 4 Provider 4.1 Provider types Providers are those people. organization or institution that provide services to those enrolled into the system i.0 Page 44 of 132 . There can be numerous classifications of providers depending upon the facilities provided by them. COMMUNITY PROVIDER: These providers do not have a contract at all with Healthcare organization. PREFERRED PROVIDER: These are those providers who work on contract basis by negotiating the compensation they charge. Every member is supposed to approach the PCP first before going to anyone else. physicians etc. BACKUP-PROVIDER:   __________________________________________________________________________________ 65736839. Hospital etc. Dentists. NON-PREFERRED PROVIDER: These are those providers who are not contracted to furnish services or supplies within ‘PREFERRED’ network. As the name suggests it is the PCP who is in constant touch with the members directly. IPA or PORG: (Independent Practice Association or Provider ORGANIZATION) It is the legal entity that provides administrative and contract related services for providers.  Other way of classifying them based on the type of contract is as follows:  PCP: Primary care physician.  NON-PAR: These are those non-participating providers whose contract with Healthcare organization is terminated.   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. Group Or Entity: These are group of people who provide services under a common name e.g. 1.

providers can be classified as following:    4.1 Provider Contract Process Providers who wish to participate in one of the networks must complete an application and the corporate credentialing process. Backup provider provides medical services to the patients of the provider when he is not available. 4. which share knowledge and intellectual property via the Internet. 1. there will be routine visits to the provider's office and a re-credentialing process every two years. which involves clearing provider claims within a fortnight (subject to the provider electronically filing the claim in a prescribe format). ICU’s. a minimum number of member (or dependent) visits.3. path labs etc. Pharmacies. E. 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 __________________________________________________________________________________ 65736839.2 Credentialing Criteria The process requires providers to present documentation of training. so as to assure a minimum amount of revenue by way of claims.2 FACILTIES: These are those providers who provide facilities such as wards. 4.g. large HCO(s) provider e-learning options to enrolled providers via virtual communities on the Internet. Based on nature of service.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.. 4. Provider Participation HCO (Healthcare organizations) usually elicit provider participation (into their network) using some standard marketing strategies.doc Ver. 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.3.Providers ___________________________________________________________________ A provider can specify another provider as his/her backup.g. These are specialist networks of providers. Hospital. individual practice associations (IPAs).PHO(s).0 Page 45 of 132 . Some HCO(s) have pioneered the E-Pay/E-Cash option. • Minimum number of member visits Some HCO(s) guarantee providers. education and other relevant information. or an appropriately delegated credentialing process. SUPPLIERS: These are those providers who provide medicines and surgical instruments. Maternity Home etc. EQUIPMENTS: These are those providers who provide medical equipment for executing medical tests such as X-ray labs. Health insurance companies sometimes delegate credentialing to some physician groups. • E Learning Virtual Communities As some of the fringe benefits. e. Once a provider is accepted as a participating provider. and physician hospital organizations .

DEA registration.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. independent practice associations (IPAs). many participating primary care physicians are compensated in accordance with the Quality Care Compensation System* (QCCS) described below. specialists. Medicare/Medicaid) Work history Malpractice insurance coverage history Clinical privileges at a hospital hospital 4.3.Providers ___________________________________________________________________     Disciplinary history (including licensure. 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. professional organizations. Specialist contracts and Hospital contracts. the system uses a three-part quality factor to adjust the physician’s capitation payments. physician hospital organizations. Under capitation. a physician receives payment for a patient whether the physician sees the patient that month or not.4 Types of Contracts All major health insurance companies have several different types of provider contracts based on the type of servicing provider.5 Provider Reimbursement Most health insurance companies incorporate the following payment methods to reimburse providers for services. 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. For example.  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. Quality Review considers: __________________________________________________________________________________ 65736839.0 Page 46 of 132 . Some of the different types of provider contracts include PCP contracts. hospitals. physicians are paid by capitation.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. 4. In most areas. Additionally.3. 1. per month)  By integrated delivery systems. membership/privileges.doc Ver.

3. details of the provider who is referring. A PCP or an authorized provider provides it when special care is required. 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. diabetes and heart failure   4. A referral once issued has a validity period.Providers ___________________________________________________________________ Results of member surveys Review of the care (like childhood immunization rates. If some referral has to be cancelled then we can do that through this process. Answers: 1. Referral maintenance – through this process one can modify the existing referral entry. Insurance Company 4. 2. Contract is an agreement between the provider or group of providers and the _________________. Referral is not always required to visit outside PCP.1 Referrals processing  Referral entry – All the referral should be entered in the referral database so that it can be used if required. Some plan has flexibility to visit any provider without any prior authorization in that case referral doesn’t come into picture. Suppliers 4. The information which needs to be entered are Member number. 4. PAR or Participating 3.5. details of the provider for whom referral given. PORG etc) 2. Referral entry can be done through batch or online processing however inquiry and maintenance is done through online screens. A PCP can issue themselves referrals for non-routine services.   __________________________________________________________________________________ 65736839.0 Page 47 of 132 . True. (E. Providers who provide medicines and surgical instruments are known as ___________. A provider is called as ________ provider if he has a valid contract with the company. It depends on the plan taken by the member. 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. Exercise The legal entity that provides administrative and contract related services for providers are also a type of provider – True or False. 1. referral validity ‘From’ and ‘To’ date and service code (it specifies the king of service/treatment). Encounter date. 4. The inquiry can be done either on the basis of member number or referral number which ever is known.g.doc Ver. 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. IPA.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.4 1.

 Electronic referrals – Direct online entry by provider. hospitals. availability of health care services. in particular. A rental network is an arrangement in which another organization (besides AUSHC) contracts with a group of providers. The first will be a detailed dump of the referral that will be written to a purge file.) who have agreed to treat AUSHC members at negotiated rates and have agreed to abide by patient and quality management programs. must meet more than two-dozen criteria for admission into our networks. All providers’ performance in monitored regularly. 1. o If the procedure/service code indicates that it is an infertility referral (e. one of the toughest participation requirements in the country. A Job will scan all referrals within the referral database. 58555. and the referral has been logically deleted. and a visit has been taken within the last 6 months. with the following exceptions: o If the date of the referral entry is less than 18 months from the current date. This is possible if the provider is connected to the company’s network directly or through a third party.doc Ver. 58560).6 Provider Network A network is a group of contracted providers (doctors. laboratories. which will do the actual erase of the referral. 58550. local practices. AUSHC then reimburses that organization for allowing our customers to use the network.5.6.1 Quality Provider Networks AUSHC believes members benefit from quality provider networks in the following ways:  Comprehensive: Several providers participate with AUSHC including. and travel time are taken into consideration when contracting with local providers to join the networks.  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. 4.  Tough Standards: All providers must meet our comprehensive credentialing standards. 4. o If the referral is 18 months or older. the referral will not be purged. Our objective is to establish networks large enough to satisfactorily serve the targeted population to whom they will be available.Providers ___________________________________________________________________  Referral purging – This can be done in batch mode. __________________________________________________________________________________ 65736839. and a visit has been taken within the last 30 months. the referral will not be purged. the referral will not be purged. If the referral meets the purge criteria below.0 Page 48 of 132 . primary care physicians. it will be written to two output files. This information will be written to a yearly archive file that is used to recall purged referrals. Primary care physicians.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. 58552. Factors such as population. All referrals over 18 months old are purged.  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. specialists. 4. and acute care hospitals. 58551. etc. The second is a file that is used by another job.g.

Aetna reimburses the rental network organization for allowing our members to use the network. and when members have access to the various types of medical services they may need. closed.0 Page 49 of 132 . Pro Net) contracts with the providers.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. The status can be retired. If it is any group or hospital then name of that should be stored. licensure or accreditation status. Labs etc. 1. network staff target providers to be recruited and contracted. and provide evidence of such insurance upon request. Almost all the system uses this database to get any information about any provider. They compare the existing network with adequacy guidelines for the specific service area and identify whether there is a need for new providers.7.Providers ___________________________________________________________________ 4. Instead of engaging in direct contracting arrangement with individual providers.g.. 4. A provider who is providing healthcare services on current date is an active provider.4 Network Hospital Standards Our current hospital contracts require network hospitals to represent and warrant that they are. appropriately licensed and accredited by either the American Osteopathic Association (AOA) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Provider status – Shows current status of the provider. which includes hospitals. 4. given to each provider to identify the provider easily.7 Provider maintenance This process involves collecting information on all type of Health Care Providers. one the major database is Provider database. They must also maintain adequate malpractice and general liability insurance or self-insurance. The criteria used to select participating providers reflect minimum network composition standards. and will remain during the term of the contract. The local Network Management staff has the ongoing responsibility of ensuring that each network has the proper composition of providers. After developing a list of providers by type needed to meet customer needs.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.6. A PPO network must be complete enough to provide members’ access to a participating provider for a core of essential medical/dental services. 4.3 Rental networks A rental network is an arrangement in which another organization (e. All facilities are also required by contract to notify us of any change in coverage.6.6. 4. Provider name – it is the name of the provider if he is an individual provider. but may vary to accommodate local supply and regulatory requirements.   __________________________________________________________________________________ 65736839.doc Ver. deceased etc. In other words. In the healthcare organization. All the inquiry or maintenance of providers is done based on provider number. networks are adequate when there are enough providers available for the member population in a geographic area. Provider maintenance should be done everyday in order to keep the provider database up to date all the time. Doctors.

____________________ is the interval of claim payment to the provider. Nutritionist. Provider Specialty . Nurse Practitioner.Providers ___________________________________________________________________ Provider type – Provider type is categorization of the providers depending on the type of healthcare services they provide. Dentist. only then the payment is made to the principle service address. – Physician.  4.8 1. bi-weekly or monthly. one of their addresses is identified as principle billing address. transportation etc. 1. 02…. __________________________________________________________________________________ 65736839. 14 or 15 billing address. Providers will participate with an organization for a certain period and may discontinue. A provider can have more than one billing addresses. he can specify level 14 billing address for payment of capitation and level 15 billing address for payment of claims. 4. E. It can be weekly. Clinical Social worker.The address at which the payment of claims is made to a provider is called the billing address.0 Page 50 of 132 . Psychologist. is ____________. 3. There would be providers in the database. 2.doc Ver. but the company needs to put their details as well. Radiology center.The area in which a provider specializes is called his SPEC or specialty. Provider can have maximum of ten Service Locations (SLs).All information maintained are time sensitive. c) Both of the above. There are some plans available in which the member can visit any provider irrespective to his contract with the company. which are not in contract with the company. If there are no levels 10. Exercise Referral is mandatory to visit a specialist irrespective of insurance plan/policy – True or False. If a provider wishes to have a billing address.    o   Claims payment schedule – It is the interval of claim payment to the provider. If the code for billing address is o It’s the principle service address.g. If a provider has more than one service locations. o This is CAP and Claims billing address. he specifies a level 10 billing address. Billing Address . which ease in maintenance of that provider record. Contract info – this information tell whether the provider is in contract with the company or not. d) None of the above. b) Members have access to the various types of medical services they may need.09 Service addresses. Provider network is adequate when: a) There are enough providers available for the member population in a geographic area. Midwife. Effective and termination date . which is different from all his SL addresses. 14 & 15 – If a provider wishes to have separate addresses for capitation and claims payment. The addresses of rest of the nine SLs are stored as 01. to process their claims. A unique number given to each provider. Both claims and capitation payments go to this address only if provider has not specified level 14 and level 15 addresses.

com/www/provider. 4.Providers ___________________________________________________________________ Answers: 1. 4. 3.com/healthcareproviderinfo.doc Ver. 4.com/ http://www. C.com/ http://www.g.edu __________________________________________________________________________________ 65736839.ucla.10 References AETNA Intranet http://www. (E.com/ http://www. In Indemnity plan referral is not mandatory) 2.asp/ http://www. False.masslegalnurse.9 1.doctorandpatient.org/ http://www.healthinsurance. Claims payment schedule 4. 1.healtheon.0 Page 51 of 132 .doctorquality.htm/ http://healthcare. 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.healthaffairs. 2.

Providers ___________________________________________________________________ __________________________________________________________________________________ 65736839.doc Ver. 1.0 Page 52 of 132 .

Key Producer Compensation – Sometimes the company identifies key producers and gives them bonus if they get more than a fixed number of new subscribers.V 5 Sales 5. Brokers are also called Producers in this context. Producer Data is frozen at the end of a year. Users within the company need to maintain particulars of brokers and information regarding broker-customer relationship. Medicare Promotion Compensation – Some companies pay bonus to brokers for bringing in new Medicare Applications. In such cases the Customer and Cash receipts information is maintained and broker commission is calculated from that. Each Customer group should submit a stipulated minimum number of applications for corresponding broker to qualify for commission.00a Page 53 of 150 .1 Unit Objectives This unit aims to familiarize the reader with some aspects of insurance sales and quote creation. A substantial percentage from customer groups’ payments result in distributing some percentage as commission to brokers.2 Introduction Sales and Marketing form an important activity in the health insurance industry. here buyers being the customer group buying a plan and sellers being the insurance company. as there is stiff competition in the market. The bonus distribution could be something like this: Net Subscribers Produced Override % of Premium 150-750 1% 750-2500 2% 2501+ 3% Cap of $60.1 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. 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. The various entities involved like Brokers and Underwriters are also discussed. 5.Sales ___________________________________________________________________ UNIT . As in every other business. Together they use various methods and strategies to sell the plans to as many customers as possible. The banding of the medicare promotion award could be something like this: Program To Date Application Level Payoff per Application   65736839.doc Ver 0. 5.3. 5. An insurance company has its own marketing workforce and also a pool of external agents (brokers). This bonus is in addition to commission a producer receives on premium paid by Customer Groups.3 Brokers An insurance company generally has a pool of brokers.000 per Customer group per calendar year. in health insurance too brokers bring together buyers and sellers against a commission. This bonus is one time payment for new application and it depends on number of new application submitted.

However. benefits and new locations where plans will be offered for sale. In case of a group insurance policy the rates may be banded on basis of age/ gender/ family status).4 5. possibly after relevant customizations. All these affect the cost of the plan.) These are all mainly data-entry operations. Hence Book Rates are same for any customer group availing a particular plan in the same area and hence the name Community Rates. (In section 5.1 Quote Creation What is a quote? A quote is a statement of rates of a particular product. They enter data about new/updated plans. On the basis of statistical considerations and mathematical calculations and with the aid of rating applications. It contains information about: 1.4. given by a seller to prospective buyers. inpatient hospitalization etc) 5.000 per Customer group per calendar year.00a Page 54 of 150 .Sales ___________________________________________________________________ 1-250 $100 250-500 $125 500-1000 $150 1000-2000 $175 2000+ $200 Cap of $60. In context of health insurance. for the member(s). Effective Date & Renewal Date (date from which the policy will take effect and date when the policy will be due for renewal.e. They group and combine benefits into plans and maintain data about product-offerings in different service-areas i.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. State regulations affect prices.4. If not renewed by that time. Rates (the premium due per member.doc Ver 0. benefits and conditions of a chosen plan.  The effective date . These rates need to be approved by the concerned department in some states. Actuaries also calculate the values of group-specific factors for different locations at different times.rates are revised from time to time and hence the dae of commencement of coverage affects the rates. Name of the firm buying the policy 2. A highly specialized and trained user group called Actuarials does rate Setup.  The location / service area of the customer group . Name of Plan 4.Government regulations often mandate certain kinds of coverage. Actuaries come up with rates for each product. do not take account of any factors specific to any customer-group. statutory information etc 5. But they do not apply these factors.6 we will study in details how Actuarials arrive at these rates. (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. make certain products saleable in certain area and withdraw some products from some areas as and when required. tax structures etc. 6.the benefits included in a plan are basis of the cost of the plan. the policy becomes void) 1.) 65736839. 5. Some standard information – like applicable conditions. Admin users usually do product setup. Details of coverage (benefits like pcp visit. Service Area – Area in which the members will be based 3. These rates are called Community rates or Book Rates or Base Rates and they depend only on:  The plan chosen . a quote is a statement of cost.

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

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: 65736839.7).00a Page 56 of 150 . If rates are acceptable to the customer group they sign on the quote sheet. (We will discuss activities of underwriters and special rates in detail in section 5. They can make adjustments according to their discretion. Once they approve the quotes the marketing people present them to the customers. thus entering into a legally binding contract and members are enrolled for the accepted policy.doc Ver 0.Sales ___________________________________________________________________ Underwriters have the final say on the rates.

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. The difference between Book Rate and final rate would be due to ______________factors. 4. Group-specific 65736839.c . Admin applications are used by Admin Users for Product Setup. An optional layer above these would be a web-based front end .doc Ver 0. Actuaries to calculate the Base Rates of Products use rating applications.which would act as a single interface or gateway for all marketing. Product Setup is done by (a) admin users (b)marketing people (c)actuaries 2. managerial and underwriter users to the suitable application. 3.2.0 Here we see that central to the system are the Admin and the Rating Applications.same 4. The final say on the rates is with (a) marketing people (b)actuaries (c) underwriters (d)underwriters 3.00a Page 57 of 150 . Exercises: 1. Quoting Engines generate quotes with customer specific rates. a . Enveloping all these there may or may not be a Quote front end . Underwriters and Marketing assistants use both of these. Quoting Engines and Renewal Applications use the data generated by these applications.Intranet for use of all internal users and Internet for use by customers to get data online. and are also used for renewing contracts. Answers: 1. Renewal Applications pick up contracts that will be shortly due for renewal.Sales ___________________________________________________________________ Marketing assistants Fig 3.

g. 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 time between the occurrence of the illness and filing of claims. when one takes a mortgage. Actuaries first estimate the cost the insurer has to incur in terms of payments towards doctors / hospitals/ equipment etc. Further. in order to calculate Book Rates. and the technician of the continually changing field of financial security systems. Time until termination . conservatism & adjustments: last but not least.number of claims arising from a specified block within any given time . from time to time. II. Examples of random variables: I. This is where the judgment factor comes in. the time between filing of a claim and the actual settlement etc. the rate of investment return). Each plan is a collection of benefits. Number of claims . if Copay for a specialist consultation increases a member may go in for specialist consultation less frequently. In all these the actuaries must exercise utmost caution and judgment. some show a long term trend III. 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. if income is expected to increase in future. Conservatism would lead to higher prices.g. prices etc. Total Claims . Assumptions.The total dollar amount of claims arising from a particular block over a particular time period Rate of interest: (or more generally. the adapter. Interest rates vary in many dimensions. But too much of conservatism would make prices uncompetitive.measures length of time that some well-defined status exists e. The PMPMs of all the benefits in a plan are added to get the PMPM of the entire plan. 65736839. 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. Random variables: actuaries use statistics and probability to estimate what they call "the certainty of uncertainty".some coverages show a seasonal variation. the estimated duration of hospitalization for a particular coverage. 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. Evaluation of benefits and estimation of costs is done along these lines. taxation laws. the innovator.Sales ___________________________________________________________________ 5.g.doc Ver 0. the risk estimator. than Y days down the line. On this.5 Actuaries The role of the Actuary is said to be that of the designer. So. 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. a high percentage of all actuarial calculations is based on one or more assumptions. to provide that benefit to one member in a certain period of time.00a Page 58 of 150 . then this future income can be brought into the present e. from place to place. or a higher value of a liability. and by time to maturity and thus affect any financial assessment. the problem solver. 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. Risks: the risks associated with providing the benefit. Sometimes adjustments also need to be made in view of unusual circumstances. by degree of security risk.

 Mutualized : Some customer groups may have outlets/ offices in various locations across the country.false Underwriters form a very important user group in any insurance industry. 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. Class rating is a rating methodology where rates are banded into tiers (single. For example people working in S/w industry are likely to go for routine eye check-ups more frequently. and suitable factors are applied to account for these. Profits are included in the rates by applying _______________ factor. Accordingly underwriters apply factors specific to the industry to adjust the rates. couple. Retention factor. PMPM of a plan identifies the income of the company per member per month for that plan. Prior experience: Underwriters need to analyze the customer-group’s prior history of claims.6 Underwriters 3. If number of claims for a plan is low. thus generating a table or matrix. false 2. Q2. parent child and family) and members pay according to the kind of coverage they want. Here each member pays more accurately for the risk he/she adds. 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. The probable frequency of members availing this benefit varies accordingly. Exercises Q1.    Dependant age: A firm may want employees’ dependents to be covered to a higher / lower age than the default coverage. Rates need to be raised or lowered accordingly. E. For estimating the values of group specific factors also they use similar considerations. Class Rate/ Tabular Rate: Sometimes firms requests and sometimes state regulations mandate that the demographic composition of the group needs to be considered. PMPM of a plan is the same as Book Rate. (True/ False) Q2.00a Page 59 of 150 .g. This would affect the probable usage of relevant benefits. Thus. (True/ False) Answers 1. they get a discount and vice versa. 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. they have the final say on the rates. while the latter may be more prone to a heart attack. Tabular Rating is a rating methodology wherein multiple tier rates are exploded into age/gender bands.Normal profits are hereby built into the rates Thus the actuaries arrive at the Book Rates or the Community Rates for the plans. Depending on the geographical factors and state regulations even the 65736839. Retention 5.Sales ___________________________________________________________________ ii) iii) Trend factor: This takes care of market trends and possible changes in rates over subsequent quarters.doc Ver 0. Sometimes underwriters have exclusive access to some special factors.

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

Responders are customers. Answers : 1.1 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. It also helps to ensure that same set of prospects are not getting selected for marketing too often. Seeds are sales department employees and if the mail reaches the seed. Their expiry date is one year from the date on which it was entered. Responders expire from the database after one year. new prospects with phone numbers are loaded to the Dialers. Exercises True or False 1. False 2. True 4. Marketing by mailing involves sending e-mails to prospects. d) Vendors who maintain latest information like addresses of all prospects and update our data files by matching it with theirs. 65736839. Code1 plus software validates addresses. US Postal Department gives discount on CASS certified mails. seeds are implanted in each batch of mails dispatched. The responders names do not expire from database.7. To ensure if the mails are delivered. Mailstream system is used to pre-sort the mails to obtain further discounts from postal department. These prospective customers are entered into the database by Tel Marketing department.00a Page 61 of 150 . Meeting mailing informs prospects about meetings and seminars. These names stay on the database for one year from the date the names were received from the vendor. Postal mails sent by sales department fall in three categories: a) Regional mailing: Mailing is restricted to selected regions or states.Sales ___________________________________________________________________ The mails to prospects are processed through Code1 Plus software which validates addresses and gives CASS certification. 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. True 3. 4. History of mailing is maintained for each prospect and each product to ensure that one product is not marketed to the same prospect twice. c) Member mailing: Involves mailing to existing customers of Aetna. Telemarketing department gets new prospective customers by calling people. False 5. who voluntarily contact healthcare company to get information on it’s products. 2. b) Vendors who supply data of all the deaths in a given service area. b) Meeting mailing: Informing the new prospects about seminars or meetings conducted by Aetna and requesting them to attend the same. Tele marketing department retrieves the names from Dialer box for phone follow-ups. it’s a fair assumption that all the prospects addressed in that batch of mails must have received the mails too. 3. • • • 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.doc Ver 0. After sending mails.

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.

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Sales ___________________________________________________________________

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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.

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But. It involves a lot of paperwork and is time consuming.00 80% if true emergency. 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. Members have to pay heavy premiums and need to meet deductibles before they can start claiming benefits. Managed care plans originated in the early 1970s. which are more cost effective. the maximum amount.   For the entire family to be covered. which the member may have to pay is $1000. Managed Care Plans   6. They prefer to use managed care plans.Benefits ___________________________________________________________________  Filing of claims is the responsibility of the member.00a Page 65 of 150 .doc Ver 0. rest the member will have to pay out of his pocket.Above this. i. insurer will provide 100% reimbursement of costs. as explained earlier.e. this amount is $600. For people who cannot afford to spend large amounts on their healthcare. There is no coverage for any preventive care.4 Indemnity plans. provide great flexibility to members in choosing a provider. this freedom comes at a very high cost. The insurer will reimburse only 80% of the costs. a routine checkup is not covered. The coinsurance limit is $1000. Indemnity insurance is not a good option.this means that. 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. 65736839.

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

In contrast. but it can also lead to complications if the PCP doesn't provide the referral needed by the member i. a provider not contracted by the insurer) without prior permission of the insurer.e.e.The HMO will continue to cover his treatment as long as he is a member. before health problems become severe. HMOs often have nominal copayments. the focus is on wellness and preventative care.Benefits ___________________________________________________________________ the PCP and the insurer manage their complete healthcare.doc Ver 0. Advantages  With most types of insurance (other than HMO). HMO members pay a fixed monthly fee. This leads to ‘Low out of pocket costs’.00 copay 100 % 65736839.00 100% None $35. there may be a deductible that must be met before the insurer starts picking up the tab. Besides reducing out-of-pocket costs and paperwork. Additionally. tight controls can make it more difficult to get specialized care. members are responsible for paying a percentage of the bill every time they receive medical care.   Disadvantages:  An HMO member must choose a primary care physician (PCP).  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. Members cannot use services of any out-of–network provider (i. The PCP provides general medical care and must be consulted before members seek care from another physician or specialist. Instead of deductibles. HMOs encourage members to seek medical treatment early. regardless of how much medical care is needed in a given month. HMO members are required to obtain all treatment from HMO providers. Except for emergencies occurring outside the HMO's treatment area. there may be a strict definition of what constitutes an emergency. Additionally.00a Page 67 of 150 . The HMO will not pay for non-emergency care provided by a non-HMO provider. Additionally.e. Hence. HMOs generally do not place a limit on the member’s lifetime benefits (i. This screening process helps to reduce costs both for the HMO and the members. many HMOs offer health education classes and discounted health club memberships. the total amount of money he can claim during his lifetime) .

When a member receives care from a participating provider they receive benefits. In return. PPO members usually pay for services as they are rendered. 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. Advantages  Free choice of healthcare provider. there are several important differences between HMOs and PPOs. it becomes clear that the cost for the member is much less. When members receive care from a non-participating provider they receive benefits. However. by one or more employers. A PPO is actually a group of doctors and/or hospitals that provide medical services only to a specific group or association.00a Page 68 of 150 . members may receive 90% reimbursement for care obtained from innetwork physicians but only 60% for out-of-network treatment. 6. or by some other type of organization.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.00 copay $10. the insurance company will pay 100% of the providers charges  If compared with the Indemnity plan provided in the earlier section. usually 80% payment rate. In case he has to use the emergency room facilities. known as ‘Non-Preferred Benefits’. which are at the higher level of benefit coverage. The insurer then pays the covered amount directly to the healthcare provider.doc Ver 0. known as ‘Preferred Benefits’. which are at the lower level of benefit coverage. In order to avoid 65736839.00 copay 100%  For all kinds of treatment. the provider may submit the bill directly to the insurance company for payment. The PPO sponsor (employer or insurance company) generally reimburses the member for the cost of the treatment minus any co-payment. In some cases. a preferred provider organization (PPO) is a managed healthcare system. usually 100% payment rate. as PPO members are not required to seek care from PPO physicians.4.  Every time he avails the service of a provider he has to pay $10 irrespective of the kind of services availed. For example. PPO physicians provide medical services at discounted rates and may set up utilization control programs to help reduce the cost of medical care. The healthcare providers and the PPO sponsor(s) negotiate the price for each type of service in advance. and the member pays his or her co-payment amount. he will have to pay $35 as $10.  copay. there is a strong financial incentive to do so. However. The PPO may be sponsored by a particular insurance company.2 Preferred Provider Organization (PPO) Like an HMO.

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. most PPO members choose to receive their healthcare within the PPO network.00 3x deductible None 80% / 20% $1000.4.00 $200.00 office visit 100% None 100% after $10. The benefits are reduced in case of non-preferred option. and members may be required to meet a deductible.  6.00 80%/20% Same as preferred if true emergency. For example. most PPOs have larger copayment amounts than HMOs. Thus.  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 $10.00 100% 100% Non-preferred Benefit $200. the expenses and paperwork are higher as compared to HMOs. Hence.3 Point Of Service (POS) POS plans give two benefit levels. Like an HMO. members may receive 90% reimbursement for care obtained from in-network providers but only 60% for treatment provided by out-of-network providers. Disadvantages  As mentioned previously. When a member uses the in-network benefits. The plan can be visualized as having 2 sides.00 copay $25. A PPO member has to file claims on his own. the POS plan mirrors an HMO. he may choose to continue seeing him.Benefits ___________________________________________________________________ paying an additional 30% out of their own pockets. else none. if a member’s longtime family doctor is outside of the PPO network. Additionally.00a Page 69 of 150 .doc Ver 0. but it will cost more. 80% / 20% 80% / 20% Preferred option closely mirrors the HMO option while the non-preferred option approaches the Indemnity option. One side is for in-network services and the other side is for out-of-network services.

he can mix the types of care he receives. Unlike HMO coverage.   Disadvantages  There are substantial co-payments and deductibles for out-of-network care.  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 $10.00 $200.00 copay $25. else none. When he uses the out-of-network benefits. while there is no PCP for out-ofnetwork services. But.00 3x deductible None 80% / 20% $1000. 80% / 20% 80% / 20% 65736839. as with HMO coverage. Advantages  POS coverage allows a member to increase his freedom of choice. members must have paid a specified deductible before coverage begins on out-of-network care. As in an HMO.00a Page 70 of 150 . the member’s child could continue to see his pediatrician who is not in the network. In most cases. co-payment is around $10 per treatment or office visit.doc Ver 0. Like a PPO. members always retain the right to seek care outside the network at a lower level of coverage. while the member himself receives his healthcare from in-network providers. the POS plan is an indemnity plan. members must choose a primary care physician (PCP) and hence there is a tight control to get specialized care within the network. POS plan encourages members to use innetwork providers but does not make it mandatory. No deductible is required for in-network services. For example. members pay only a nominal amount for in-network care. Usually.00 100% 100% Out-of-network $200.00 80%/20% Same as preferred if true emergency. As with HMO coverage. The member will likely be subject to a deductible and co-payment. he also must choose a primary care physician who is responsible for all referrals within the POS network.00 100% None 100% after $10.Benefits ___________________________________________________________________ network healthcare provider.

and employers. 65736839. and the price is somewhat higher. the PPO plan gives more flexibility for choice of provider. 6. Indemnity plans. EPO Plans—a hybrid of POS plans were developed.4 In order to fulfill the diverse needs of participants. while providing them with the option to make appointments directly with a larger group of providers (instead of just their primary care provider). also. These plans offer members great flexibility at the lowest price by combining various plans. managed care plans are better suited for the average individual because they end up being more cost effective in the long run.4. providers. 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. Disadvantages  Members need to choose from the HMO and EPO networks. some insurers will offer an EPO/HMO plan. The choice of providers is greater than the typical HMO. In contrast. with maximum benefits within network and reduced benefits out-of-network.00a Page 71 of 150 . give more freedom than managed care plans in terms of using the healthcare provider of choice. However. there is no such thing as ‘the best plan’. The major difference between them is in the in-network option. All the plans outlined till now are generic plans. however. A PPO may also make an EPO option available to members.Benefits ___________________________________________________________________  The POS plan is very similar to a PPO plan.5 Which plan is the best? The first thing to note is that. in general. For example. this leads to less flexibility in choice of provider.doc Ver 0. The variation in the various plans can be understood more effectively by referring to the following table. Here. as compared to the POS plan. Exclusive Provider Organization (EPO)  6. which can be customized according to the members needs. as there are no deductibles and very less copays. Advantages  Limited out-of-pocket expenses. This provides members with the ease and low cost of the HMO.

Plot a graph of ‘cost to member’ (x axis) versus ‘freedom of choice’ (y axis) and place the various plans on it. 2.5. If the goal is to minimize costs. PPO plan members do not have to choose a PCP (Y/N). 5.1 Exercise Plan offers the maximum freedom of choice for a member.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. if his goal is maximum flexibility and cost is not a major factor. Considering the cost for a member. the choice ultimately depends on the member’s personal circumstances and preferences. indemnity plans should be preferred. 6. 4. 3. 4. Answers Indemnity HMO N Y Indemnity Freedom EPO HMO PPO POS 1.00a Page 72 of 150 . On the other hand. 3. 65736839. which plan is most effective? POS plans do not offer out-of-network coverage (Y/N). 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. 5. 2.doc Ver 0. he is probably better off with a managed care plan. 1.

Reasonable and customary charges generally don't include the cost of glasses and contact lenses.6.Benefits ___________________________________________________________________ Cost Figure 3: Variation of Freedom with Cost 6. Dental plans are of three types based on the mode of treatment and payment.00a Page 73 of 150 . 6. It typically covers services delivered by an optometrist or ophthalmologist. Most of these plans in some or other will belong to the two main categories listed above. With some employer-sponsored vision plans. This keeps the cost of dental care much lower than medical care. while others may limit coverage to reasonable and customary charges incurred during routine eye exams. insurers offer a wide variety of specific plans. 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. Regular dental checkups and cleaning will be sufficient to maintain dental health. The regular dental visits allow problems to be diagnosed early and corrected without involved diagnostic testing or treatment. 65736839.1 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. Depending on the specific plan.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. 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. 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. It depends on the specific plan.6 Other Plans In addition to the common Indemnity and Managed care plans listed above. Or the member may be required to cover the charges out-of-pocket at the time of service.doc Ver 0. insurers provide the following plans: 6.

Participating dentists receive a fixed monthly fee based on the number of patients assigned to the office. Single tier plans  Fixed copay for all types of drugs mentioned in the plan. Direct Reimbursement Plans: Under this self-funded plan.Benefits ___________________________________________________________________ Indemnity Plans: This type of plan pays the dentist on a traditional fee-for-service basis. rather than paying premiums to an insurance company. The plan may limit the amount of dollars a member can spend on dental care within a given year. A Dental Health Maintenance Organization (DHMO similar to a medical HMO) is a common example of a capitation 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. in conjunction with the dentist. Members can select a dentist of their choice and. Generic Drugs . The dentist is paid on a per capita (per head) basis rather than for actual treatment provided. The member pays the dentist directly and.00a Page 74 of 150 . A monthly premium is paid by the member. They usually involve a ‘Managed Pharmacy Benefit Network’ (network of pharmacists which contracts with the Insurer). an employer or company sponsor pays for dental care with its own funds. The typical three tiers of a pharmacy plans are 1. the employer reimburses the employee a fixed percentage of the dental care costs. 2. can play an active role in planning a treatment that is most appropriate and affordable. which offers drugs to plan holders at reduced rates.6. patient copays may be required for each visit.which are Non-patented compositions and are relatively cheaper. In addition to premiums.The types of drugs can be classified as   Branded drugs – which are patented drugs (10 yrs patent) and hence costly. while generic medications are in the lower tier and are least expensive . once furnished with a receipt showing payment and services received. Pharmacy Plans    6.3 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. which directly reimburses the dentist for the services provided. Insurance companies usually pay between 50 percent and 80 percent of the dentist's fee for covered services. Non-Formulary drugs . Capitation Plans: This type of plan provides comprehensive dental care to enrolled patients through designated provider dentists. drugs with same chemical  Most health plans have three or four pharmacy benefit tiers. the member pays the remaining.doc Ver 0. but some have as many as seven. Two tier plans  Lower copay for Generic drugs  Higher copay for Branded drugs 65736839.which are the cheapest. Brand-name drugs that are usually in the top tier are most expensive. but often places no limit on services provided. Most pharmacy plans that pay for prescription drug benefits have benefit tiers that group certain medications together for pricing purposes.

has overall responsibility for administering the Medicare program. There is no variation in the types of medigap policies provided by various insurance companies. Department of Health and Human Services. and private fee-forservice plans. medical savings accounts. However. a division of the U. Also covered are laboratory tests.e. Medicare coinsurance amounts.00a Page 75 of 150 .6.6. Members may purchase a supplemental medical insurance policy called Medigap. Although the Social Security Administration processes Medicare applications and claims.  Part C expands the kinds of private health-care plans that may offer Medicare benefits to include managed care plans.Benefits ___________________________________________________________________ 3.Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). skilled nursing facility. 6. A third part. Only ten standardized plans can be offered as Medigap plans. and ambulance service. such as charges for the hospital room.S. Medicare coverage consists of two main parts . Three tier plans  Lowest copay for Generic drugs  Medium copay for branded drugs  Highest copay for Non formulary drugs 6. people may be eligible if they are disabled or have endstage terminal disease. Medigap policies are sold through private insurance companies. They are in addition to the fee-for-service options available under Medicare Parts A and B.doc Ver 0. meals. 65736839. or as an outpatient at a hospital or other health-care facility. All ten must cover certain services. Part A also covers hospice care and home health care. Most people become eligible for Medicare upon reaching age 65. physical therapy or rehabilitation services.. whether it was received while member was an inpatient at a hospital. the costs associated with an overnight stay in a hospital. at a doctor's office. In addition. Some also provide coverage for deductibles and services that are not covered by Medicare such as prescription drugs and preventive care. and nursing service s). Physician care. if not all. they are standardized and regulated by federal and state law. Medigap is specifically designed to fill some of the gaps in Medicare coverage. or psychiatric hospital. regardless of their medical condition. The Health Care Financing Administration (HCFA). 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.4 Medicare Plans Medicare is a government-sponsored program that provides health insurance to retired individuals. Medigap policies pay most.  Part B covers other medical care.5 Medigap Medicare does not cover all health-care costs during retirement. the HCFA sets standards and policies.

6. 65736839. However the maximum lifetime limit of benefits is high enough to cover the cost of catastrophic illness. medical transportation. Most of the plans seen till now can be customized to include coverage for catastrophic illnesses. and speech therapy.7 Long Term Care Most of plans discussed till now are the kind. Long-term care. including hospital bills. each state (1) determines its own eligibility requirements. which is usually very high. The treatments covered by long term care insurance usually include four general types of care: in home care. This may be used to help the aged. a disability buy-out policy disburses funds for one partner or business entity to buy a disabled partner's share of the company.Benefits ___________________________________________________________________ 6. It is a joint federalstate program to provide medical assistance to aged. (2) prescribes the amount.9 Catastrophic Coverage Plans Catastrophic coverage is not a separate entity by itself but forms a part of an existing plan. Employers can provide coverage for employees too. As with other insurance policies. physician services. 6. Each state administers its own Medicaid programs based on broad federal guidelines and regulations. Some of the most frequently covered optional services are clinic services. occupational therapy. duration. or blind individuals (or to needy. disabled. States may elect to provide other services for which federal matching funds are available. The funds paid are not specified for medical expenses . (3) chooses the rate of reimbursement for services. dependent children) who cannot afford the necessary medical care. home health care. services for the mentally retarded in intermediate care facilities. They pay hospital and medical expenses above a certain deductible.6. and long-term nursing home care.6. assisted living and nursing home living.6. and (4) oversees its own program. 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.6 Medicaid Medicaid is a health insurance program for people with low income. however. 6.8 Disability Income Insurance Disability income insurance provides members with an income if they become sick or injured and are unable to work. and types of services. Within these guidelines.they can be used in any way the member wishes them to use. adult day care. 6. For jointly owned businesses. members pay a set premium that offsets the risk of a much larger out-of-pocket expense.00a Page 76 of 150 . Medicaid pays for a number of medical costs. as well as young and middle-aged people who have been injured or have suffered a debilitating illness. prosthetic devices. optometrist services and eyeglasses. which pay for hospital bills and doctor visits. and are reestablishing a customer or client base. offers the assistance people need if they have a chronic illness or disability that leaves them unable to care for themselves. Recovery benefits that pay after members return to work full-time.doc Ver 0. prescribed drugs.

individual insurance is generally more difficult to obtain and more costly than group insurance. where each person's risk potential is evaluated and used to determine insurability. Policy extends the Medicare policy by offering additional benefits. This is generally done through a series of medical questions and/or a physical exam. Medigap 4. 6. Key person insurance 5. the initial cost of establishing group coverage is lower than the cost of issuing a separate policy to each person. 3 (hospital. catastrophic PPO and catastrophic EPO coverage. members purchase individual insurance directly from an insurance company. Y 7. All people who cannot afford medical care.Benefits ___________________________________________________________________ The most common example is the Medicare plans which include a clause for catastrophic coverage. Individual insurance is somewhat more risky for insurers than group insurance. Capitation 6. 8. Because only one policy is issued for the entire group. Others include disability income insurance. 3 2. With group health insurance. such as average age and degree of occupational hazard. Unlike individual insurance. 4.6. 7. the only real disadvantage of group insurance is limited or no freedom to customize the policy to member’s individual needs. The policy is typically negotiated between the insurer and the "master" policy owner (employer or association) without any inputs from 65736839.7 Individual Insurance and Group Insurance. The premium for group insurance is calculated based on characteristics of the group as a whole. Unlike group insurance. For this reason.10 Exercise Pharmacy plans usually have tiers of benefits. Answers 1. 2. In general. When they apply for individual insurance. Medicare has parts. Y 8. plans are similar to HMO plans The federal government regulates Medicare benefits? (Y/N). with the sponsoring employer or association paying all or part of the premium.00a Page 77 of 150 .doc Ver 0. medicare+choice) 3. a single policy covers the medical expenses of many different people (a group) instead of covering just one person. Is used to protect a firm against the loss of income resulting from the disability of a key employee. because group insurance allows the insurer to spread the risk over a larger number of people. they are evaluated in terms of how much risk they present to the insurance company. Member’s risk potential will determine whether he qualifies for insurance and how much the insurance will cost. medical. 6. Employer-sponsored plans and associations are among the most common sources of group health insurance. Individual health insurance is a type of policy that covers the medical expenses of only one person. Long Term care covers nursing home care? (Y/N) Who all are eligible for Medicaid benefits? 1. In case of Dental insurance. all eligible people can be covered by a group policy regardless of age or physical condition. 5. 3. 6.

In addition. if his employment has been terminated or if his work hours have been reduced. However. The two most important of these are – 6. So the federal government has provided certain laws to help people cope with the situations mentioned above. his dependents may be eligible for COBRA benefits if they are no longer entitled to employer-sponsored benefits due to divorce.Benefits ___________________________________________________________________ the member. leaving them without health benefits. The major provisions of HIPAA do the following:  Allow workers to move from one employer to another without fear of losing group health insurance. They could suffer a serious injury and become disabled.1 Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) If a person and his dependents are covered by an employer-sponsored health insurance plan.A count on their employer for health insurance coverage.S.S. death. his employer is not required to pay any part of it. In 1996.8.  Increase the tax deductibility of medical insurance premiums for the selfemployed. If a person is entitled to COBRA coverage for other qualifying reasons. the person will have to pay the premium for COBRA coverage. he can continue the coverage for 36 months. or in certain other situations. the Health Insurance Portability and Accountability Act (HIPAA) expanded on COBRA.  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.A. COBRA entitles him to continue coverage under circumstances that would otherwise cause him to lose this benefit. The specific policy provisions are all determined in advance. 65736839. As an employee. These events can occur when least expected.8 Laws and Legislations Most people in U. Most employers are required to offer COBRA coverage.00a Page 78 of 150 . 6. he is entitled to COBRA coverage only if his employment has been terminated or downsized.  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.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. as are the deductible amount and co-payment percentage.doc Ver 0. 6. A person can continue his health insurance for 18 months under COBRA.8.

  Deductible is usually zero for most HMO plans. each partner can take out an insurance policy to cover the expenses. http://www. 6. 2.Benefits ___________________________________________________________________ 6. Long-term care is covered under Medicare.doc Ver 0. 5. the other partner is no longer able to perform his duties.00a Page 79 of 150 . 2.   Medicaid policy is the most expensive type of Indemnity plan. 6.  In case of a joint business venture. 3.  Review Questions.  Coinsurance is the insurance provided by two insurance companies to one individual.9 1.10 References 1. 4. Abhishek Virginkar and Saurabh Kulkarni.com http://www. “Managed Care – An Overview ” – By Amit Shukla. “A to Z of Health Insurance” – By Prashant Burse. 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.com 3.insurance. 4. 65736839. which plan is most cost effective and why? State whether true of false – Private insurance companies provide Medicare plans. in case. Copay is what the member pays to the insurance company for treatment.yourhealthplans.

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

1 Claims Intake Process Claims are received from health services providers either as paper documents or in electronic form. This means that they get a fixed fee on a monthly or bi-monthly basis. Receipts system performs basic edits on these claims and loads it to the Claims database. Manual intervention is required for further processing such claims. They do not bill Insurance Company for services provided. to decide the payment to be made to providers or denials if any.Claims ___________________________________________________________________ UNIT . for a combination of fixed number of visits and fixed duration. The referral acts as an authorization for the member to visit a specialist. The Receipts system is required to receive a transaction in CCFMQ format.doc Ver 0. The HMO Reformat will be responsible for reading a CCFMQ record 65736839. Complex or ambiguous claims. 7. A record of this referral is maintained in the system.VII 7 Claims 7. Generally these visits by member are made to PCPs. desired cheques are cut by AP (Accounts Payable). Edits within the pre-receipts system are enhanced to include HMO claims. The claims are received by the Integrated Receipt system. If the primary physician deems fit he may refer the member to a specialist. Paper claims are received on standard forms. The claim may be filed either on a standard paper form or electronically. On completion of claims adjudication. Claims Online/Pend systems are used for this purpose. Feedback is sent to Claims system again which is used to store the completed claims history in Claims database/files. These claims are then adjudicated using Insurance Company’s business rules and policies.1 Claim generation and submission to Providers Members enrolled in Insurance Company’s healthcare programs visit health services providers such as a primary physician. This specific combination depends on plan to which the member has subscribed. Electronic forms are routed through a third party (Envoy). Claims that fail the edits are routed back to the provider for corrections.1. 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. are put in a ‘PEND’ status. They are scanned to capture image copies that are then translated to electronic form. The UCK is passed along with each transaction to the appropriate adjudication engine. this process is known as HMO REFORMAT. This pre-receipts system will identify each claim with a Universal Claim Key (UCK).00a Page 81 of 150 . validated for basic information necessary and then loaded into the Claims database. Each visit that a member makes to a provider is called an encounter. who are Primary Care Physicians and are Capitated Providers. specialist. hospital or pharmacy to receive healthcare. The users have the ability to modify the claims online. as well as for catering to general claims enquiries. All HMO electronic claims from the Envoy submitter will be directed to a system (pre-receipts) before sending them to core Receipts System. This PCP files a claim with Insurance Company for non-capitated or specialist services he might have provided to the member.

in order to determine if a claim will be Accepted or Rejected. Receipts system Conversion. Due to limitations of the HMO Adjudication.doc Check Information CLAIMS SYSTEM Ver 0. Encounter PROVIDER MEMBER EDI Claim 7.1. This process will evaluate each edit flag. The Reformat will also be responsible for passing the UCK along to the HMO system on each transaction. Users enter these claims online. When Hospital claims are processed Revenue codes are grouped and rolled and then translated into Benefit codes. The generation of a status response is required to be sent back to Pre-receipts system at this point. At the completion of all Receipts system edits.00a DENIALS Page 82 of 150 ACCOUNTS PAYABLE Check to Provider/ Member . Some paper claims cannot be loaded into Receipt System usually due to non-standard formats. The last process within the Receipt System is the Load to the HMO database. These claim forms are captured on microfilm. The Load is responsible for passing the UCK to the HMO Adjudication system. 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. Each benefit code represents a detail line. The Conversion process handles Hospital and Specialist claims differently. The modifications consist of inquiring on the UCK database table or file and generation of the event response for pre-Receipts system. directly into the Claims Online Adjudication system. This response status serves as the initial response for all HMO claims. The newly reformatted claims will follow the existing Receipts system path for electronic claims.2 ENVOY Claims Intake : DiagrammaticIKFI Paper Claim EDI Referral Prereceipts REFERRAL SYSTEM Receipts Verification 65736839. modifications are made to establish the UCK segment number.Claims ___________________________________________________________________ as input and produce a UB92 Hospital transaction format or a NSF1500 Specialist transaction format as output. The response for claims that have been rejected also represents a final response. subject to existing Receipts system edits. claims will flow into the Generate Response process. If a claim is split in the Conversion.

o Provider Specialty is validated .e if the provider is hospital type or a specialist etc.e.Capitation of the Provider is validated . o Provider no is validated. Determination of whether the claim is too old. o Determination of whether member is suspended or terminated ( i. o Provider type is evaluated i.1  Claim Preparation and determining eligibility The member information is validated. o Provider name and address is validated. o Date of Service of the Claim is compared with the current date. o Determination of whether this claim is a fraudulent specific member claim.2.00a Page 83 of 150 . o Check is done for whether Provider is suspended. Determine if the claim is timely filed    65736839. o Par status of Provider is validated . DOS > suspense or term date). The provider information is validated. o Member no is validated. 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.doc Ver 0.2 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.Claims ___________________________________________________________________ 7.

Place of Provider network. o Determination of whether the member is covered under the GROUP.Area . Place of service and the benefit code of the claim . it is determined if the member is eligible for the benefit of the product under which the member is covered. Provider no .  Provider network. Also a 65736839. Product exception o In this. if the claim has not been file within the proper timeframe it is denied . Group.doc Ver 0. AND PRODUCT which for which the Claim has has been filed Benefit eligibility is checked o Here depending on the Provider type. 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).   Determination of whether this is a member reimbursement or provider is already reimbursed. procedure code . Group/plan eligibility is checked. proc code . CONTRACT. member no . etc it is determined if there is to the benefits payable for the product for which claim is filed. provider specialty .Claims ___________________________________________________________________ o Date of service of the Claim is compared with the received date of the Claim. PLAN. any exception override is checked on various factors like service start and end dates . based service.Place of service is checked with a history claim for determining duplicity.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.  Claim emergency or non emergency.  Par status of provider.e for which no authorization needed).  Presence/Absence of referral. The difference of the dates is compared with the timely filing limits which is predecided based on different types of Provider.member category etc . diagnosis code.00a Page 84 of 150 . and presence of any rider .  Determination of whether the claim is duplicate ( by comparing with history).  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.types of benefits provided. depending on the member region.    Product benefit eligibility is checked  Here.  Direct access ( i. it is determined if the member is eligible to receive the particular benefit for which claim has been filed. o Here the Date of service of the claim.  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.

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.

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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

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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

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the process followed is . a.3  Update Claim Accumulator updates o This involves updating of Various accumulators for Copay . o Denial letters are sent if :  other insurance paid in full  experimental procedure not covered  Cosmetic surgery not covered    65736839.  Inform the provider that he/she can return their previous payment or elect to have them debit his/her account after 60 days.  Provide the name and address of the primary carrier and the patient’s name and address and any other pertinent information. 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 . Healthcare company discovers that another insurer is the primary carrier.2. coinsurance etc depending upon the processing of the claim.  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. they will:  Notify the provider that they have discovered that another insurer is the primary carrier. deductible . Claims database updates o Processed Claims stored for maintaining History. 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.Claims ___________________________________________________________________ Cross/Blue Shield).00a Page 88 of 150 . Referral updates o Referrals are updated for no of visits after the claim has been processed properly.Penalties etc that a Healthcare company liable to pay in certain cases  Any Other Information required . The insurance industry has established standard rules to determine which insurer is primary payor. thereby giving him/her an opportunity to seek reimbursement from the member’s primary insurer. This provision prevents double or over-payment by the carriers.2.4  Claim adjudication outputs Check extract o Adjudicated claims that are passed to Accounts payable for check printing.   7. after a provider has been paid.doc Ver 0. o o 7. If.

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

doc Ver 0.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 65736839.00a Page 90 of 150 .

If the provider is non-capitated.7 Provision for Advance Payment Some providers. both with a few exception. a survey is conducted where in the member fills in a form to comment about the quality of service provided by the hospital. provider has tendency to file the same claim again. then the claims filed would require specific referral already in place. assign points / marks.6 Provision for Advance Payment Some insurance companys also have a facility to pay the providers some lumpsum amount in advance.doc Ver 0. would come in the form of claims filed by the providers. then the insurance company will pay the provider adjudicated amount less the copay amount as described by member’s plan. then all his claims are bound to get denied if filed for services covered under capitation. 7. Once the service is provided to a member. based on some algorithms.2 Provider as Specialist If a provider is giving services to member as a Specialist. Mostly all the In-patient type of services and none of the Out-patient type of services are eligible for this incentive.3.1.1 Capitated Provider If provider is a Capitated Provider. are paid extra for the quality of services they provide.5 Duplicate Claims In case of late payments by insurance company. 7. In the physician surveys. Hospitals send the survey results to Insurance company.1.1. Over a specific period of time.3. 7. these providers will file claim for the services rendered to the member.Claims ___________________________________________________________________ 7. It becomes mandatory to identify all the types of services that will become eligible for consideration under quality incentive. especially the big providers like Hospitals.3.1 Claim Payments Provider Payments Inputs for any provider payment.3.1.4 COB Adjustments If Coordination of benefit applies for any member. in most of the general scenarios.1. This incentive to be paid is decided as fixed % of the contractual amount between Insurance company and the provider. administration in the hospital etc. Procedures are in place which detect such duplicate claims and avoid the repayments. Otherwise claims without proper referral get denied. then claim gets adjudicated against Insurance Company’s business policies and rules as imposed by federal/state laws. then provider receives payment from primary and secondary insurance companies. This data is then passed through ‘United States Quality Algorithms (USQA)’ routines. these amounts are then adjusted during adjudication against the claims filed by provider. Higher these points. 7. He has to file claims with all the involved insurance companies.3 7. the physicians fill in the data such as quality of operating rooms.1. 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.00a Page 91 of 150 .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.  Efficiency of Care 65736839. which should be covering the visit and specific services for the member.1. 7. 7.3. These routines (which are black box to the insurance company’s system).3 Copay Adjustments If the claim filed required member to pay some copay amount. 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. When members have encounters with provider. the higher will be the incentive.3.3.

the payment is made.2.1.4 Claim Adjustments These are the various types of adjustments that can be made to the claim. If a member spends more time in hospital for a service.4 Co-insurance Applies In this case.2.Claims ___________________________________________________________________ It measures the efficiency of the care based on length of stay for surgery.3. 7.2 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.2. When provider’s claim is adjudicated.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. 7. 7. 7. If the member has not reached the Deductible limit. as defined in the plan adopted by member.3. adverse events and C-section rates. whether denied or paid. So.doc Ver 0.3 Deductible Applies Member pays to the provider Out-of-Network and files a claim with the Insurance company.  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.2 Member Re-imbursement Following are various scenarios when member is eligible for re-imbursement by The Insurance Company. In this case insurance company pays directly to member.3. medicine and OB/GYN.3.3. 7. insurance company intimates provider of the extra payment made and provider is required to repay to the company accordingly. higher will be the payments. 7.00a Page 92 of 150 . lower will be the payments. Under such circumstances. a fixed % of adjudicated claim amount is paid back to the member.8 Payment to Insurance Company It may happen that provider claims are incorrectly adjudicated and provider is overpaid. then higher will be the costs that hospital incurs and hence the claim amount. then the insurance company will reimburse all the amount paid towards copay back to member. the provider is informed by the Insurance Company regarding the reasons and split of payments.2. longer the stay. then Insurance Company will then deny such a claim. 7. Based on the answers. 65736839.3. lower will be the payments as it is hospital’s responsibility to see that fewer adverse events arise. points are assigned and based on the points. Higher the points. For this category: higher the points. the lesser will be the incentives paid. higher the adverse conditions. part or full payment made by him to provider. system assigns points. Also. through USQA routines. For each of these measures.

Original completed claim remains unchanged.00a Page 93 of 150 . 7. New negative claims created with negative dollar amount. Further claims of the provider are not paid till the all the amount on the negative claim has been recovered.Claims ___________________________________________________________________ 7. This is to account for the payment being made using the manual check. the original claims remain untouched. Only in this scenario a stop can be issued on the check. 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. If provider does not agree to cut and send check to refund over-payment. Such a check is created by entering data into the system manually. When provider agrees and refunds over-payment (provider will cut check and send in). In the process. 7.4. The check status is also changed from open (blank) to Void (V). The original claims are overridden with new payment codes. The claim does not undergo adjudication.4.2 Minus Debit Adjustment In case of overpayment to providers.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).3 Manual Check Adjustment Sometimes a check is required to be created manually if there is a need to adjust amount of payment. Deduction may be split across multiple claims. 7.e.4. there has to be a claim for which a check is created. It is completed and stored. 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. A new set of claims are generated which have amount equal to negative of the amounts of the original claims. 65736839. when stop payment is done.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. cash date for check is recorded and necessary deductions are applied to claim. a letter is sent to the provider notifying of over-payment. A connection is established between the manual check and the claim entered.1 Refund Adjustment This type of adjustment takes place when a Health Services Provider overpays the provider.4. Claim gets completed without adjudication. minus debit option is used to create an equal amount negative check.4. i. 7. Provider over-payment letter is generated one claim per letter. The manual check request paperwork is then sent to Claims system. The check status is changed from open (blank) to Stopped (S).doc Ver 0. On receipt of the manual check paperwork a Manual claim is entered.

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. And similarly no matter how much money the health care company spends on a person who was a frequent visitor to the hospital. the government assigns a severity code (PIP SCORE) to the particular member. the risk adjustment model emerged. the aged. If a Health care company has Medicare and Medicaid as the two sponsored programs.5 Government reporting There are two types of government-sponsored plans in U.doc Ver 0.00a Page 94 of 150 . the healthcare company would still get paid for that member.Medicaid is a jointly funded. Depending on the diagnosis that has been performed on a particular claim. If a person has not visited a hospital during the entire year. Citizens. This is the reason why government reporting is important for a Healthcare industry. But sometime around the end of 2000. Hence now it was important for the health care company to report each and every claim that it received. Medicaid . The score calculation and the payments are made on an annual basis.Claims ___________________________________________________________________ 7. and people who are eligible to receive federally assisted income maintenance payments. earlier the government used to pay the health care companies a flat rate per member. and/or disabled. to the government.          65736839. It covers approximately 36 million individuals including children. 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).S. This is where Encounter data reporting started coming into picture. blind. With this model there is not a very stringent need for the healthcare company to report all of its encounters correctly to the government. Since the number of encounters and the particular diagnosis that was performed had very less significance in the payments that were made. For Medicare encounters. 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. But there’s a gradual increase in its share. the nation's largest health Insurance program. it would still get the same flat rate from the government. which covers 37 million U. it still doesn’t form a significant portion in the payment model. The scores for AIDS/Chemotherapy are the highest. Federal-State health insurance program for certain low-income and needy people. It means that no matter a person visited a hospital or not. Medicare provides health insurance to people aged 65 and over and those who have permanent kidney failure and people with certain disabilities. 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. a government body administers Medicare. Government reporting is needed in a Healthcare industry especially for those plans that are funded by the government. Thus. Although the risk adjustment model has come up. Health care company reports the claims that have been filed by the providers to the government. the Federal government sponsors Medicare while the Medicaid plans are specific to the particular state.

It gives the member a detailed explanation of these amounts. coinsurance. dedicated to accumulating specific type of data over a specific period. Claims rejected and reasons for the same. which acts as an intermediary between Health Care Company and the Federal government. The encounters have to be submitted in a fixed format called the Uniform Billing Code1992 form. 65736839. The list of claims in the wait status for more information.7 7.00a Page 95 of 150 .7. When requesting payment from a secondary payer it is extremely important that the EOB/remittance information be provided from the primary payer.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. etc are applicable and not for all type of claims. for indemnity or fee for service claim where deductible.  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. While the Medicaid submissions go directly to the state.      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.1 What are Accumulators? Accumulators are generally database records. It is not a bill but an explanation of the benefits.doc Ver 0.g. 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. It also gives the cap amounts applicable to him.7.6 Claims accepted. 7. 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. Medicare submissions are sent to CMS (Center for Medicare and Medicaid services). The Explanation of Benefits provides members a statement of claim payments.1 Accumulators 7.

3. o Members pays remaining deductible (part or full. 7.3.2 Function/Purpose of Accumulators The main use of accumulators is during the claims adjudication process. Accumulators records are updated accordingly in such cases.4 Visits – for member Visits of the member to provider are accumulated. 7. (Details will come down the line in the document) 7.7. member + family Co-insurance is also accumulated separately for member as well as member and all his/her dependents. 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.1 Periodic Accumulators These accumulators will cover up the amounts for period as mentioned in the effective plan for the member. in case member chooses to continue. o Member’s deductible limit is say $ 500. So. o Accumulator for yr.5 Family Dollars Insurance company’s disbursement to member or the provider. Once the maximum limit set by plan is met. deductible paid by member in a specific later portion of the effective year.7.7. 7. the corresponding accumulators are updated with those amounts for the latest instance under consideration.7.3.3. say $100) during the last 30 days of plan year.2 Co-insurance – for member. In this case. member no more pays copay to provider.Claims ___________________________________________________________________ 7.7.member. this figure may be used to decide the method of payment. Say.3 Deductible . 7. In a general scenario.7.00a Page 96 of 150 . say partial/full/some percentage of billed. o Plan provision says Carry over deductible is applicable for last 30 days of the plan year.for member.7. depending upon how many visits covered for a specific service to same provider. will be considered as deductible paid towards next year. during predefined period.1 Copay – for member.3. 2001 will go on accumulating the data till end of Nov-2001. 65736839. Carry over Deductible Updates Some plans provide for the provision that.6 Out of Pocket .2 7.7.3. member + family Co-insurance is also accumulated separately for member as well as member and all his/her dependents.4 Types of Accumulator  7. It comes into picture when deductible limit is met. 7. 7. 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).4. Some plans provide for facility of carry over deductible.7. it accumulates $ 350.7. accumulators for the next period will get updated for the deductibles paid. member + family Copay is accumulated separately for member as well as member and all his/her dependents. Example: o If a member XYZ has plan year 01-Jan-2001 to 31-Dec-2001.3 What is accumulated? 7.doc Ver 0. This reduces burden on member and acts as incentive for member to continue with the co-insurance company. When the same has been decided.7.

7. 3.4.8 Overall Claims system diagram : Figure 3: Claims overview 7. 7.2 Lifetime Accumulators These accumulators will sum up the amounts for the life time for a member. 4. he now needs to pay $100 less towards deductible in the next plan year. $100 will get updated in these accumulators. 7. Review Questions. because of this facility. 5. 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? 65736839.00a Page 97 of 150 . 2. If member chooses to continue.Claims ___________________________________________________________________ o o Then new accumulators will be generated as if paid for the next year 2002.9 1.doc Ver 0.

DOC (System appreciation document for Claims maintainance project) SA_AETEDR2. Accumulators are updated for denied claims.doc Ver 0.10 References http://www.   Member encounters have to be submitted to the government in a fixed format. 7.  Pre-certification penalty is in excess of any deductible and/or coinsurance applicable to the claim. Copay is not the member’s responsibility.    State whether true of false – COB deals with claim payment.CLDJABDJ. Claim adjustments can be done before Claim adjudication.00a Page 98 of 150 . EOB is letter sent after adjudication.com/ Aetna Batch driver file (CLPRD.DRIVER) SA_AETHMOM2.DOC (System appreciation document) and other docs from Encounter data reporting project 65736839.Claims ___________________________________________________________________ 6.ehealthinsurance.

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CMS also regulates all laboratory testing (except research) performed on humans in the United States. CMS:  assures that the Medicaid.doc Ver 0. with the Departments of Labor and Treasury.1 Government Agencies Centers for Medicare & Medicaid Services (CMS) The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.3 8.1 Unit Objectives This unit will acquaint the reader with the role played by the external agents in the Healthcare Industry. and makes available to beneficiaries.00a Page 100 of 150 .2 Introduction In Heath Care Industry. Approximately 158.VIII 8 External Agents 8.  conducts research on the effectiveness of various methods of health care management. Department of Health and Human Services.S. CMS also performs a number of quality-focused activities. all the services and management activities cannot be carried by the insurance payer itself on it's own. including regulation of laboratory testing (CLIA). It requires some help from some external sources or agencies. CMS maintains oversight of the survey and certification of nursing homes and continuing care providers (including home health agencies.3. helps millions of Americans and a small company get and keep health insurance coverage.two national health care programs that benefit about 75 million Americans. 8. CMS runs the Medicare and Medicaid programs . treatment. Medicare and SCHIP programs are properly run by its contractors and state agencies. Medicaid and SCHIP. 65736839. intermediate care facilities for the mentally retarded. CMS spends over $360 billion a year buying health care services for beneficiaries of Medicare. researchers and State surveyors information about these activities and nursing home quality. and quality-of-care improvement. 8. development of coverage policies.000 laboratory entities fall within CMS's regulatory responsibility. This unit deals with the various different agencies in a Health Care Industry and the role played by them. And with the Health Resources and Services Administration. a program that is expected to cover many of the approximately 10 million uninsured children in the United States. providers. And CMS. and hospitals). and  assesses the quality of health care facilities and services and taking enforcement actions as appropriate. and financing.External Agents ___________________________________________________________________ UNIT . and helps eliminate discrimination based on health status for people buying health insurance.  establishes policies for paying health care providers. CMS runs the State Children's Health Insurance Program (SCHIP).

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.

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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.

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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.

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

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

2003 for most covered entities.  give patients new rights to access their medical records and to know who else has accessed them.4. PRIVACY AND CONFIDENTIALITY The Final Rule for Privacy was published just as President Clinton was leaving office. 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.2 CORBA Health insurance programs allow workers and their families to take care of essential medical needs. there will be specific federal penalties if a patient's right to privacy is violated.00a Page 106 of 150 . 2001. 8.  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. The Privacy standards:  limit the non-consensual use and release of private health information. If you are entitled to COBRA benefits.  restrict most disclosure of health information to the minimum needed for the intended purpose. improving the quality of care. 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. DHHS received over 11. DHHS Secretary Tommy Thompson used the time to solicit additional comments during March.doc Ver 0. solutions will vary from business to business. conducting medical research.  Accountability: Under HIPAA. There was a time when group health coverage may have been terminated when a worker lost his job or changed employment. In general. no transactions adopted under HIPAA currently require an electronic signature. including treatment and payment.000 comments and plans to issue guidelines and clarification of the final rule in response. The rule covers all individually identifiable health information in the hands of covered entities. That changed in 1986 with the passage of health benefit provisions in the Consolidated Omnibus Budget Reconciliation Act (COBRA). regardless of whether the information is or has been in electronic form. What Is the Continuation Health Law? 65736839.External Agents ___________________________________________________________________ The Security Standard does not require specific technologies to be used. privacy is about whom has the right to access personally identifiable health information. Compliance will be required on April 14. on December 28. Once COBRA coverage is chosen. A paperwork glitch delayed notification of Congress.  establish new criminal and civil sanctions for improper use or disclosure. 2001. These programs can be one of the most important benefits provided by an employer. Also. an individual's health care information should be used for health purposes only. Now. depending on the needs and technologies in place. so the Congressional Review period didn't begin until February. and fighting health care fraud and abuse. pushing the effective date of the rule until April 14.  establish new requirements for access to records by researchers and others.  Security: It is the responsibility of organizations that are entrusted with health information to protect it against deliberate or inadvertent misuse or disclosure. you may be required to pay for the coverage. You have 60 days to accept coverage or lose all rights to benefits. your health plan must give you a notice stating your right to choose to continue benefits provided by the plan. for the first time.

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

Qualifying Events "Qualifying events" are certain types of events that would cause. an individual to lose health coverage. 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. Employers and plan administrators have an obligation to 65736839.00a Page 108 of 150 . the retired employee's spouse and dependent children. except for COBRA continuation coverage. A plan. and plan administrators and qualified beneficiaries. a retired employee. 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. 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.External Agents ___________________________________________________________________ and dependent children. and in certain cases.doc Ver 0. at its discretion. Qualified beneficiaries have the right to elect to continue coverage that is identical to the coverage provided under the plan. The qualifying events contained in the law. create rights and obligations for employers. may provide longer periods of continuation coverage.

notification and type of coverage options.External Agents ___________________________________________________________________ determine the specific rights of beneficiaries with respect to election. 65736839. their spouses and newly hired employees informing them of their rights under COBRA and describing provisions of the law. 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. termination. These beneficiaries also must notify the plan administrator within 30 days of a final determination that they are no longer disabled. A notice must be provided within 60 days of a disability determination and prior to expiration of the 18-month period of COBRA coverage. Qualified beneficiaries have a 60-day period to elect whether to continue coverage. 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. Second. Multi-employer plans may provide for a longer period of time. 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. 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. the time frame for providing notices may be extended beyond the 14. Employers must notify plan administrators within 30 days after an employee's death. There are two special exceptions to the notice requirements for multi-employer plans. Notice Procedures General Notices An initial general notice must be furnished to covered employees. qualified beneficiaries and plan administrators when a qualifying event occurs.doc Ver 0.00a Page 109 of 150 . First. ERISA requires employers to furnish modified and updated SPDs containing certain plan information and summaries of material changes in plan requirements. This period is measured from the later of the coverage loss date or the date the notice to elect COBRA coverage is sent. must automatically provide a notice to employees and family members of their right to elect COBRA coverage. reduced hours of employment or entitlement to Medicare. Disabled beneficiaries must notify plan administrators of Social Security disability determinations. Specific Notices Specific notice requirements are triggered for employers. 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. COBRA coverage is retroactive if elected and paid for by the qualified beneficiary. upon notification of a qualifying event.and 30-day requirements if allowed by plan rules. Plan administrators.

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

If this option is available from the plan under COBRA. 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. however. Some plans allow beneficiaries to convert group health coverage to an individual policy. or a second qualifying event during the initial period of coverage. Paying for COBRA Coverage Beneficiaries may be required to pay the entire premium for coverage. is not available if the beneficiary ends COBRA coverage before reaching the maximum period of entitlement. the option must be given for the beneficiary to enroll in a conversion health plan within 180 days before COBRA coverage ends. 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. Beneficiaries also may change coverage during periods of open enrollment by the plan. the premium for those additional months may be increased to 150% of the plan's total cost of coverage. Although COBRA specifies certain maximum required periods of time that continued health coverage must be offered to qualified beneficiaries. including both the portion paid by employees and any portion paid by the employer before the qualifying event.External Agents ___________________________________________________________________ A change in the benefits under the plan for active employees may apply to qualified beneficiaries. The premium is generally not at a group rate. 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. The premium cannot exceed 102 percent of the cost to the plan for similarly situated individuals who have not incurred a qualifying event.doc Ver 0. Premiums reflect the total cost of group health coverage. may permit a beneficiary to receive a maximum of 36 months of coverage. The plan must allow you to pay premiums on a monthly basis if you ask to do so. COBRA does not prohibit plans from offering continuation health coverage that goes beyond the COBRA periods. however.00a Page 111 of 150 . In this case. Duration of Coverage COBRA establishes required periods of coverage for continuation health benefits. 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. 65736839. A plan. the 18-month period is expanded to 29 months. The conversion option. For disabled beneficiaries receiving an additional 11 months of coverage after the initial 18 months. it must be offered to you. Certain qualifying events. plus two percent for administrative costs. may provide longer periods of coverage beyond those required by COBRA.

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

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

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

most income derives from insurance companies and is formally referred to as "rebates". but render unique and superior audits resulting in improved services at a lower cost to the HealthCare Provider. Guaranteed Delivery & Connectivity. Answers: 1. however. Cash Flow. "Administrator" does not include any of the following: 65736839. As Type 1 clearinghouses developed "rebate" income. Rebates. all clearinghouses are not created equal. 8.  Type 2  Type 3 8. health. dental. close affiliation with insurance companies Unbiased.5.3 Clearinghouse Income  Type 1 Biased. 2. standard working relationship with insurance companies Unbiased.5. 8. Insurance companies typically do not charge anything to receive claims.4 1. residents of this state in connection with life. to whom services are rendered. Unbiased and "rebate" free. Typically competitive in cost and superior in service. They typically fall into one of three possible group types. Type 2 clearinghouses followed up by negotiating rebates as well.00a Page 115 of 150 . 2.doc Ver 0.   It may be helpful. Type 3 clearinghouses "lease" Type 2 gateways to insurance companies at volume driven rates. or disability insurance or self-insurance programs. Exercise List down the Benefits of a Clearinghouse. Insurance Claims. thus avoiding the typical enormous overhead of Type 2 clearinghouses. close affiliation with leading Type 2 clearinghouses. "Administrator" means any person who adjusts or settles claims on. Type 3 clearinghouses utilize Type 2 gateways for transporting claims. The following chart will illustrate all the groups Clearinghouse Types  Type 1 Type 2 Type 3 Biased processing. Primary income is derived from the submitting HealthCare Provider. A HealthCare Transaction Clearinghouse performs auditing services on ___________ _______.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. imply that something was initially received. to understand how clearinghouses make their money.External Agents ___________________________________________________________________ As indicated.

identifying what each fixed cost includes. or provide administrative services to.7 Specialized Adjudication Engines/Companies Adjudicator A powerful engine that links to the existing software equipped with simple Boolean rules. to the plan sponsor all of the following: All fixed plan costs.  Fail to disclose in written form the method of collecting and holding any plan sponsor's funds. including any minimum attachment point factors. The aggregate excess insurance stop-loss attachment point factors. Any person who administers or operates the workers' compensation program of a selfinsuring employer under of the Revised Code. provided the state of domicile recognizes and grants licenses to administrators of this state who have obtained licenses under such sections.00a Page 116 of 150 .   Administrators may be tested and shall be licensed by the superintendent of insurance in accordance with rules adopted by the superintendent. 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. The names of all insurance payers providing protection for the plan sponsor's plans. Features: Repricing 65736839.  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. Levels of the specific excess insurance stop-loss deductible.doc Ver 0. dental.01 to 3959.  Fail to disclose in written solicitation material and on an on-going basis. health. 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. 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. be licensed without testing. or disability benefits exclusively for the person's own members or employees. 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 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. 8. No person shall solicit a plan or sponsor of a plan to act as an administrator for.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. Any person that administers an insured plan or a self-insured plan that provides life. at least once annually. 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. that enables to conquer the mysticism of Claims Adjudication. and any ownership relationship of five per cent or more between the administrator and such insurance payers.16 of the Revised Code. upon application.

They are the people who work behind the scenes to reduce administrative hassles. Once the application and base fee are received by URAC (The American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC). but is not limited to. 8. As a full-service agency. diagnoses and the Medicare fee schedule. This system comes equipped with "AccuChecker for Windows". purchase. like for example Workers Compensation cases.00a Page 117 of 150 .1 Accreditation Agencies The Accreditation Process Organizations applying for accreditation participate in a process that entails a rigorous review occurring in four phases. the leading accreditation organization for traditional health insurers). including licensing and appointment with insurance payer. formal policies and procedures. the system allows you to insert additional files with the information needed. After receiving a desktop review summary. a comprehensive database that contains procedures. which consists of completing the application forms and supplying supporting documentation. The initial phase "Building the Application". usually takes several months. position descriptions. case installation and communication. "AccuChecker for Windows" has the 2001 tables of procedures and ICD-9 codes.9 8. resolve complex service issues. sample template letters.8 General Agents They provide end-to-end connectivity that allows brokers and their clients to shop. enroll.1 Desktop Review In the desktop review process. consultation. as well as plan management and customer service. in an effort to maximize cost containment and fairness in adjudicating claims. If you process claims that require different fee schedules. 8. and program descriptions and plans for departments such as quality management and credentialing. negotiation. one or more full-time URAC reviewers analyze the applicant's documentation in relation to the URAC standards. serve and renew policies. organizational charts.doc Ver 0. The applicant's documentation usually consists of.9. supporting brokers in plan development. and preserve the integrity of brokerclient relationships. 65736839. 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. the applicant usually must provide additional documentation clarifying any pending issues. they provide valuable services.External Agents ___________________________________________________________________ Validates eligibility of patients. the remaining three phases of the accreditation process cover a period of approximately three to six months. These phases include the following: 8. also uses the HFCA published guidelines for medical procedures. contracts. procedures. 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.1.9.

denied accreditation.4 Accreditation Status Applicants who successfully meet all requirements are awarded a full two-year accreditation. During this review. An accreditation recommendation is then forwarded to URAC's Executive Committee.1. URAC reviewers also share "best practices" and provide other helpful guidance. Each accredited site is given its own certificate.9.00a Page 118 of 150 . e. Ongoing Compliance with the Standards Accredited organizations must continue to remain in compliance with the applicable standards throughout the accreditation cycle.g. Conditional accreditation may be awarded to applicants who have appropriate documentation.. management is interviewed about the organization's programs and staff is observed performing its duties. During the onsite visit.1. attesting to the program the organization is accredited for. Education and quality management programs are reviewed in detail as well. Accreditation Certificates A certificate of accreditation is awarded to accredited organizations. carried out by the same team that performed the desktop review. audits are conducted and personnel and credentialing files analyzed. a follow-up executive summary is submitted to URAC's committees for a possible change to full accreditation. This summary is submitted to URAC's Accreditation Committee for evaluation with discussion with the review team as needed. 8.1.External Agents ___________________________________________________________________ 8. but incomplete implementation of certain policies and procedures. 8. 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. Accredited organizations also provide copies of accreditation certificates to regulators in states where URAC accreditation is deemed.9. The committee review process begins with a written summary documenting the findings of the desktop and onsite reviews.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. the Executive Committee makes a final accreditation determination. After reviewing the summary and considering the Accreditation Committee's recommendation. and an accreditation certificate is issued to each company site that participated in the accreditation review. the accreditation review team conducts an onsite review to verify compliance with the standards. In addition. or choose to withdraw.doc Ver 0. Complaints against an Accredited Company 65736839. Follow-up activities for organizations receiving conditional accreditation or corrective action may include submission of additional or revised documentation and another onsite review. If an accredited company is unable to comply with URAC Standards.9. When these follow-up activities are complete. its accreditation will likely be rescinded.2 Onsite Review After the desktop review is complete. which has the authority to grant accreditation. Conditional accreditation may also be awarded to companies determined to be "start-ups". This will help the applicant differentiate its various products in the health care market and target a variety of current and potential clients. Organizations that are unable to meet URAC standards may be placed on corrective action status.

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

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. all eligible people can be covered by a group policy regardless of age or physical condition. In general. The contract details of every manufacturer are set up through some process like Volume Discount on-line processes. regarding rebates that can be obtained from the individual manufacturers when drugs bought under health insurance policies cross pre-defined limits. either electronically or through postal mails. The Volume Discount System runs on a quarterly basis. Formulary and Cost Management Group using VDS on-line transactions only enter all these information. The drug information is obtained from First Data Bank. as are the deductible amount and co-payment percentage. which allows him to buy outside the preferred network for same Co-pay. based on the manufacturer. the relevant details are entered through Volume Discount Allocation system. Doctors can prescribe a drug outside this preferred list. The premium for group insurance is calculated based on characteristics of the group as a whole. 8. he has to pay higher Co-pay. for all the products they wish to add to preferred drug list.00a Page 120 of 150 . The policy is typically negotiated between the insurer and the "master" policy owner (employer or association) without any input from the member. who to promote the sales. it is entered in the database.10 Drug Manufacturers Health Insurance group identifies potential drug manufactures. product indicator etc. client. Whenever a member goes to buy a drug from a pharmacy. Invoices for the dollar amounts payable by each manufacturer is prepared. but this plan attracts higher premium. such as average age and degree of occupational hazard. A member can take a plan. 65736839. 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). Doctors as well as pharmacies are provided with the preferred drug list (usually on-line).doc Ver 0. Actual rebate value is decided when the contract is set up and varies over a wide range depending on the contract and manufacturer.External Agents ___________________________________________________________________ Unlike individual insurance. but if he buys drug outside the preferred drug network. The specific policy provisions are all determined in advance. contract. his claim is adjudicated online by the Real time Adjudication System. The invoice amounts and the details are communicated to the manufacturing companies. where each person's risk potential is evaluated and used to determine insurability. Various inclusion/exclusion rules are applied. This process also generates detailed utilization information to support rebates invoiced. Once the claim is adjudicated. A member has to pay standard Co-pay when he buys a preferred drug. An extraction job runs on this database every quarter and pulls out those claims for which there are rebate contracts set up. a set of jobs does the actual rebate amount calculations. 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. Health Insurance sets up a contract with each of them. In the invoicing stage. along with the business rules from the contracts and summary files are obtained which form the input to the invoicing stage. the only real disadvantage of group insurance is limited or no freedom to customize the policy to member’s individual needs. which is an independently managed US wide database for drugs. want to put their products on preferred drug list/network. Once the rebate checks arrive. group.

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

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

00a Page 123 of 150 .Summary ___________________________________________________________________ UNIT .1 Unit Objectives This unit will summarize the contents of this course material by presenting a detailed description of healthcare industry workflow. 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. 9.IX 9 Summary 9.

the marketing department of the company creates a quote and presents it to the plan sponsor. which is submitted. The PCP will also file a claim on behalf of the member. The actuaries calculate the rates for the various services to be offered by the insurance company.Summary ___________________________________________________________________ 9. doctors are contracted by paying them a fixed capitation fee (this is the case for most individual doctors). then the insurance company pays him a commission based on the size and nature of the deal. network they need to get accreditation 9. they will have to meet a deductible before they can avail this facility. their age. The member first has to visit his PCP. then things are very simple. However. Hospitals and pharmacies are usually contracted on a volume-for-rebate basis. This data goes into an offer presentation. If this quote is accepted. as in the staff model. They can also be contracted in the form of an IPA or may be put on the payroll of the insurance company.00a Page 124 of 150 . He pays the provider then and there and files a claim with the insurance company. In case of POS and PPO plans. But before the providers can become a part of the from the relevant accreditation agencies.2. Now the member is formally enrolled with the insurance company. 9. etc to prepare a quote. The insurance company guarantees an increased patient volume and they in turn give rate discounts to the members.3 An Enrolled member wants to seek medical services. to the quote requester. Based on their judgment and experience they tailor the rates and prepare the details of plan coverage and commercial agreements. it is necessary that he should have satisfied his deductible for that particular year. previous medical history. income data. Also the concept of coinsurance will come into picture. type of plan. This referral authorizes the member to seek medical services of a specialist provider. The member only has to pay fixed copay to both the PCP and the specialist. In case of PPO plans the member has the added advantage that he does need to have a PCP for In-network care. They collect the required information such as number of members. Based on these rates. If the member is enrolled in an Indemnity plan. He can go to any provider of his choice. Usually. if a medical condition arises which requires treatment from a specialist. the flow is a bit more complicated.2 Getting a provider For an insurance company to deliver healthcare services to its members. If there was any broker involved in the deal. member number.doc Ver 0. In case of managed care plans.1 The Beginning: Member wants to purchase insurance The sales and marketing department approaches potential member(s). then the policy department of the insurance company prepares a policy which has details such as policy number. 65736839. the PCP will provide a referral to the member. the underwriters validate the rates offered by the marketing department. claim posting address amongst other things. payment details. hospitals and pharmacies. But. The PCP will try to provide as many services as he can.2. This is the flow in case of HMO and EPO plans. However. it needs to have an agreement with healthcare providers such as doctors. If this is accepted by the quote requester. PCP information (in case of managed care plans).2. the member can seek services from out of network providers.

the primary payer takes care of the COB or coordination of benefits. As a matter of fact. There is usually a rule engine (a software) in place for adjudication. The federal spending on healthcare also has been on a steady rise. In case the claims have incomplete information or the information is ambiguous.3 Review Questions. If the claim requires very specialized processing (and if the rule engine for that is not available with the insurance company). which has since then dominated the market. The company validates the claims based on various factors (as were detailed out in the unit on claims). 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.A. If the claims are found to be free of such errors. He is also sent an EOB detailing the payments made and the reasons for those. plays an important role in shaping the way the industry functions.4 References.S. In short claims adjudication requires lot of database interaction and is the most complex of all processes. 9. The information about the entire processing is usually stored in a database for further reference. There are several government agencies that help in regulation of the healthcare industry.2. policy that are stored in their respective databases.doc Ver 0. 65736839. NA 9. providers. it was the path breaking HMO act of 1973. then the claim adjudication is outsourced to a company specializing in adjudication of such claims. as otherwise these claims would have to be adjudicated manually.00a Page 125 of 150 . The government controlled Medicare and Medicaid are amongst the most important healthcare plans available. Claims adjudication requires a lot of information about various entities such as members. they are sent to the insurance company. In case of the member having coverage with multiple carries. which paved the way for the managed care model.2. 9. If the claim is found to be a valid one.5 Effect of external agencies Health insurance is a highly regulated area in the U. then the member is paid for his expenses. The turn around time take to process the claims is also an important consideration for members and providers. 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. The federal government too. Hence the insurance companies try to reduce the time for adjudication by going automatic claim adjudication systems. Incorrect claims are returned back to the member (or his PCP whoever has file the claim). the claim examiners do the adjudication manually. This helps reduce the burden on the insurance company and speeds up the process.4 Member has filed a claim In most cases the claim is first validated for typographical and information errors by clearinghouses.Summary ___________________________________________________________________ 9.

doc Ver 0.Summary ___________________________________________________________________ 65736839.00a Page 126 of 150 .

140 5.393 411.3 Source: Dataquest (January 2000) 10.408 69. by Region.081 81.122 17.606.1 1.800 20.5 45.551 45.285 816.444 184.146 592.8 Asia/Pacific Canada Europe Japan Latin America Rest of World United States Total Healthcare Worldwide 42. 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.6 43.850 48.819.477 141.834 10.752 140.479 9.187 40.020 293.505 54.2 Appendix B: The world Healthcare market and Healthcare IT spending The US healthcare market is predominantly privately run.164 417. In Germany/ France.917 29. 65736839.979 3.8 46.144 13.113 500.201 2.437 266.668 44. Other countries spend less on IT as a % of revenues.877 1.2 835.S.Appendix ___________________________________________________________________ 10 Appendices 10.988 210. there are Insurance-based systems in which providers are subcontracted by the government.018 91.805 646.979 363.doc Ver 0.749 5.612 1.268. 1998-2003 (Millions of U.090.829 31.523 442.931 1.314 25.1 Appendix A: Total E-Business Services Forecast for Healthcare Total E-Business Services Forecast for Healthcare.804 109.964 151.674 32.5% in Europe.843.5 515. Japan and Australia.867 161.756 50.628 289.1.403 1.259 194.050.402 66.00a Page 127 of 150 .682 258.741.086 14.

Other countries spend less on healthcare than the US does because single payer systems tend to have efficiencies in purchasing.doc Ver 0.3 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. a core focus for most governments around the world will continue to grow as newer technologies and sciences (Genomics. (Source: Gartner Research. less choice to patients and administration efficiencies. Proteomics and Bio technology) revolutionize health care. (Source: Gartner Research.Appendix ___________________________________________________________________ Worldwide. Healthcare market. but the profit angle is increasingly focused on. Inc) 10.00a Page 128 of 150 . Inc) 65736839. investment in IT in healthcare is at a low of 3% as compared to an overall average of 6% and 12% for Financial services.

3 Trillion.a whopping number by any standards.70 $413.60 $227. 65736839.4 Appendix C: Sample Quote Sheet Page 1 XXXX Proposal For July 26.00 $264. 70% of the Federal budget of the US. Inc) 10.00a Page 129 of 150 . (Source: Gartner Research.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.US also leads in the IT development of this market. The total health care spending (by private and public in the US) is 1. 2001 ABCDEF Inc Effective Date 10/01/2001 Renewal Date 10/01/2001 Service Area Colorado .Appendix ___________________________________________________________________ US is the largest spender in this market. Service Area is determined by the location of the subscriber's primary care doctor. Rates will vary for other service areas.30 The foregoing rates apply in the Service Area specified above. account for 43% of the world spending.doc Ver 0.

Benefit Waiting Period (BWP) Standard BWP is 3 months minimum. spouse or children and employee/family and (c) 4 tier which is an average rate for employee only. employee/children and employee/family.within three(3) business days. upon oral or written request. 07/26/2001 1:48:14 PM 7011882 LIFRAM12 65736839.doc Ver 0.Groups with under 10 employees may only elect an age banded rate structure.Groups with 10 or more eligible employees have the right to see what the premium would be quoted either of two ways. an unmarried child who is a full-time student under twenty-four (24) years of age and who is financially dependent upon the parent. 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. 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). Any changes in benefit level or conditions stated above may require a change in rates. 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. i. and an unmarried child of any age who is medically certified as disabled and dependent upon the parent..Appendix ___________________________________________________________________ Quote Conditions Assumed Dependent Eligibility Dependent means a spouse.e. 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.00a Page 130 of 150 . an unmarried child under nineteen (19) years of age. (a) 2 tier which is average rate for employee only and employee/family. 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. There are two different rate structures available depending on the employer case size.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.employee. 6 months maximum or match the incumbent carrier's BWP up to 6 months maximum.employee/spouse.The form must be provided automatically within three (3) business days to a potential policyholder who has expressed interest in a particular plan.which is intended to facilitate comparison of health plans.

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

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

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