Domain Knowledge Healthcare Industry Part 2

Posted on Dec 4 2007 - 12:03pm by Raj

Continued from Part 1… 

This article discuss common healthcare terms from a payer perspective and gives a overview basic HIPAA messages.

POS:

  • Point-of-service plans are health benefit arrangements that evolved in response to consumer desire for broader choice in physicians and health care facilities. Health maintenance organizations offer POS plans to give their members a choice of either in-network benefits or out-of-network benefits.
  • "In-network" refers to health care professionals and facilities that are members of the health plan’s provider network. They are usually listed as "participating providers" in membership materials. Except in special cases, such as emergency treatment, HMOs usually cover care delivered by in-network providers only.
  • "Out of network" refers to health care professionals who have no contractual relationship with the health plan. Out-of-pocket costs vary according to how a member chooses to receive care at the "point of service" (hence the name).

Defined Contribution Plan

  • Involve employer funding of a fixed (as opposed to variable) dollar amount for health benefits, which employees may then use to purchase benefits from an employer arranged funding mechanism.
  • The benefits could either be group benefits packaged and arranged by the employer, or purchased individually by the employees.

Carrier vs. Payer

Carrier
An insurer; an underwriter of risk that finances health care. Also refers to any organization, which underwrites or administers life, health or other insurance programs. When an employer has a “self-insured” plan, the carrier (such as Aetna or Blue Cross) may not serve as carrier in this case, but may serve only as “third party administrator”.

Payer :
The public or private organization that is responsible for payment for health care expenses. Payers may be insurance companies or self-insured employers.

Medicare

  • A federal program that pays for certain health care     expenses for people aged 65 or older. Enrolled     individuals must pay deductibles and co-payments,     but much of their medical costs are covered by the     program.
  • Medicare is less comprehensive than     some other health                                     care programs, but it is an important source of post-    retirement health care.
  •  Medicare is divided into three parts.
  • Part A covers hospital bills,
  • Part B covers doctor bills, and
  • Part C provides the option to choose from a package of health care plans.

Medicaid

  • State programs of public assistance to persons regardless of age whose income and resources are insufficient to pay for health care.
  • The United States federal government provides matching funds to the state Medicaid programs.

Coordination of Benefits (COB)

  • Provision regulating payments to eliminate duplicate coverage when a claimant is covered by multiple group plans. The procedures set forth in a Subscription Agreement to determine which coverage is primary for payment of benefits to Members with duplicate coverage.
  •  A coordination of benefits, or "nonduplication," clause in either policy prevents double payment by making one insurer the primary payer, and assuring that not more than 100 percent of the cost is covered. Standard rules determine which of two or more plans, each having COB provisions, pays its benefits in full and which becomes the supplementary payer on a claim.
  • Also called cross-over

Continues to Part 3…

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