Health insurance in the United States

Question

This piglix contains articles or sub-piglix about Health insurance in the United States

Answer 1

Medical billing

Medical billing is a payment practice within the United States health system. The process involves a healthcare provider submitting, and following up on, claims with health insurance companies in order to receive payment for services rendered; such as treatments and investigations. The same process is used for most insurance companies, whether they are private companies or government sponsored programs: Medical coding reports what the diagnosis and treatment were, and prices are applied accordingly. Medical billers are encouraged, but not required by law, to become certified by taking an exam such as the CMRS Exam, RHIA Exam and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field. Some community colleges in the United States offer certificates, or even associate degrees, in the field. Those seeking advancement may be cross-trained in medical coding or transcription or auditing, and may earn a bachelor's or graduate degree in medical information science and technology.

For several decades, medical billing was done almost entirely on paper. However, with the advent of medical practice management software, also known as health information systems, it has become possible to efficiently manage large amounts of claims. Many software companies have arisen to provide medical billing software to this particularly lucrative segment of the market. Several companies also offer full portal solutions through their own web-interfaces, which negates the cost of individually licensed software packages. Due to the rapidly changing requirements by U.S. health insurance companies, several aspects of medical billing and medical office management have created the necessity for specialized training. Medical office personnel may obtain certification through various institutions who may provide a variety of specialized education and in some cases award a certification credential to reflect professional status.

The medical billing process is an interaction between a health care provider and the insurance company (payer). The entirety of this interaction is known as the billing cycle sometimes referred to as Revenue Cycle Management. Revenue Cycle Management involves managing claims, payment and billing. This can take anywhere from several days to several months to complete, and require several interactions before a resolution is reached. The relationship between a health care provider and insurance company is that of a vendor to a subcontractor. Health care providers are contracted with insurance companies to provide health care services. The interaction begins with the office visit: a physician or their staff will typically create or update the patient's medical record.

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Answer 2

Kaiser Permanente

Kaiser Permanente

Kaiser Permanente (/ˈkaɪzər pɜːrməˈnɛnteɪ/ – (KP)) is an integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser Permanente is made up of three distinct but interdependent groups of entities: the Kaiser Foundation Health Plan, Inc. (KFHP) and its regional operating subsidiaries; Kaiser Foundation Hospitals; and the regional Permanente Medical Groups. As of 2014, Kaiser Permanente operates in eight states and the District of Columbia, and is the largest managed care organization in the United States.

As of December 31, 2015, Kaiser Permanente had 10.2 million health plan members, 186,497 employees, 18,652 physicians, 51,010 nurses, 38 medical centers, and 622 medical offices. As of December 31, 2015, the non-profit Kaiser Foundation Health Plan and Kaiser Foundation Hospitals entities reported a combined $1.9 billion in net income on $60.7 billion in operating revenues. Each Permanente Medical Group operates as a separate for-profit partnership or professional corporation in its individual territory, and while none publicly reports its financial results, each is primarily funded by reimbursements from its respective regional Kaiser Foundation Health Plan entity. KFHP is one of the largest not for profit organizations in the United States.

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Answer 3

Independent medical review

An Independent medical review is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether there was any mis-diagnosis, mistreatment or any systemic problems involved which led to the sentinel event.

Physicians who perform independent medical reviews must be board certified and in active practice in that same area of treatment. These physicians are contracted by an independent review organization, medical management companies, third party administrators (TPAs) or utilization review companies to provide objective, unbiased determinations on what the root cause of the treatment was, whether there is medical necessity, if there was a sentinel event, what was the reason for it, etc.

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Answer 4

Independent medical examination

An independent medical examination (IME) occurs when a doctor/physical therapist/chiropractor/psychologist/neuropsychologist who has not previously been involved in a person’s care examines an individual. There is no doctor/therapist-patient relationship.

IMEs may be conducted to determine the cause, extent and medical treatment of a work-related or other injury where liability is at issue; whether an individual has reached maximum benefit from treatment; and whether any permanent impairment remains after treatment. An IME may be conducted at the behest of an employer or an insurance carrier to obtain an independent opinion of the clinical status of the individual. Workers' compensation insurance carriers, auto insurance carriers, and self-insured employers have a legal right to this request. Should the doctor/therapist performing the IME conclude that a patient’s medical condition is not related to a compensable event, the insurer may deny the claim and refuse payment.

Every state has different laws when it comes to Worker's Compensation and No-Fault claims and every insurance company works differently. In a Massachusetts No-Fault claim the insurance companies may require a report to be dictated by the doctor within 24 hours of the IME and sent to all parties of interest. In New York State, the Worker's Compensation Board allows the doctor 10 business days from the date of the IME to dictate the report and have it sent to all parties. Most often, there is an IME Vendor/Company involved in which they schedule the exams, send out appointment letters, follow up with the doctors, proof read the reports for any errors or missed information, and finally, send out the reports to all parties. The insurance company just makes the request to a preferred IME vendor, and the vendor takes care of the rest.

New York State has some very strict laws when it comes to Worker's Compensation. In some cases, a claimant may have what is called a C-4 Authorization case, which indicates the claimant needs surgery or Physical Therapy. The claimant's treating doctor will send a C-4 Authorization Request to the insurance adjuster. The adjuster then sends a referral to an IME Vendor and requests that per the Worker's Compensation Board, an IME is completed and the report is due back to all parties within 30 days of the treating doctor's request. If a vendor cannot supply a doctor who can book an appointment this soon, a File Review or Records Review may be proposed by the vendor to the insurance company. In this case, the doctor will not see the claimant, but will just review their medical records and dictate a report. The IME Vendor is usually instructed by the insurance company not to tell the claimant they are having a records review.

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Answer 5

ICan Group

iCan Group

The iCan Group is a family of companies in the fields of health insurance, telehealth, marketing, and medical bill advocacy. Recently, the group launched an on-demand telehealth start-up called InteractiveMD, allowing for the extension of telemedical benefits to members of its group health insurance programs, as well as general consumers who wish to sign up exclusively for telehealth benefits. The functionality of the real-time video consultations offered through the telehealth portal was recently demonstrated for a local ABC affiliate.

In June 2009, the iCan Group's insurance brokerage firm, iCan Benefit, was featured on Pitchmen, a Discovery Channel show hosted by their late spokesperson, Billy Mays.

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Answer 6

ICan Benefit

iCan Benefit Group, LLC is a US based insurance agency that provides access to a wide range of health care plans and lifestyle benefits, some of them through association membership in a not-for-profit corporation called the Healthcare Cost Containment United Association (HCCUA). The company was represented by Billy Mays from May 2008 until his death in June 2009. Mays referred to iCan's insurance product as "the most important product I've ever endorsed." He also featured iCan Benefit on his Discovery Channel show Pitchmen, just prior to his death.

iCan Benefit is a part of the iCan Group, a family of companies in the fields of health insurance, telehealth, marketing, and medical bill advocacy.

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Answer 7

Medical underwriting

Medical underwriting is a health insurance term referring to the use of medical or health information in the evaluation of an applicant for coverage, typically for life or health insurance. As part of the underwriting process, an individual's health information may be used in making two decisions: whether to offer or deny coverage and what premium rate to set for the policy. The two most common methods of medical underwriting are known as moratorium underwriting, a relatively simple process, and full medical underwriting, a more indepth analysis of a client's health information. The use of medical underwriting may be restricted by law in certain insurance markets. If allowed, the criteria used should be objective, clearly related to the likely cost of providing coverage, practical to administer, consistent with applicable law, and designed to protect the long-term viability of the insurance system.

It is the process in which underwriter takes the notice of the health conditions of the person who is applying for the insurance, keeping in mind certain factors like health condition, age, nature of work, and geographical zone. After looking at all the factors, underwriter suggest whether policy should be given to the person and, if so, what will be the premium.

Underwriting is the process that a health insurer uses to weigh potential health risks in its pool of insured people against potential costs of providing coverage.

To search the medical underwriting, an insurer asks people who apply for coverage (typically people applying for individual or family coverage) about pre-existing medical conditions. In most US states, insurance companies are allowed to ask questions about a person's medical history to decide whom to offer coverage, whom to deny and if additional charges should apply to individually-purchased coverage.

While most discussions of medical underwriting in health insurance are about medical expense insurance, similar considerations apply for other forms of individually-purchased health insurance, such as disability income and longterm care insurance.

From the insurers' point of view, medical underwriting is necessary to prevent people from purchasing health insurance coverage only when they are sick, pregnant or need medical care. Adverse selection is a system that attracts high-users and discourages low-users from participating. Proponents of underwriting believe that if given the ability to purchase coverage without regard for pre-existing medical conditions (no underwriting), people would wait to purchase health insurance until they got sick or needed medical care. Waiting to obtain health insurance coverage until one needs coverage then creates a pool of insureds with "high use," which then increases the premiums that insurance companies must charge to pay for the claims incurred. In turn, high premiums further discourage healthy people from obtaining coverage, particularly when they realize that they will be able to obtain coverage when they need medical care.

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Answer 8

Medical-bill advocacy

Medical-bill advocacy is the name generally attributed to the industry that has developed in response to a growing problem of erroneous charges on medical bills. According to the Medical Billing Advocates of America (MBAA), as many as 9 out of 10 bills from hospitals and medical providers include errors that may erroneously inflate the cost of actual healthcare received.

Medical bill advocates help patients find errors in their bills, negotiate with their insurer to appeal coverage denials, and/or negotiate lower fees with their medical care providers.

Examples of common medical bill errors identified by advocates include the following:

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Answer 9

Medigap

Medigap (also Medicare supplement insurance or Medicare supplemental insurance) refers to various private health insurance plans sold to supplement Medicare in the United States. Medigap insurance provides coverage for many of the co-pays and some of the co-insurance related to Medicare-covered hospital, skilled nursing facility, home health care, ambulance, durable medical equipment, and doctor charges. Medigap's name is derived from the notion that it exists to cover the difference or "gap" between the expenses reimbursed to providers by Medicare Parts A and B for the preceding named services and the total amount allowed to be charged for those services by the United States Centers for Medicare and Medicaid Services (CMS). As of 2006, 18% of Medicare beneficiaries were covered by a Medigap policy. Public-option Part C Medicare Advantage health plans and private employee retiree insurance provides a similar supplemental role for almost all other Medicare beneficiaries not dual eligible for Medicaid.

Medicare eligibility starts for most Americans when they turn 65 years old. Those who have been on Social Security eligibility for 24 months can also qualify for Medicare Part A and Part B. A person must be enrolled in part A and B of Medicare before they can enroll in a Medigap plan. When a person turns 65 - or if they are older and new to Medicare Part B - they become eligible for Medigap open enrollment. This period starts on the first day of the month you turn 65 and lasts for 6 months. During this period, a person can buy any Medigap plan regardless of their health.

This is different than if someone is losing group coverage or retiring. When this occurs the person is eligible to exercise his or her "Guarantee Issue" right. With a Medigap guarantee issue right a person can buy a Medigap Plan A, B, C, F, K, or L that’s sold by any insurance company in their state. In addition, the insurance company cannot deny or raise the premium due to past or current health conditions. Also, the insurance company must cover any pre-existing conditions. Instead of exercising the guarantee issue right a person can opt to go through the underwriting process in order to buy a *plan G or N. Once a person is outside their open enrollment period and or guarantee issue they can change their Medigap plan but they will be subject to health underwriting by the insurance company they are applying with.

It is also important to know that monthly premiums apply, and plans may not be cancelled by the insurer for any reason other than non-payment of premiums/membership dues. Furthermore, a single Medigap plan may cover only one person. Finally, Medigap insurance is not compatible with a Medicare Advantage plan. You cannot have both a Medicare supplement and a Medicare Advantage plan at the same time. You can only have a Medigap plan if you are still on Medicare Part A and Part B and have not replaced your coverage with a Medicare Advantage Part C coverage.

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Answer 10

MinnesotaCare

MinnesotaCare is a health coverage program in the U.S. state of Minnesota for low-income individuals and families who do not have access to employee-sponsored health insurance. It is administered by the Minnesota Department of Human Services. Enrollees pay a monthly fee based on income and family size, among other factors. According to the Minnesota House of Representatives, 121,731 individuals were enrolled in MinnesotaCare as of November 2006.

MinnesotaCare coverage includes "doctor visits, hospitalization, prescriptions, eye exams, eye glasses, dental care" and other services. Services are provided through prepaid health plans, who negotiate reimbursement rates with health care providers. In fiscal year 2006, the MinnesotaCare program paid $438 million for medical services provided to enrollees. Thirty-five percent of the cost was paid for by the federal government, 8 percent by premiums paid by enrollees, and the remainder by the state.

According to Minnesota Department of Human Services, in year 2012, following health plans were available for MinnesotaCare applicants:

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