Health insurance in the United States

Question

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

Answer 1

Preferred provider organization

In health insurance in the United States, a preferred provider organization (or PPO, sometimes referred to as a participating provider organization or preferred provider option) is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

A preferred provider organization is a subscription-based medical care arrangement. A membership allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor). They negotiate with providers to set fee schedules, and handle disputes between insurers and providers. PPOs can also contract with one another to strengthen their position in certain geographic areas without forming new relationships directly with providers. This will be mutually beneficial in theory, as be billed at a reduced rate when its insureds utilize the services of the "preferred" provider and the provider will see an increase in its business as almost all and or insureds in the organization will use only providers who are members. PPOs have gained popularity because, although they tend to have slightly higher premiums than HMOs and other more restrictive plans, they offer patients more flexibility overall.

Other features of a preferred provider organization generally include utilization review, where representatives of the insurer or administrator review the records of treatments provided to verify that they are appropriate for the condition being treated rather being largely or solely being performed to increase the amount of people due. Another near-universal feature is a pre-certification requirement, in which scheduled (non-emergency) hospital admissions — and, in some instances, outpatient surgery — must have the prior approval of the insurer and must often undergo "utilization review" in advance.

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Answer 2

Prior authorization

Prior authorization is a process used by some health insurance companies in the United States to determine if they will cover a prescribed procedure, service, or medication. The process is intended to act as a safety and cost-saving measure, although it has received criticism from physicians for being costly and time-consuming.

Prior authorization is a check run by some insurance companies or third party payers before they will agree to cover certain prescribed medications or medical procedures. There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied, or an insurance company requiring the patient to go through a separate process known as "step therapy" or "fail first". Step therapy dictates that a patient must first see unsuccessful results from a medication or service preferred by the insurance provider, typically considered either more cost effective or safer, before the insurance company will cover a different service.

After a healthcare provider orders a healthcare service for a patient, the providers's staff will contact the patient's insurer to determine if they require a prior authorization check to be run. If so, a manual process is initiated. The process to obtain prior authorization varies from insurer to insurer, but typically involves the completion and faxing of a prior authorization form. At this point, the medical service may be approved, rejected, or additional information may be requested. If a service is rejected, the healthcare provider may file an appeal based on the provider's medical review process. In some cases, an insurer may take up to 30 days to approve a request.

Insurers have stated that the purpose of prior authorization checks is to provide cost savings to consumers by preventing unnecessary procedures as well as the prescribing of expensive brand name drugs when an appropriate generic is available. In addition, a prior authorization for a new prescription may help prevent potentially dangerous drug interactions. A 2009 report from the Medical Board of Georgia showed that as many as 800 medical services require prior authorizations. According to Medical Economics, physicians have expressed frustration with the current prior authorization process with regards to time spent interacting with insurance providers and the costs incurred based on that time. A 2009 study published in Health Affairs reported that primary care physicians spent 1.1 hours per week fulfilling prior authorizations, nursing staff spent 13.1 hours per week, and clerical staff spent 5.6 hours. A study in the Journal of the American Board of Family Medicine found that the annual cost per physician to conduct prior authorizations was between $2,161 and $3,430. The cost to health plans has been reported at between $10 and $25 per request. It is estimated that current prior authorization practices cost the US healthcare system between $23 and $31 billion annually.

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Answer 3

Premera Blue Cross

Type

Non-profit organization Industry Health Insurance Founded 1945 Headquarters Mountlake Terrace, Washington, United States

Area served

Primarily Alaska, Oregon and Washington Products Health Insurance

Number of employees

3,200 Parent Blue Cross Blue Shield Association Subsidiaries

LifeWise of Oregon

LifeWise of Washington
LifeWise Assurance Company
" >Premera Blue Cross

LifeWise of Oregon

Premera Blue Cross is a nonprofit Blue Cross Blue Shield licensed health insurance company based in Mountlake Terrace, Washington, United States. It sells health insurance plans under the Blue Cross license in Washington state except Clark County and under both of the Blue Cross and Blue Shield licenses in Alaska. It also has affiliate health insurance operations in Washington and Oregon under the LifeWise brand.

The company provides health insurance and related services to approximately 2 million people. Premera Blue Cross has operated in Washington since 1933, and in Alaska since 1957. Premera Blue Cross is an independent licensee of the Blue Cross Blue Shield Association.

Premera was founded as Washington Hospital Service on May 5, 1945, and began operating in Alaska in 1957. On March 14, 1969, the company's name was changed to Blue Cross of Washington and Alaska.

In 1994, Blue Cross of Washington and Alaska affiliated with Spokane's Medical Service Corporation, which had been founded in November 1933. In June 1998, the two organizations merged under the name Premera Blue Cross.

In 2002, Premera's executives first informed Washington commissioner Mike Kreidler of their intent to convert from a non-profit to a for-profit company. After five years, the request was officially ended on March 5, 2007.

In October 2009, Premera waived deductible or co-pay for 2009-H1N1 vaccine fees for its fully insured members.

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Answer 4

Self-funded health care

Self-funded health care also known as Administrative Services Only (ASO) is a self insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds. This is different from fully insured plans where the employer contracts an insurance company to cover the employees and dependents. In self-funded health care, the employer assumes the direct risk for payment of the claims for benefits. The terms of eligibility and covered benefits are set forth in a plan document which includes provisions similar to those found in a typical group health insurance policy. Unless exempted, such plans create rights and obligations under the Employee Retirement Income Security Act of 1974 ("ERISA").

Many employers seek to mitigate the financial risk of self funding claims under the plan by purchasing stop loss insurance from an insurance carrier. These policies typically provide for risk retention limitations both on a specific claim and aggregate claims basis. An important aspect of self funded group health plans lies in the requirement that the employer remain liable for funding of plan claims regardless of the purchase of stop loss insurance. What this means, in turn, is a fund or company's own bank account creates a pool of their employees and is managed & distributed to claim payouts. In other words, only the employer has a contractual relationship with plan participants and beneficiaries. The stop loss policy runs solely between the employer and the stop loss carrier and creates no direct liability to those individuals covered under the plan. This feature provides the critical distinction between fully insured plans (subject to State law insurance regulations) and self funded health plans which, under the provisions of Section 514 of ERISA, are exempt from state insurance regulations.

Stop-loss policies are instrumental in establishing a "worst-case scenario", or aggregate for any given year. The aggregate stop-loss helps establish a finite number that can be compared to a plan's guaranteed fully insured cost. If the aggregate cost does not exceed the plans' fully insured guaranteed cost, self-funding may be a viable option. Another way to look at aggregate insurance is an umbrella policy that caps a company's liability within a specified time period.

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Answer 5

Short-term health insurance

In the United States, Short-term health insurance refers to health insurance plans with a limited duration, typically several months. These plans are geared toward people who need temporary medical insurance to bridge the gap between longer term plans. For instance, people who are switching employers, starting graduate school, or young adults who have become ineligible for coverage under their parents' plans and are searching for their own insurance might use a short-term insurance plan until obtaining a more permanent solution.

Short-term health insurance plans are typically less expensive than traditional plans, but do not cover pre-existing conditions. This can cause problems for people who acquire a longer term illness, since the short-term plan is completely terminated at the end of the coverage period. Short-term plans are also not considered "adequate coverage" under the Affordable Care Act so customers would also be subject to the tax penalties of being uninsured.

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Answer 6

Silent PPO

A Silent PPO is an organization that accesses a discounted rate for services from a physician, hospital or other health care provider without direct authorization from the provider to do so.

Generally, insuring entities may negotiate contracts with the healthcare provider, with a defined set of reimbursement values for the work performed by the provider. These rates may entail a significant discount from the amount the provider would charge an uninsured patient. For a given provider, the amount of discount varies between different insuring entities, and a separate contract is negotiated with each entity.

Silent PPOs create agreements with insuring entities, allowing buyers into the Silent PPO to access the terms of the lowest discounted rate available. Patients (and other insuring entities who are members of the Silent PPO) may then access the lowest discounted rate of the healthcare provider, even though the patient is not directly a member of the plan contracted to the healthcare provider.

The members of the Silent PPO might be insurance companies, self insured employer health plans or another Silent PPO. The Silent PPO could also be a middle man and resell their created network of healthcare providers.

There are medical organizations which disagree with or dislike the concept of Silent PPOs. The problem as advocated is that when the physician negotiated the discount, they intended to give it only in exchange for referrals from members of the insurer - where a patient is given some advance incentive to choose them. Silent PPOs typically do not make referrals, but provide access to the discount after the service was rendered. Additionally, providers argue that had the patient not entered via a back-door arrangement, they would not have been given the discount applied to the contract. Thus, the provider loses money from the amount that would have been charged.

Various companies specialize in auditing medical care contracts and target issues related to Silent PPO's.

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Answer 7

Superbill

Superbill is an itemized form used by healthcare providers for reflecting rendered services. Superbill is the main data source for creation of healthcare claim, which will be submitted to payers (insurances, funds, programs) for reimbursement. Although the superbill form is not unified, and it is created/modified depending on healthcare provider specialty, type of rendered services, additional requirements, as well as ease of handling, there is a set of obligatory attributes, relevant to all superbill types.

Superbill form consists of 4 main parts, containing mandatory fields to be completed for accurate claim creation:

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Answer 8

Take Care Utah

Take Care Utah

Take Care Utah is a network of nonprofit organizations and individuals across the state of Utah focused on helping people access health insurance coverage.

Take Care Utah consists of over 100 enrollment specialists across the state. The network is led by the Utah Health Policy Project, United Way of Salt Lake / 2-1-1, and the Association for Utah Community Health (AUCH). The organization provides assistance with signing up for health insurance through the Marketplace (Obamacare), Medicaid, and the Children's Health Insurance Program (CHIP). All services are provided free of charge. Many of the people who utilize Take Care Utah's services are referred by 2-1-1 operators who can locate the nearest enrollment specialist to a person's location.

Take Care Utah's organizations receive funding from several sources, including the competitive Federal Navigator grant which is awarded annually.

Take Care Utah holds a summit every year in September for all patient navigators and Certified Application Counselors across the state to receive required trainings and set goals.

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Answer 9

Tufts Health Plan

Tufts Health Plan

Tufts Health Plan is a Massachusetts-based health insurance company under Tufts Associated Health Plans, Inc. with headquarters in Watertown.

As of March 31, 2016,the nonprofit health insurer had 1,072,000 members. The Tufts Health Plan network includes 91 hospitals and 29,000 health care providers. The health plan offers products for employers as well as individuals enrolled in Medicare, Medicaid and the Health Insurance Exchange.

In 2008, former Tufts Health Plan CEO James Roosevelt Jr. created the Tufts Health Plan Foundation so the health plan’s assets could be used to help address long-standing health care issues in the local community. The foundation funds approximately $4 million annually in investments and grants to local non-profits.

Tufts Health Plan met financial expectations for 2015, when membership grew by about 20,000 members, for a total of more than 1,035,000, according to CFO Umesh Kurpad. The health insurer became one of the four organizations in the country to achieve a 5-star rating by the National Committee for Quality Assurance.

In 2015, Tufts Health Plan entered into several partnerships and acquisitions, including:

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Answer 10

Underinsurance (healthcare)

Underinsurance is the state of an individual having some form of health insurance that does not offer complete financial protection. This results in the underinsured individual to therefore lack the ability to cover out-of-pocket healthcare expenses. There is not yet one clear definition that has been established to include all of the domains that must be addressed. There are three domains that are included when considering underinsurance in healthcare. They include; (1) the economic characteristics of health insurance, (2) the benefits that are or are not covered, and (3) actual access to health services and resources. All of these aspects must be considered when defining, measuring, and identifying instances of underinsurance.

The term “uninsured” is often better known and more often discussed. This is because it has a clear definition of an individual not possessing health insurance coverage. This clearly defined term allows for accurate measurements of the number of uninsured people, and more reliable research results. However, an individual being underinsured, or experiencing underinsurance is much more difficult to research and measure. This is because there is not one simple clear-cut definition of underinsurance. Rather there are three different types of definitions that are most commonly discussed; economical, attitudinal and structural. This difficulty and inconsistency in defining the term has led to a lack of research and knowledge of the topic. It has been established that individuals who are categorized as underinsured, are at high financial risk, and face barriers in the level of access to care. This difficulty in access to care is similar to those who are completely uninsured.

The economic definition of underinsurance is a person’s actual ability to pay for their recommended health care and services. This includes the cost of the insurance premiums, co-payments, and deductibles. An economic definition of underinsurance specifically defines a certain monetary limit above which the expenses of health care coverage become a significant financial burden, and interfere with access to care. This definition of underinsurance is utilized and identified when an individuals' out-of-pocket expenses for necessary medical care are above a specified percent of that individual’s income, within a given time frame. This definition is also used when a person chooses to delay, or not receive necessary health care services solely because of the out-of-pocket costs associated with the services.

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