Transcript Insurance

Insurance and the ATC
George Wham, MS, ATC
Costs of Healthcare
• US spent $1.1 trillion on healthcare in
1998 (13.5% of GDP)
– 34% for hospital care
– 20% for physician services
– 26.7% for other medical services
– 7.2% for prescription drugs
• Fastest growing cost – increased 14% in 2000,
20% in 2001, 16% in 2002, and 15% in 2003
More Costs of Healthcare
• 18% of people
generate 80% of
the cost
• .4% generate 20%
• In 2002 43.6 million
in US were
uninsured
– Mostly working poor
Insurance Background
• 1798 1st form of health insurance in US provided
by Marine Hospitals for seaman
• Post WWII medical insurance becomes a
common benefit for many jobs
• 1979 – 85% of population covered by private
insurance
• Mid 1990’s – 70%
• Increasing cost of healthcare making insurance
less affordable
– during 1980’s and early ’90’s moved to managed
care
Insurance Terms
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Premium
Deductible
Copay
Balance
Riders
Exclusions
Capitation
Insurance Systems
• Medical Insurance
– Only covers medical bills
• Health Insurance
– Also covers prevention and health maintenance
• Athletic Accident Insurance
– Usually supplemental to family policy to reimburse
part of cost of an athletic injury
– Some plans may only cover acute injuries, but not
overuse or chronic conditions
More Insurance Systems
• Catastrophic Insurance
– To cover lifetime medical and disability coverage
– NCAA provides to all it’s athletes free
– Takes affect after 1st $50,000 of bills accumulate
• Disability Insurance
– Protects athletes against future loss of earnings to disability
while competing
– NCAA sponsored program that may be purchased
• Workman’s Compensation Insurance
– State mandated program provides benefits to injured workers
– Employer funded
– Compensation varies with severity
Fees
• Usual, customary,
reasonable (UCR)
– Commonly used fee
system for medical
services originally
developed for
Medicare
– Ideally want to deal w/
providers who accept
UCR as payment
Types of Athletic Insurance
• Self Insured
– Institution purchases catastrophic coverage and pays all other
bills themselves
• 1º Coverage
– Insurance begins to pay medical bills as soon as deductible is
covered
• Very costly
• Less than 1% of institutions currently provide this
• 2º Coverage (AKA “Excess”)
– Policy pays for all or a portion of medical bills after the 1º has
paid
• Most common
• More cost efficient
• Provides a sense of shared responsibility with athlete and parents
• Claims process is complicated
• See Athletic Accident Insurance Sheet
***Important to communicate how this coverage works***
Important to try to decrease the
number of insurance claims to
decrease the cost of future
premiums for the institution
Ways to decrease insurance costs
for an institution
• Require athletes to have a primary policy
• Consider limitations as to what services will be
covered or to the amount paid
• Require athletes to pay an insurance fee
• Require athletes to go through your “system” to
get coverage
• Require medical providers to accept UCR
• Conduct an annual risk assessment audit
• Hire an ATC to act as a gatekeeper and reduce
outside medical costs
3rd Party Reimbursement
• Process whereby a
healthcare provider is
compensated by an
insurance company
for services provided
to a policyholder
• 1º method of payment
for medical services
in the US
• 3rd party is the
healthcare provider
Models of 3rd Party Payments
• Indemnity Plan (AKA “Fee for Services”)
– Free to choose any provider and plan reimburses a
portion of the cost of services after deductible and/or
copay
– Patient covers the balance
• Managed Care Plan
– Cost control through coordination of medical services
– 55% of all Americans covered through managed care
– 85% of working insured population in 1999
• Government Plans
Managed Care Plans
• HMO (Health
Maintenance
Organization)
• PPO (Preferred
Provider
Organization)
• Hybrids
HMO
• Members have
designated 1º physician
– gatekeeper
• Requires a referral to
specialists
• Fees paid to providers
often capitated or fixedfee system
• Usually have a copay
• Group Model or IPA
• Example: Companion
PPO
• Select a provider from
within a network
– Will pay outside
network, but pays less
• No designated 1º
care physician
• No referral required to
see specialist
• Example: State
Health Plan
Other Managed Care
• Open Access HMO
– Have 1º physician, but also may “self refer” at greater cost
• PSO (Provider Sponsored Organization)
– Owned or controlled by provider and contract with patients
– Example: MUSC option for state employees
• EPO (Exclusive Provider Organization)
– Type of PPO in which must go in-network or doesn’t pay
• POS (Point of Service)
– Like a PPO, but with a 1º physician as a gatekeeper
– May “self refer”, but at higher cost
• Open Access PPO
– may go to any provider
– higher premiums
Government Sponsored Programs
• CMS – Center for
Medicare and Medicaid
– Medicaid (1965)
– Medicare (1965)
• Champus/TRICARE
Medicaid
• Cost shared by federal & state governments
• 40 million Americans covered in 1997
• Provides coverage for low income, blind, and
disabled
– Covers inpatient, outpatient, labs, and diagnostic tests
– States decide whether to also include prescription drugs
and hearing aids
– Eligibility based on income (poverty level)
– See Medicaid Handout
Medicare
• Provides coverage for those 65 and older, and
disabled Social Security beneficiaries
• Part A: covers hospital, skilled nursing facilities,
home health, and hospice
• Optional parts (w/ an additional cost to enrollee):
– Part B: covers physician visits and labs
• Federal funds pay 75%, premium covers 25% ($42.50)
– Part C: optional managed care plans
– Part D: prescription drug coverage
CHAMPUS/TRICARE
• Insurance for military and their dependents
when services can not be rendered at a
military hospital
• Humana has recently signed on to convert
TRICARE to a Humana system
Other Insurance Programs
• Flexible Spending Accounts
– Set aside a certain amount from each paycheck for medical
expenses before taxes
– Use it or lose it
• Health Savings Accounts
– New in 2004
– Low premium, high deductible
– May contribute (before taxes) to an interest bearing account to
pay for medical expenses incurred before the high deductible is
met
– May take with you to other jobs
– Replaced Medical Savings Accounts
– Example: State Health Plan’s “Savings Plan”
Blue Cross/Blue Shield
• 1 out of 4 Americans
is insured with BCBS
• 95% of all doctors
and hospitals are in
their network
Coding
• Diagnostic
– ICD-9-CM
• International Classification of Disease
• 5 digit code used to identify an injury
• Assigned by doctor
• Procedural
– CPT
• Current Procedural Terminology
• 5 digit code for various procedure or services rendered
• In 2002 AT evaluation and reevaluation codes were
established
• ATC’s may also use physical medicine (97000 series) codes
to describe services rendered
Insurance Claims
• What does the ATC’s need to do to file an
insurance claim for an injured athlete?
– See claim form
• EOB (Explanation of Benefits)
– Describes how benefits were paid and the
remaining balance
– See copy of EOB
Read recommendations for
ATC’s in dealing w/ insurance
on page 210
Claim forms completed by the
provider and sent to the insurer….
• In a clinic a HCFA1500 claim form must be
completed
• In a hospital must complete an UB-92
claim form
*** Best if these are submitted electronically
using EDI (electronic data interchange)***
When Purchasing Insurance for the
Athletic Program at an Institution…
• Shared function between the AD, business
office, risk managers, and hopefully ATC’s
• Bid?
• Direct Purchase?
• Ask companies to present their package?
• Details of the policy
– Coverage
– How to file a claim