1. The Blues Plans, Private Insurance, and Managed Care Plans
Chapter 11
The Blues Plans, Private Insurance,
and Managed Care Plans

2. BLUE CROSS BLUE SHIELD

3. Blue Cross Blue Shield Independently owned in each state
Spider-web network
ID card
Type of policy
1-3 alpha characters; 9-12 numbers
PPO/POS/IPA/HMO/Medicare HMO
BCBS Association
Corporation administering rules/regs for regional plans
For-profit status

4. Blue Cross and Blue Shield cont’d
Billing Concerns
Local or Blue Card filing
Appeal procedures/forms
Where to call – benefits/authorization/claim status
Contracts
Contract only good for state – not out of state
Group vs individual provider enrollment

5. MANAGED CARE

6. Managed Care Plans Indemnity plans Managed Care HMO
Insured pays monthly premium; ded must be met before ins pays any claims
Managed Care
Insured pays premium in exchange for specific medical benefits
Use PCP as gatekeeper
HMO
Prepaid group practice sponsored by govt, med schools, clinics, foundations, hospitals, employers, labor unions, community/consumer groups, ins co, hospital med plans, VA
Prepaid Group Practice Health Plans
Ex: Cigna; Kaiser Permanente Medical Care Centers

7. Managed Care Systems
HMO
EPO
FMC
IPA
PPO
Silent PPO
POS

8. Health Maintenance Organization (HMO)
Advantages
Low cost for benefits
Preventive health care
Fixed, low copayments
Low monthly premium
Less out-of-pocket expense
Disadvantages
Restricted access to providers, other services

9. HMO Models Prepaid Group Practice Model Staff Model Network HMO
Delivers service at one or more locations through a group of physicians who contract with the HMO to provide care or through its own physicians who are employees of the HMO
Staff Model
Health plan hires the physicians directly and pays them a salary instead of contracting with a medical group
Network HMO
Contracts with 2 or more group practices to provide health services
Direct Contract Model
Open-panel HMO; contracts directly with private practice physicians

10. Exclusive Provider Organizations (EPO)
Combines features of HMOs and PPOs
Employers agree not to contract with any other plan
Providers give negotiated discounts
No out-of-network benefits
Patient must use a gatekeeper

11. Foundations for Medical Care (FMC)
Sponsored by state or local medical association
Concerned w/ development/delivery of medical services and cost of health care
Two types:
Comprehensive – designs/sponsors prepaid health programs or sets minimum benefits of coverage
Claims review – provides evaluation of the quality and efficiency of services by a panel of physicians to fiscal intermediaries
Dedicated to incentive reimbursement
Patient may see any member or non-member physician he chooses

12. Independent Practice Associations (IPA)
Physicians paid for services on a capitation or fee-for-service basis
“Withhold” fees

13. Preferred Provider Organizations (PPO)
More flexible than an HMO
Doesn’t‘ require a gatekeeper
Patients can choose network or non-network providers
Higher out-of-network costs
Providers give negotiated discounts
Reduced drug costs
Preventive services may not be covered
Copay/coinsurance/deductibles apply

14. Silent PPO
Happens when PPO payer buys another existing PPO without telling the provider of the change
Billing issues
Determining the PPO
Contacting payer
Claim submission
Payment
Carefully review the insurance card
Carefully review the EOB

15. Point of Service (POS) Combines elements of HMO & PPO
Patients free to choose physician
Higher benefit level in-network

16. MEDICAL REVIEW

17. Quality Improvement Organization (QIO)
Contract with CMS to review medical necessity, reasonableness, appropriateness, and adequacy of inpatient hospital care
Evaluates the quality and efficiency of services rendered by the physician

18. Utilization Review/Utilization Management
Assessment of the cost and use of components of health care systems
Reviews individual cases to determine medical necessity for tests and procedures

19. BREAK
10 MINUTES

20. FUNCTIONAL PLAN MANAGEMENT

21. Contracts and Carve-Outs
Contract – agreement between provider and insurance that outlines payment, billing, utilization review, medical review, and fee schedules
Carve-out
Medical services not included in standard contract
Higher than standard reimbursement for certain procedures

22. In the Office Patient responsibility Financial Class assignments
Appointments
Encounter form
Preauthorization/Pre-notification
Referrals
Diagnostic tests

23. Bankruptcy
MCO is obligated to pay all bills incurred before the filing

24. HEALTH CARE REFORM

25. Transition Rural – urban Generalist – specialist Solo – group practice
Fee-for-service – capitation

26. Necessary Evil Uninsured Americans Escalating health care premiums
Government need to reduce the deficit by reducing increases in the Medicare/Medicaid programs
Increase in physician/facility costs
Medications
Equipment
Patients spend more money for less care
Overuse of services by patients

27. Patient Protection and Affordable Care Act of 2010
Forbids insurers from canceling ins coverage
Requires insurers to use a high percentage of premiums for benefits instead of profits or overhead
Gives tax credits to small businesses that offer coverage
By 2014 almost everyone required to be insured or pay a fine
Small businesses, self-employed, uninsured may choose from plans offered through state-based purchasing pools

28. PPACA cont’d Eliminates pre-existing condition exclusions
Ends lifetime limits on benefits
Provides temporary insurance until 2014 for people who have been denied because of health status
Allows young people to remain on their parents insurance until age 26
Makes preventive measures free to Medicare beneficiaries

29. ALMOST DONE…..

30. Recap
Managed care plans are prepaid health care programs in which a specified set of health benefits are provided in exchange for a yearly fee
Primary care providers act as gatekeepers who control patient access to specialists and diagnostic services
Types of managed care plans include EPO, FMC, PPO, silent PPO, and POS

31. Recap
The Patient Protection and Affordable Care Act was established in response to the overarching need for health care reform
Includes provisions for coverage, benefits, and insurability

32. Homework READ CHAPTER 12 MEDICARE WORKBOOK ASSIGNMENT
Part I Fill in the Blank
All questions
Part II Multiple Choice
Part III True/False