1. Chapter 8
Private Payers

2. Employer-sponsored Group health plans Carve out~designed plan
Open enrollment periods
Regulated by state laws

3. Features of Group Plans
Specific rules for eligibility
Waiting period
Late enrollees
Premiums, deductibles, limits

4. COBRA Consolidated Omnibus Budget Reconciliation Act
Continued coverage with employer
HIPAA rules
Preexisting conditions
Credible coverage

5. Federally Guaranteed Provisions
Newborns’ and Mothers’ Health Protection Act
Women’s Health and Cancer Rights Act
Mental Health Parity Act
Genetic Information Nondiscrimination Act

6. Thinking It Through 8.2
If a GHP has a 90-day waiting period, on what day does health coverage become effective?
In terms of enrollment in a health plan, what is the status of an infant born to a subscriber in the plan?
A patient pays for a cosmetic procedure that is not medically necessary under the terms of the plan, Does this payment count toward the deductible?

7. Self-funded Health Plans
Self-insured
Funds set aside for payments
Regulated by federal laws
Third-party claims administrators
Process and pay claims, collect premiums

8. Individual Health Plans
Students
Self-employed
Early retirees
Part-time employees not on group plan

9. Private Payers PPO—most popular HMO—second most popular POS
Discount fee for service
More choices than an HMO
HMO—second most popular
Least amount of choices, lowest cost
PCP
Use a business model (financially responsible)
Staff model-physician’s are employees
Group model-owned facilities (capitation)
POS
Choose from a primary or secondary network

10. Payment Methods PPO—premium, deductible, coinsurance
HMO—premium and copay
POS—premium and copay
Indemnity—premium, deductible, coinsurance

11. Consumer-driven Health Plans
High deductible
Tax deferred saving accounts
Consumer makes more decisions about health payments
Have web tools to help with decisions

12. Funding Accounts Reimbursement Savings Flexible Savings
Employer funded
High deductibles
Savings
Funds set aside by employee to be spent on health care costs
Also high deductible
Flexible Savings
Augment a health insurance plan
Pretax dollars put into an account

13. Consumer-driven Payments
Bill the patient
Patient submits to reimbursement account
OR withdraws from savings account
OR pays bill and submits for funds from flexible account
Once funds are exhausted”
Coinsurance is paid by reimbursement account
Patient pays out of pocket for savings accounts

14. Participating Providers’ Contracts
Determine obligations with the contract
Definitions of medical necessity
Allowable fees
Acceptance of members
Referrals and preauthorizations
Payment guidelines

15. Physician Responsibilities
Services offered
Acceptance of members (all or a percentage)
Referral rules
Preauthorization necessity
Utilization review (access to records)

16. Managed Care Plan Responsibilities
Specific identification of enrolled patients
Quick payment turn around
Stop-loss provision (capitation)

17. Billing Guidelines Fees Billing requirements Filing deadlines
Patient responsibilities
Balance billing rules
Coordination of benefits rules
Timelines for incorrect payments

18. Billing Guidelines
Bill from provider’s fee schedule—not allowed amounts
Write off happens after all payers have paid before billing patient
Payment for no shows
When and how many copays are made

19. Preauthorization/Precertification
Elective surgery
Scheduled surgeries
Emergency surgeries (48 hours)
Use of a utilization review organization
Out of network services
Forms sent before admitting for surgery

20. Preparing Correct Claims

21. Capitation Contracts Patient eligibility Referral requirements
Reports and write offs
Billing procedures