1. Methods of Payment for Healthcare
IMPORTANT TO UNDERSTAND INSURANCE PLANS VARY IN THE AMOUNT OF PAYMENT AND THE TYPE OF SERVICES THEY COVER. 3
Foundation Standard 3
3.15 Discuss common methods of payment for healthcare.

2. Where would you go???.....
If you were an elderly person that needed assistance and care?
If you were in a car accident and needed care for maximum self-care and function?
If you needed special diagnostic test performed?

3. Background
The cost of health care has increased significantly over the years….
What are some reasons to why medical services cost so much?
Health care cost have risen so high that most people have some sort of insurance plans called third-party payers.
Technological advances, aging population, health related lawsuits

4. Third- Party Payers
Insurance companies require the subscriber to pay a fee for insurance coverage and in return agrees to pay for specific medical and or dental care.

5. Health Insurance Plans
Health insurance plans help pay for the costs of health care.
Reimbursement regardless of who provides care.
15% of gross national product (money spent on goods and services in USA) is on health care.
What can happen to individuals and families if they do not have health insurance?

6. Health Insurance Plans
Plans are offered by thousands of different insurance agencies.
For example, Blue Cross Blue Shield.

7. Insurance Terms
Premium – the cost you pay each month for the insurance policy.
THIS IS YOUR MONTHLY BILL.
This is kind of like paying rent. You have to pay each month whether you have used the insurance or not.

8. Deductible – the amount the patient pays for a medical service before the insurance company pays.
For example, the patient may have to pay the insurance company $1,000 before the insurance company will pay towards the medical bill.

9. Co-insurance – percent of expense shared by the patient.
For example, a patient may be required to pay 20 percent of every medical bill.
In addition to the premium, deductible, and co-payment.

10. Which is the best example of Western Medicine?
A. Using diet to control diabetes?
B. Treating arthritis with acupuncture?
C. Treating depression with medication?
D. Using hypnosis to treat overeating?
True or False you should never smile during an interview? C
False

11. Co-payment – specific amount a patient pays for a particular service

12. Health Insurance Plans
Employer-sponsored (Group insurance) = Employer assisted health insurance coverage for employees. Employer often pays part of premium.
Private insurance = purchased by an individual
What is supplemental insurance? Have you ever seen TV commercials advertising supplemental insurance companies?

13. Managed Care is…
An effort to provide quality care at the lowest possible cost.
WRITE IN… MANAGED CARE WAS DEVELOPED IN RESPONSE TO RISING HEALTHCARE COST…. 2

14. BONUS QUESTION…. YOU MUST RAISE YOUR HAND!!
What should you do first when meeting the person who is going to interview you???
Greet the interviewer by name and shake hands.

15. Policies that help managed care cost…
Patient’s are encouraged to focus is on preventive measures.
Routine physical
Well-baby care
Immunizations
Screenings for patients with specific risk factors
Wellness education
Health Education programs
How can you help promote your physical wellness? (you may want to write this on your notes ).
Avoiding alcohol, tobacco, caffeine, drugs, and risky sexual behavior

16. Managed Care Cont…
A second opinion or pre-approval is often required for special care.
If a patient needs to go to a specialty care doctor for treating a more specific illness.
Some examples:
Surgery
Podiatry
Audioloy
Obstetrics
Orthopedics
Chiropractic
Urology

17. Managed Care Cont…
Emergency and Urgent care provide different services…
Emergency Care-
Life threatening conditions that require hospitalization.
Urgent Care-
Non-emergencies that require prompt treatment.

18. Managed Care Cont…
HMOs and PPOs are the main providers of managed care.

19. Health Maintenance Organization (HMO)
Monthly fee (premium) paid for membership
Fee stays the same regardless of amount of health care used
Premium paid by employer or individual
Focus on preventive health care
Participants required to use ONLY HMO-affiliated healthcare providers

20. Preferred Provider Organization (PPO)
Monthly fee (premium) paid for membership
PPO contracts with health providers and agencies to provide health care at reduced rates.
PPOs usually require a deductible and co-payment
If non-affiliated provider used, the PPO may require co-payments of 40 – 60%

21. Government - Medicare Provides health care for:
Individuals over the age of 65
Person with disability for two or more years
Three types of coverage:
Type A for hospital insurance
Type B for medical insurance
Type D for pharmaceutical expenses
Individuals pay a premium and deductible for Type B coverage
Medicare only pays 80% of services

22. Government - Medicaid
Jointly funded by federal and state government, but operated by individual states
States establish eligibility standards, payment rates, etc.
Usually pays healthcare for:
Individuals with low incomes
Children who qualify for public assistance
Individuals who are physically disabled or blind
Question # 1

23. Diagnostic-Related Groups (DRGs)
Government effort to control costs for Medicare and Medicaid
Patients with certain diagnoses classified in one payment group
Limit placed on cost of care
Agency only gets the set amount, so makes every effort to stay within the expense limit allowed

24. Government – Worker’s Compensation
Health insurance plan for workers injured on the job
Administered at the state level
Payments made by employers and the state
Plan also reimburses for wages lost because of on-the-job injury.

25. Government - TRICARE
U.S. Government health insurance plan for military personnel.
Provides civilian health care for active duty military members and their families, survivors of military personnel, and veterans

26. BONUS QUESTIONs….
YOU MUST RAISE YOUR HAND and ANSWER FOR AN EXTRA POINT ON THE TEST!!!!!!!!
Who is the Father of Medicine?
Hippocrates