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Healthcare Administrative
Services
Patient Administration
Given that the Payer
part of the Provider/Patient/Payer Triad is the most
complex administrative portion of the process; how then
does it work?
www.eHealthInsurance.com provides the following
example.
Imagine you have a
$100,000 heart surgery, which is a covered medical
expense under your health insurance plan, and you have a
$1,000 annual deductible, plus a 20% coinsurance after
the deductible, a $2,000 out-of-pocket limit per year,
and $5 Million lifetime maximum. Typically, a deductible
is the amount of money you must pay each year before
your health insurance plan starts to pay for covered
medical expenses. So with a $100,000 heart surgery bill,
you are responsible for paying the first $1,000. After
this $1,000 deductible is met, the insurance company
will pay a percentage of the bill in what is called the
coinsurance. Coinsurance is a cost-sharing requirement
where you are responsible for paying a certain
percentage and the insurance company will pay the
remaining percentage of the covered medical expenses
after your deductible is met. For a health insurance
plan with 20% coinsurance, once the deductible is met,
the insurance company will pay 80% of the covered
expenses while you pay the remaining 20% until your
out-of-pocket limit is reached for the year. The
out-of-pocket limit is the maximum amount you will pay
out of your own pocket for covered medical expenses in a
given year. For a plan with a $2,000 out-of-pocket
limit, you will pay a $1,000 deductible and $1,000
coinsurance while the insurance company covers the
remaining $98,000 of the heart surgery bill. If you are
hospitalized again in the same year, the insurance
company will pay 100% of your covered expenses within
the limit of the lifetime maximum. A lifetime maximum is
the amount your insurance plan will pay for covered
medical expenses in the course of your lifetime. Since
the health insurance plan has a lifetime maximum of $5
million, and as you pay your deductible, coinsurance and
out-of-pocket limit each year, the insurance company
will pay for all remaining covered medical bills up to a
maximum of $5,000,000 in your lifetime. Some health
insurance plans offer a co-payment option. A
co-payment or co-pay is a specific flat fee you pay for
each medical service, such as $30 for an office visit,
after which the insurance company often pays the
remainder of the covered medical charges.5
Though this example serves a purpose to illustrate the
concept, it must be noted that not insurance companies
offer these same options of deductibles, coinsurance,
out-of-pocket limits, lifetime maximums, or co-pays. And
among and between insurance companies and within agreed
upon arrangements with healthcare providers the options,
conditions, and amounts will vary.5
It should also be
noted the medical providers will sometimes charge prices
higher than the prevailing allowable payment rates in an
attempt to demonstrate that cost of the service has
risen. When the insurance companies see a preponderance
of claims coming to them at a consistently higher rate,
they will often renegotiate the payment threshold to a
higher ceiling.
Healthcare
Clinical Services
Patient Care
Patient care is not a
standardized procedure and may vary between regions,
medical groups, or even individual physicians within a
medical group. A case in point is hypertension. High
blood pressure is widely dispersed and highly common
among the patient population of the United States. There
seems to be no standard treatment practice for
hypertension, but there are acceptable guidelines.
HighBloodPressureConnection.com offers the following
example as a treatment option.
Patients with
hypertension should work with their doctors to set blood
pressure goals based on individual risk factors.
Lifestyle and medication programs need to be planned on
an individual basis. Healthy life style changes are
imperative for anyone, and are critical for people with
even normal blood pressure (120/80 mm Hg) and above. In
appropriate patients, aggressive drug treatment of
long-term high blood pressure can significantly reduce
the incidence of mental decline and death from heart
disease and other serious physical effects of
hypertension. In people with diabetes, controlling both
blood pressure and blood glucose levels prevents serious
complications of that disease. Anti-hypertensive drugs
may even prevent mental decline, including in people
genetically susceptible to Alzheimer's disease.
Nevertheless, only slightly over half of patients with
hypertension are treated at all, and only a quarter have
adequately controlled pressure. It is not clear when
drugs should be started, particularly for people with prehypertension
or mild high blood pressure. To help make treatment
choices, the U.S. National Heart, Lung, and Blood
Institute has created categories (denoted as groups A,
B, and C) according to a patient's risk factors for
heart disease. Applying these categories to the severity
of hypertension helps determine whether lifestyle
changes alone or medications are needed.6
The reference to
“aggressive drug treatment” is deceptively simplistic.
The number and types of high blood pressure medicine is
creates a complex mix of possible drug-based treatments.
The web site,
http://www.cardiologychannel.com/hypertension/pharm.shtml,
offers more information on the variety of drugs by type
and also lists so of the more common side effects of
each grouping of drugs. The healthcare provider has
choices and needs to know the patient’s medical history
in detail in order to make the right choice. Regular
follow-ups should be the norm to ensure a consistent and
continual positive response to any drug prescribed. |
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