HSEM 255 Lecture Notes - Lecture 1: Insurance Commissioner, Arthroscopy, The Employer
22 May 2018
School
Course
Professor
Health Insurance
More comprehensive than medical insurance because it often includes provisions for maintaining good
health rather than simply paying for illnesses and injuries
athletic accident insurance
most institutions buy this policy for their students, which is intended to supplement a student's family
insurance plan and reimburses the cost of athletic accidents only
accident
usually include acute, traumatic injuries, independent of any other cause or preexisting condition, that
occur during practice or games
exclusions: injuries caused by overuse (tendinitis), illnesses, and degenerative conditions.
riders
cover the cost of chronic conditions, but increase the premium
catastrophic insurance
takes effect after the first $75,000 in medical bills has been reached and provides lifetime medical,
rehabilitation, and disability coverage for athletes who have suffered long term or permanent handicaps
as a result of athletic injury (NCAA has this as no cost, also available to non NCAA-institutions)
Disability Insurance
designed to protect athletes against future loss of earnings because of a dibilitating injury or sickness to
that occurred while they were engaged in sport activities (NCAA sponsors athletes who are exceptional
to have this) (NCAA has a insurance assistance fund program to help athletes pay for medical and dental
expenses for D1 athletes)
Dental/Vision insurance
can be bought separately and added to insurance plans
Experimental treatments
usually excluded from medical or health insurance. when ATs experiment with new therapeutic methods
to help patients return to health faster and more safely, doesn't get approved by insurance companies
until several years after
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1. when it is listed in the policy as experimental
2. list the criteria by which they will determine if a procedure is experimental (less exact, hard to defend)
3. decide on a case-by-case basis which methods are experimental (most common)
Elective Surgical procedures
usually excluded from medical or health insurance, those that are not considered necessary from a
medical perspective and having them performed is the individual's choice ex. vision surgery
Diagnostic procedure
performed when a specific diagnosis cannot be made from clinical findings and would be more
accurately identified via a surgical procedure, allows for a selection of appropriate treatment
intervention ex. arthroscopy
usual, customary, and reasonable (UCR) reimbursement
a flexible-fee system developed by the federal government to reimburse health care professionals
through the Medicare system (now used by most insurance companies)
UCR payment by insurance is determined by...
1. the usual fee charged by each health care provider for the particular service
2. the customary fee for that geographic area (average fee or the 90th percentile fee, whichever is
lowest)
3. reasonable fee (lower of either usual or customary)
Avoid having a claim denied
- that the provider the AT refers to does only nonexperimental procedures
- that they will accept the UCR fee as payment for all services
- if the procedure is considered experimental, AT consults a representative of the insurance company
before referral
- find out the reasons that the claim was denied (law requires insurance companies to have this
information)
- obtain a statement from the physician or other health care provider explaining why the treatment was
implemented and justifying the fee
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- if the self-insurance fund of a parent's employer covers a patient, correspond with the employer
directly. The employer has final legal authority to reverse the denial
- provide evidence from clinical studies to support your claim that the treatment should not be
considered experimental
- try to convince the physician or other health care provider to waive the portion of the fee above the
UCR amount
- Contact the state insurance commissioner and request assistance in challenging the denial
Self-Insurance (1 of 3 options of athletic insurance for educational institutions)
institutions that do this are speculating that the amount they pay out for the medical expenses will be
less than the amount they will pay for the insurance premiums. This institution buys no medical or
accident insurance except for catastrophic coverage and pays medical bills incurred by athletes. (NCAA
has rules that the institution can't pay for medical expenses that don't directly relate to the participation
in athletics) Must be careful to create and monitor procedures used to ensure compliance with these
rules, especially with off season conditioning programs and other non-supervised activities.
+: saving money and keeps money from insurance, simplified claims process bc no forms to complete,
greater flexibility when paying for procedures that insurance might exclude
-: high risk for large claims (could put left over insurance funds in an endowment for cushion from large
claims, but keeps money away from program), risk of bankrupting fund, institutional dollars tied up
*best to have the athlete use their personal insurance whenever possible
Primary coverage (2 of 3 options of athletic insurance for educational institutions)
is medical or accident insurance that begins to pay for covered medical expenses as soon as the
institution pays the deductible. the athlete's personal medical insurance is not a source for payment of
medical bills arising out of athletic participation.
- moral obligation to pay for all athletic medical expenses w/o involving families or their insurance
- have a student population that is uninsured anyways , so it's logical to choose this plan
- this plan simplifies and accelerates claims processing because the family doesn't have to be involved
-: expense, higher premium because insurance company takes on more risk
Secondary coverage (3 of 3 options of athletic insurance for educational institutions)
AKA excess insurance, a policy that pays for covered medical expenses only after all other insurance
policies (including athlete's personal medical insurance) have reached their limit
+: institutions can lower their costs by spreading the risk associated with athletic injuries to other
potential payers, secondary coverage can be as low as 60% less than primary coverage since they share
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Dental/vision insurance can be bought separately and added to insurance plans. Elective surgical procedures usually excluded from medical or health insurance, those that are not considered necessary from a medical perspective and having them performed is the individual"s choice ex. vision surgery. That the provider the at refers to does only nonexperimental procedures. That they will accept the ucr fee as payment for all services. If the procedure is considered experimental, at consults a representative of the insurance company before referral. Find out the reasons that the claim was denied (law requires insurance companies to have this information) Obtain a statement from the physician or other health care provider explaining why the treatment was implemented and justifying the fee. If the self-insurance fund of a parent"s employer covers a patient, correspond with the employer directly. The employer has final legal authority to reverse the denial.
