HSEM 255 Study Guide - Summer 2018, Comprehensive Midterm Notes - Primary Care, Medicaid, Health Insurance
12 Oct 2018
School
Course
Professor
HSEM 255
MIDTERM EXAM
STUDY GUIDE
Fall 2018
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
find more resources at oneclass.com
find more resources at oneclass.com
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
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.
