Introduction
We always say I am healthy but what does being healthy actually means? The term healthy is defined different by different persons. Generally, being healthy means being void of illness or any form of injury. But is this actually true? Can anyone be really free from any form of illness of injury? The answer to this question is no. People are prone to illness or injury but after falling sick what? Then comes the step of visiting the provider. Number of visits (to physician offices, hospital outpatient and emergency departments) is 1.2 billion alone in the US [1]. Also, such visits turns out to be very costly. The only factor that makes it affordable is the health insurance
What is health insurance
According to the Health Insurance Association of America, health insurance is defined as "Coverage that provides for the payments of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment" [2]. Health insurance processing is one of the few complex processes that take place after visiting the provider. Applying for claims is carried out after pre authorization. Pre authorization is an integral part of utilization management.
What is utilization management
Utilization management (UM) is the process by which a health care system and services and facilities can be evaluated to check if it is appropriate and if it is established as per the guidelines set by the health benefit plans. Utilization management describes proactive procedures, discharge planning, concurrent planning, precertification and clinical case appeals. UM also covers concurrent clinical review and appeals introduced by the provider, payer or patient.
Utilization m...
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...lanation of Benefit (EOB) is created along with benefit check which is mailed to the patient and the physician respectively.
Conclusion
Reference:
[1] Selected patient and provider characteristics for ambulatory care visits to physician offices and hospital outpatient and emergency departments: United States, 2009-2010
[2] How Private Insurance Works: A Primer by Gary Caxton, Institution for Health Care Research and Policy, Georgetown University, on behalf of the Henry J. Kaiser Family Foundation.
[3] http://chiroeco.com/chiro-blog/medical-clearinghouse/2009/04/07/paper-claims-vs-electronic-claims/
[4] http://www.ihealthbeat.org/picture-of-health/2013/what-percentage-of-health-insurance-claims-were-filed-by-paper-or-electronic-processes
[5] http://www.wisegeek.org/what-is-claims-adjudication.htm
[6] http://www.staysmartstayhealthy.com/health_insurance_deductibles
Due to the Patient Protection and Affordable Care Act signed into law on March 23rd, 2010; health care in the US is presently in a state of much needed transition. As of 2008, 46 Million residents (15% of the population) were uninsured and 60% of residents had coverage from private insurers. 55% of those covered by private insurers received it through their employer and 5% paid for it directly. Federal programs covered 24% of Americans; 13% under Medicare and10% under Medicaid. (Squires, 2010)
The Crowded Clinic Case Study (Colorado State University - Global, n.d.) discusses the issues of practice management as they apply to access to care. Access to care may be as inconvenient as lengthy patient wait times to issues far more serious that may have a profound effect on the health and well-being of a single patient or an entire cohort.
Starfield, B, Cassady, C, Nanda, J, Forrest, C, & Berk, R. (1998). Consumer experiences and provider perceptions of the quality of primary care: implications for managed care. The Journal of Family Practice, 46(3), 216-226.
The United States health care system ranks 37th in the world. Statistically, it’s bizarre how United States is amongst one of the most advanced nations in the world and the fact that it spends more on its healthcare than any other country, yet its standards are incomparable to other European nations. Unlike most countries, America doesn’t have universal coverage for health care. This means that it is the responsibility of an average American to obtain health insurance either through private insurance companies or through their employer. Under this system, there is a notion of a certain premium due at regular intervals of time but the insured may need to “co-pay” or pay a certain deductible for their treatment before their insurance takes care of the rest.
The concept of Health Insurance and managed health care the inventions of the twentieth century that were started as prepaid health care. The early insurance concept was merely a way for people to pay medical bills not a way of protecting individual financial assets as the case is today. Overall the health care industry has endured significant changes since its inception.
The main shortcomings of health care in the U.S. include limited access and difficulty in coordination of care. In an 11-country survey conducted by the Commonwealth Fund, Americans were found to have a greater wait period than adults from other countries. In fact, 20% of adults reported a delay of six or more days to see a doctor or nurse (Schoen, Osborn, Squires, Doty, Pierson & Applebaum, 2010). Access to care is further complicated as only 29% of U.S. primary care practices make arrangements for patients to receive care on evenings, weekends, and holidays (Abrams, Nuzum, Mika & Lawlor, 2011). Physicians also face frustrations in the coordination of care. U.S. physicians are more likely to report that patients cannot afford treatment and are less likely to have electronic patient records that facilitate patient-centered care (Osborn, Schoen, Doty, ...
Health insurance is currently an important issue in the United States. Everyday more and more Americans become uninsured due to job loss and an increase in premiums. These Americans add to the ever growing population of 45.7 million people who are currently uninsured (Bialik). Moreover only 27% of those uninsured are under the age of 65 (NCHC). This is staggering considering most of those who are uninsured have, or soon will, suffer from some sort of illness or injury. As a result they will not be able to afford proper treatment. Insurance premiums can range in cost from fifty dollars per month, to fifteen hundred dollars per month (Kreidler). An individual’s premium is determined by factors they choose as well as other factors looked at by their provider. The cost of health insurance in America varies depending on the controllable factors, like particular insurance policies, and uncontrollable factors, like age.
Given the fact that one-third of all healthcare expenditures is for ambulatory care, it is safe to say that patients spend most of their time in an ambulatory care setting (Carper, 2013). This setting has a significant impact in the overall assessment of the healthcare industry and how care is delivered. It is important to address data collected by surveys to implement strategies for quality improvement. Affecting care in Ambulatory settings will have the largest significance in the health outlook.
The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care.
Three areas that define the provisions of comprehensive health care services and are commonly used for utilization monitoring and control are gatekeeping, case management, and utilization review (UR). Gatekeeping is used by HMOs where each member designates a primary care provider (PCP) that is responsible for coordinating all care services needed for the enrollee in a managed care plan. Case management involves an experienced health care professional with knowledge of available health care resources. `Case management services are designed to identify spec...
According to healthinsurance.org (1994), medical underwriting is “when you apply for individual health insurance, the health insurance company uses a process called underwriting to look at your age, sex, and health history to decide whether it will cover you and how much it will cost to provide you coverage.
Medical Health insurance is a formal agreement to provide and/or pay for medical care. The health insurance policy describes what medical services are "covered" by the insurance company. There are medical services that are not "covered" and will not be paid by your insurance company.
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals ...
Health insurance provides benefits for sickness, injury, surgery, and prescription medication. There are a variety of plans with different
Health is described as physical and mental well-being and freedom from disease, pain or defect. However, such descriptions only superficially define the actual meaning of health. There may be many occasions when individuals are not necessarily ill or in pain but may be overweight, stressed or emotionally unstable. Health is a quality of life involving dynamic interaction and interdependence among the individual’s physical state, their mental and emotional reactions, and the social context in which the individual exists. There are many factors that influence your health, but three major components contribute to general well-being: Self-awareness, a balanced diet and, regular physical activity.