Insurance and the ATC

1. Insurance and the ATC George Wham, MS, ATC

2. Costs of Healthcare • US spent $1.1 trillion on healthcare in 1998 (13.5% of GDP) • 34% for hospital care • 20% for physician services • 26.7% for other medical services • 7.2% for prescription drugs • Fastest growing cost – increased 14% in 2000, 20% in 2001, 16% in 2002, and 15% in 2003

3. More Costs of Healthcare • 18% of people generate 80% of the cost • .4% generate 20% • In 2002 43.6 million in US were uninsured • Mostly working poor

4. Insurance Background • 1798 1st form of health insurance in US provided by Marine Hospitals for seaman • Post WWII medical insurance becomes a common benefit for many jobs • 1979 – 85% of population covered by private insurance • Mid 1990’s – 70% • Increasing cost of healthcare making insurance less affordable • during 1980’s and early ’90’s moved to managed care

5. Insurance Terms • Premium • Deductible • Copay • Balance • Riders • Exclusions • Capitation

6. Insurance Systems • Medical Insurance • Only covers medical bills • Health Insurance • Also covers prevention and health maintenance • Athletic Accident Insurance • Usually supplemental to family policy to reimburse part of cost of an athletic injury • Some plans may only cover acute injuries, but not overuse or chronic conditions

7. More Insurance Systems • Catastrophic Insurance • To cover lifetime medical and disability coverage • NCAA provides to all it’s athletes free • Takes affect after 1st $50,000 of bills accumulate • Disability Insurance • Protects athletes against future loss of earnings to disability while competing • NCAA sponsored program that may be purchased • Workman’s Compensation Insurance • State mandated program provides benefits to injured workers • Employer funded • Compensation varies with severity

8. Fees • Usual, customary, reasonable (UCR) • Commonly used fee system for medical services originally developed for Medicare • Ideally want to deal w/ providers who accept UCR as payment

9. Types of Athletic Insurance • Self Insured • Institution purchases catastrophic coverage and pays all other bills themselves • 1º Coverage • Insurance begins to pay medical bills as soon as deductible is covered • Very costly • Less than 1% of institutions currently provide this • 2º Coverage (AKA “Excess”) • Policy pays for all or a portion of medical bills after the 1º has paid • Most common • More cost efficient • Provides a sense of shared responsibility with athlete and parents • Claims process is complicated • See Athletic Accident Insurance Sheet ***Important to communicate how this coverage works***

10. Important to try to decrease the number of insurance claims to decrease the cost of future premiums for the institution

11. Ways to decrease insurance costs for an institution • Require athletes to have a primary policy • Consider limitations as to what services will be covered or to the amount paid • Require athletes to pay an insurance fee • Require athletes to go through your “system” to get coverage • Require medical providers to accept UCR • Conduct an annual risk assessment audit • Hire an ATC to act as a gatekeeper and reduce outside medical costs

12. 3rd Party Reimbursement • Process whereby a healthcare provider is compensated by an insurance company for services provided to a policyholder • 1º method of payment for medical services in the US • 3rd party is the healthcare provider

13. Models of 3rd Party Payments • Indemnity Plan (AKA “Fee for Services”) • Free to choose any provider and plan reimburses a portion of the cost of services after deductible and/or copay • Patient covers the balance • Managed Care Plan • Cost control through coordination of medical services • 55% of all Americans covered through managed care • 85% of working insured population in 1999 • Government Plans

14. Managed Care Plans • HMO (Health Maintenance Organization) • PPO (Preferred Provider Organization) • Hybrids

15. HMO • Members have designated 1º physician • gatekeeper • Requires a referral to specialists • Fees paid to providers often capitated or fixed-fee system • Usually have a copay • Group Model or IPA • Example: Companion

16. PPO • Select a provider from within a network • Will pay outside network, but pays less • No designated 1º care physician • No referral required to see specialist • Example: State Health Plan

17. Other Managed Care • Open Access HMO • Have 1º physician, but also may “self refer” at greater cost • PSO (Provider Sponsored Organization) • Owned or controlled by provider and contract with patients • Example: MUSC option for state employees • EPO (Exclusive Provider Organization) • Type of PPO in which must go in-network or doesn’t pay • POS (Point of Service) • Like a PPO, but with a 1º physician as a gatekeeper • May “self refer”, but at higher cost • Open Access PPO • may go to any provider • higher premiums

18. Government Sponsored Programs • CMS – Center for Medicare and Medicaid • Medicaid (1965) • Medicare (1965) • Champus/TRICARE

19. Medicaid • Cost shared by federal & state governments • 40 million Americans covered in 1997 • Provides coverage for low income, blind, and disabled • Covers inpatient, outpatient, labs, and diagnostic tests • States decide whether to also include prescription drugs and hearing aids • Eligibility based on income (poverty level) • See Medicaid Handout

20. Medicare • Provides coverage for those 65 and older, and disabled Social Security beneficiaries • Part A: covers hospital, skilled nursing facilities, home health, and hospice • Optional parts (w/ an additional cost to enrollee): • Part B: covers physician visits and labs • Federal funds pay 75%, premium covers 25% ($42.50) • Part C: optional managed care plans • Part D: prescription drug coverage

21. CHAMPUS/TRICARE • Insurance for military and their dependents when services can not be rendered at a military hospital • Humana has recently signed on to convert TRICARE to a Humana system

22. Other Insurance Programs • Flexible Spending Accounts • Set aside a certain amount from each paycheck for medical expenses before taxes • Use it or lose it • Health Savings Accounts • New in 2004 • Low premium, high deductible • May contribute (before taxes) to an interest bearing account to pay for medical expenses incurred before the high deductible is met • May take with you to other jobs • Replaced Medical Savings Accounts • Example: State Health Plan’s “Savings Plan”

23. Blue Cross/Blue Shield • 1 out of 4 Americans is insured with BCBS • 95% of all doctors and hospitals are in their network

24. Coding • Diagnostic • ICD-9-CM • International Classification of Disease • 5 digit code used to identify an injury • Assigned by doctor • Procedural • CPT • Current Procedural Terminology • 5 digit code for various procedure or services rendered • In 2002 AT evaluation and reevaluation codes were established • ATC’s may also use physical medicine (97000 series) codes to describe services rendered

25. Insurance Claims • What does the ATC’s need to do to file an insurance claim for an injured athlete? • See claim form • EOB (Explanation of Benefits) • Describes how benefits were paid and the remaining balance • See copy of EOB

26. Read recommendations for ATC’s in dealing w/ insurance on page 210

27. Claim forms completed by the provider and sent to the insurer…. • In a clinic a HCFA1500 claim form must be completed • In a hospital must complete an UB-92 claim form *** Best if these are submitted electronically using EDI (electronic data interchange)***

28. When Purchasing Insurance for the Athletic Program at an Institution… • Shared function between the AD, business office, risk managers, and hopefully ATC’s • Bid? • Direct Purchase? • Ask companies to present their package? • Details of the policy • Coverage • How to file a claim