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The Physician’s View of Health Insurance

The Physician’s View of Health Insurance. The Physician’s View of Health Insurance. Relationships Decision Making Reimbursement Coverage Managed Care Goals and Solutions. Relationships. Doctor/Patient The original relationship Patient/Insurer Started as a “perk” for employment

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The Physician’s View of Health Insurance

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  1. The Physician’s View of Health Insurance

  2. The Physician’s View of Health Insurance • Relationships • Decision Making • Reimbursement • Coverage • Managed Care • Goals and Solutions

  3. Relationships • Doctor/Patient • The original relationship • Patient/Insurer • Started as a “perk” for employment • Doctor/ Insurer • Developed as a courtesy to patients • Became a convenience for reimbursement

  4. What Drives the Insurer/Patient relationship? • Who is the Insurer responsible to? • The Patient • The Employer • The Owner or Stockholder of the Company • Which of these relationships is ultimately most important? • Which relationship is likely to suffer first?

  5. How does the Insurer affect the Doctor/Patient relationship • Positive • Subsidizes • Negative • Delay • Treatment • Payment • Adequate Coverage of Patients • Who is covered? • What is the coverage? • Interference • Doctor/Patient Decision making • Diagnostic tests • Treatment Plan • Choice of Doctor and facility

  6. Medical Decision Making • Who makes the decision and what is the motivation? • The Patient-with the guidance of his Doctor? • Insurance company? • How do Insurers influence medical decisions. • Reimbursement • Precertification/Preauthorization • What is precertification? • Why is it required? • How is it abused?

  7. Reimbursement- How are Doctors Paid? • Salary vs. Fee for service • Fee for service medicine tends to attract Doctors who relate well and tend to cater to their clients (patients) • Salaried medical care historically does not provide the same quality or continuity of care.

  8. “Fee for Service” Medicine • In order to earn a living, a doctor must perform a service and charge a fee • Basis for charges • Cost of performing service • Fair and consistent pricing

  9. Where Are There Discrepancies in Fee for Service? • “Usual, Customary and Reasonable” • Perceived meaning of UCR • Actual meaning of UCR

  10. Other Problems with Third Party Reimbursements • Delay • Failure to pay • Denial • Pre-existing conditions • Excluded services • “Down-coding and Bundling”

  11. Coverage Problems • Pre-existing waiting periods • Noncovered procedures • Uninsured • Not eligible for coverage • Lapsed policy • Who referees disputes?

  12. Managed Care • What is it? • Some form of the medical decision making or treatment process is “managed” by someone other than the Patient or his chosen Doctor • Some types of Managed Care • Health Maintenance organizations • Preferred Provider organizations • “Gatekeeper” medicine • What is the motivation? • To reduce the cost of medical insurance • By Controlling (decreasing or denying) Services • Who wins? • Who looses?

  13. How Would Managed Care Work in the Cayman Islands • Physician Participation is dependant on the “volume” of patients available. • Quality vs. Quantity.  • Quantity of patients is limited, therefore a doctor can’t maintain an income by working harder and seeing more patients • It is difficult to justify a reduced level of services to individual patients

  14. Goals for Insurer, Patient and Doctor Compatibility • Preserve the patient’s right to have the best possible treatment. • Protect the Physician-Patient relationship for privacy, treatment options and decision making. • Preserve access to appropriate medical care, at the discretion of the patient. • Assure medical services are fairly compensated in a manner acceptable to Patients, Doctors and Insurers.

  15. What are the Solutions? • Strive to educate and inform Patients • A responsibility of Insurer, Doctor and Employer • Clear and concise coverage that can be determined at the point of service so that no confusion exists about coverage or fiscal responsibility. • Unify procedures for billing and reimbursement • “CPT” procedure coding • ICD diagnosis coding • Standardized forms for claim submission • HCFA 1500 • UB92 • Provide Adequate appeal process not controlled by payer. • Eliminate delay in processing and payment

  16. How Have Doctors Tried to Facilitate These Goals? • Published guidelines for fees • Attempt to educate patients about their insurance • Difficult to do because of the variation in programs, confusion about coverage, deductible, co-pay. etc • Help patients with filing forms • Making patients aware of alternate procedures, costs and options for treatment • Attempted to establish a dialogue with the insurance industry.

  17. Conclusion • Relationships • Decision Making • Reimbursement • Coverage • Managed Care • Goals and Solutions

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