Chapter 8 Part 2
What is an EPO?
A hybrid health insurance plan where a primary care provider is not necessary, but providers must be seen within a predetermined network.
What is an Individual Practice Association (IPA)?
A managed care model where an HMO provides services through individual medical practitioners.
What is a third party in the context of third-party reimbursement?
A medical vendor with no binding interest in a particular insurance contract.
What is a Point-of-Service Plan (POS)?
A plan similar to a PPO that allows policyholders to choose any provider, but offers financial incentives for using providers identified by the plan; It is a managed care plan similar to PPOs, but with assigned primary care physicians.
What is a POS plan?
A plan that assigns primary care physicians to coordinate patient care.
What does the plan reimburse in a Fee-for-Service Plan?
A portion of the cost of covered services.
What is capitation?
A system where medical vendors receive a fixed amount per patient.
What is an Exclusive Provider Organization (EPO)?
A type of PPO where services are reimbursed only if contracted providers are used.
What is a Fee-for-Service Plan?
A type of insurance where patients can seek services from any provider.
What is a National Provider Identifier (NPI) Number?
A unique 10-digit identification number used in standard health care transactions.
What should institutions do to limit their financial obligations?
Adopt and communicate policies that align with their insurance coverage.
Who needs to obtain an NPI?
All individual HIPAA-covered health care providers or organizations.
How does secondary coverage work?
Athlete's insurance covers cost first, then school covers remaining cost.
Who should communicate with coaches?
Athletic trainers and sports medicine team members.
How do athletic trainers earn income through third-party reimbursement?
Athletic trainers who work in hospitals and clinics might earn a portion of their income through third-party reimbursement.
How are physicians or providers paid in capitation?
Based on the number of patients they see.
What is the main similarity between an EPO and a PPO?
Both require using approved medical vendors.
What should athletes be encouraged to do?
Buy their own personal insurance.
How can medical providers be encouraged to treat athletes on an insurance-only basis?
By having the physician treat the athlete in the office and bill the athlete's insurance.
How can athletic trainers help reduce insurance premiums?
By implementing risk-management measures.
How can an institution limit its financial obligation for costs associated with athletic injuries?
By only covering medical services that have been preapproved by an institutional representative.
How can the cost of athletic accident insurance be passed on to athletes?
By requiring them to pay a modest sum for the insurance.
What should institutions with self-insurance consider purchasing?
Catastrophic coverage
What is another term for secondary coverage?
Excess insurance.
What is the disadvantage of primary coverage?
Expense.
What do patients have the freedom to do in a Fee-for-Service Plan?
Go to the medical provider of their choice.
What do private medical insurance companies provide?
Group and individual coverage for employees and their dependents.
What are Preferred Provider Organizations (PPOs)?
Health insurance plans that provide incentives to use approved medical vendors.
What are Health Maintenance Organizations (HMOs)?
Health insurance plans that require policyholders to use approved medical vendors.
Where is care provided in an IPA?
In a physician's office instead of a large medical center.
What should be communicated to parents/guardians and athletes?
Information about the school's insurance policy and covered injuries.
What is self-insurance?
Institutions pay medical bills for student-athletes without purchasing insurance
What is primary coverage?
Insurance that pays for covered expenses after a deductible has been paid
What is secondary coverage?
Insurance that pays for covered expenses after primary coverage has been exhausted
What is one way to spread the risk?
Involving all concerned parties (school, athletes, parents/guardians).
What is the role of third-party reimbursement in the US healthcare system?
It is the primary mechanism for paying for medical services.
What is required for reimbursement through the third-party reimbursement system?
Knowledge of diagnostic and procedural coding and strict adherence to certain legal requirements.
What is the disadvantage of self-insurance?
Large claims can deplete insurance fund, tying up money that could be used for other purposes
What are the advantages of secondary coverage?
Less costly, shared responsibility for safety, promotes cost controls.
What are the disadvantages of secondary coverage?
Longer claims process, requires more communication, labor-intensive claims process.
Is the athlete's personal medical insurance used for athletic-related medical bills in primary coverage?
No
Do most insurance policies cover athletic-related injuries?
No.
What are PPOs and EPOs?
PPOs are transitioning into EPOs, which are similar to HMOs.
What is the difference between PPOs and HMOs?
PPOs offer more provider choice and use fee-for-service payments, while HMOs use fixed fees and require a primary care provider.
What is the benefit of buying secondary coverage?
Personal insurance of athletes becomes primary source of payment.
What are the advantages of self-insurance?
Potential cost savings, simplified claims processing, flexibility in paying for procedures
What types of third-party payers exist?
Private medical insurance companies, Fee-for-Service Plans, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Exclusive Provider Organizations (EPOs).
How can insurance costs be reduced?
Risk-management, spreading the risk, buying secondary coverage, limiting financial obligations, communicating policies.
What are the three types of athletic insurance?
Self-insurance, primary coverage, secondary coverage
Why do institutions purchase primary coverage?
Sense of responsibility, high percentage of uninsured student-athletes, simplified claims processing
What is a carrier?
A charge-based provider contracted by the federal government to review Medicare claims.
What is the difference between an EPO and an HMO?
EPOs are similar to HMOs, but with more flexibility in provider choice.
What is the main difference between an EPO and a PPO?
EPOs have no out-of-network coverage, while PPOs do.
What is required to have expenses covered in an HMO?
Staying in the network.
Who issues the NPI Number?
The Centers for Medicare and Medicaid Services (CMS).
What does the patient pay in a Fee-for-Service Plan?
The copay or deductible.
What do government-sponsored programs provide coverage for?
The elderly, the needy, and members of the armed forces and their dependents.
What happens if you step out of the network in a PPO?
The plan will still cover costs, but not as much as if you stayed in the network.
What is third-party reimbursement?
The process by which medical vendors receive reimbursement from insurance companies for services provided to policyholders.
How do PPOs operate?
They allow greater choice of health care providers and pay medical vendors on a fee-for-service basis.
What requirement can be imposed on injured athletes covered by managed care plans?
They can be required to use medical providers approved by the plan.
What can annual risk assessment audits help with?
They can help reduce the incidence of athletic injuries.
What role does a primary care physician play in a POS?
They coordinate and dictate who you see for medical care.
What role do athletic trainers play in generating reimbursable dollars?
They have historically lacked direct access to third-party reimbursement, but they have been responsible for generating significant amounts of reimbursable dollars for the clinics and hospitals that employ them.
How do hospitals and private practice health professionals rely on third-party reimbursement?
They heavily rely on it to generate income for their practices.
What is required for patients insured by an HMO?
They must use a primary care provider that participates in the HMO.
How do HMOs operate?
They provide participating health care practitioners with fixed fees for services rendered to members.
What is the role of health care practitioners in third-party reimbursement?
They receive reimbursement from a policyholder's insurance company for services they perform.
What is the reimbursement model used in the United States?
Third-party reimbursement is the #1 reimbursement model in the United States.
How are fees determined in HMOs?
Through a capitation system.
What is the role of a primary care physician in an HMO?
To coordinate all medical services and act as a gatekeeper to specialty services.
What is the purpose of self-insurance?
To save money and have flexibility in paying for medical expenses
What is the requirement to get medical services reimbursed?
You must stay in the network.
