Chapter 8 Part 1
By convincing the healthcare provider to waive the portion of the fee.
How can one try to reduce the fee above the UCR amount?
They may list specific procedures or use criteria to determine.
How do insurance companies define experimental procedures?
Increase the premium significantly.
How do riders affect the premium?
Acute traumatic injuries during practices and games.
How does the insurance industry define accidents?
A diagnosis on paper.
What needs to be provided to the insurance company for coverage of surgery?
Correspond directly with the employer for assistance.
What should be done if the self-insurance fund of a parent's employer covers a patient?
After reaching $90,000 in medical bills.
When does catastrophic insurance usually take effect?
The state insurance commissioner can be contacted.
Who can be contacted for assistance in challenging a denial?
Insurance company.
Who determines if an injury is athletic-related?
Non-NCAA institutions and high schools through national governing organizations.
Who else can access catastrophic insurance?
The employer has the authority to reverse the denial.
Who has the final legal authority to reverse a denial if the employer has a self-insurance fund?
Member institutions of the NCAA since 1991.
Who receives catastrophic insurance at no cost?
Terms do not include coverage for experimental procedures.
Why do current policies not cover experimental treatments?
To help pay the claim, the reason for denial needs to be addressed.
Why is it important to find out why the claim was denied for the secondary policy?
The lower of either the usual or customary fee
What is the reasonable fee?
Fee charged by each healthcare provider for a specific service.
What is the usual fee in UCR?
To accurately identify a diagnosis and determine appropriate treatment.
What is the purpose of a diagnostic surgical procedure?
To pay for claims without involving an insurance company.
What is the purpose of self-insurance?
Yes, it is repeated for each visit.
Do you have to pay a co-pay every time you are seen?
Yes.
Do you have to pay a premium for athletic accident insurance?
Non-medically necessary surgeries chosen by the individual.
What are elective surgical procedures?
Situations or circumstances not covered by the policy.
What are exclusions in insurance?
Therapies that have not been proven effective.
What are experimental therapies?
Treatments that have not been proven effective.
What are experimental treatments?
1. Find out the exact reasons for denial. 2. Obtain a statement from the healthcare provider explaining the treatment and fee. 3. Correspond with the employer if covered by a self-insurance fund. 4. Provide evidence from clinical studies. 5. Try to convince the provider to waive the fee above UCR amount. 6. Contact the state insurance commissioner for assistance.
What are some suggestions to resolve claims denied due to experimental treatment or UCR clauses?
Irrevocable loss of speech, hearing, sight, use of limbs, or severe mental capacity impairment.
What are the eligibility criteria for disability insurance?
Overuse injuries, illnesses, degenerative conditions.
What are the exclusions in most accident insurance plans?
Primary Coverage, Secondary Coverage, Self-Insurance.
What are the three forms of athletic accident insurance?
Primary (school pays) and secondary (patient pays first, then school pays the rest).
What are the two types of catastrophic insurance?
Standardized charges for third-party reimbursement.
What are usual, customary, and reasonable fees (UCR)?
The employer makes all the decisions regarding the fund.
What decisions are made by the employer in a self-insurance fund?
Provide coverage for conditions not normally covered.
What do riders do?
Riders to cover costs of chronic conditions.
What do some athletic accident insurance companies offer?
Conditions not normally covered by the policy.
What does a rider cover?
Athletic-related injuries.
What does athletic accident insurance pay for?
Future loss of earnings for potential professional athletes.
What does disability insurance refer to?
Treatment for injuries and illnesses, as well as prevention.
What does health insurance cover?
Provisions for maintaining good health and prevention.
What does health insurance include?
Treatment for injuries and illnesses.
What does medical insurance cover?
Paying for the entire cost.
What does out of pocket mean?
Evidence from clinical studies.
What evidence can be provided to support a claim that a treatment should not be considered experimental?
Usual fee, customary fee, and either average or 90th-percentile fee.
What factors determine the amount insurance companies pay under UCR?
The secondary policy will not pay for the claim.
What happens if a claim is denied due to UCR clauses and there is a secondary policy?
Coverage charges for each visit, not always the same fee.
What is a co-pay?
Amount of money paid before insurance coverage starts.
What is a deductible?
Surgery performed to identify a diagnosis when clinical findings are inconclusive.
What is a diagnostic surgical procedure?
A plan expressing intended behavior for a program.
What is a policy?
Baseline periodic payment for insurance coverage.
What is a premium?
Supplemental policy for additional coverage.
What is a rider in insurance?
Treatment still undergoing research/testing.
What is an experimental treatment?
Insurance for expenses associated with acute athletic accidents.
What is athletic accident insurance?
Accident insurance providing lifelong medical, rehabilitation, and disability benefits.
What is catastrophic insurance?
Insurance protecting athletes against future loss of earnings due to a disabling injury or sickness.
What is disability insurance?
Policy that reimburses medical costs for preventive and corrective care.
What is health insurance?
Insurance for medically related expenses.
What is medical insurance?
Money set aside to cover claims for an employer or patient.
What is self-insurance?
Fee for the geographic area.
What is the customary fee in UCR?
Either the average fee or the 90th-percentile fee, whichever is lower.
What is the lowest fee used in UCR?