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 1990s 70
• Increasing cost of healthcare making insurance
  less affordable
• during 1980s and early 90s 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 its 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
• Workmans 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
  doesnt 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 Plans 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
• ATCs may also use physical medicine (97000
  series) codes to describe services rendered

25
Insurance Claims

• What does the ATCs 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 ATCs 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 ATCs
• Bid?
• Direct Purchase?
• Ask companies to present their package?
• Details of the policy
• Coverage
• How to file a claim