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 1 st 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 1 st $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. 3 rd 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 3 rd party is the healthcare provider

13. Models of 3 rd 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