HCS 182 Week 2 Insurance Structures and Contracting

Resource: Insurance Structures and Contracting Worksheet

Complete Parts A and B of the Insurance Worksheet.

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Part A: Match the appropriate term to its definition.

1.	_______ Point of Service Contract	A.	Review by insurance that grants approval for reimbursement of a health care service.
2.	_______ High Deductible Contract	B.	Reimbursement methods based on the number of individuals covered by the contract.
3.	_______ Capitation	C.	Patient insurance may stipulate a percentage of charges a patient must pay after reimbursement.
4.	_______ Health Savings Accounts	D.	Subscriber responsible for a large amount of health care costs during the year.
5.	_______ Copays and Deductibles	E.	Medicare regulations state a provider must refund a payment received from a patient for a service that is deemed by Medicare as unnecessary, experimental, or unapproved, unless the patient agrees to pay the provider in advance.
6.	_______ Gag Clause	F.	Gives tax-favored treatment for expenditures on health care cost. Enrollees of high deductible plans can save the money needed for health services.
7	_______ Preauthorization	G.	Special clauses in contract that stipulate additional coverage over and above the standard contract.
8.	_______ Coinsurance	H.	Amount of out-of-pocket costs a subscriber must pay each year for provider visits or procedures.
9.	_______ Rider	I.	Prevent providers from discussing all treatment options with patients; banned by Medicare and many states.
10.	_______ Medically necessary	J.	Subscribers can choose in-network or out-of-network provider.

Part B: It is no secret that patients ask many questions about their insurance. In fact, many will assume the doctor’s office knows everything about insurance. Understanding various insurance structures will give you the tools needed to assist your patients. In the following scenarios, you are answering the phone at a health care center and patients are calling with insurance questions.

Write a 90- to 175-word response to each of the following questions. Format your answers according to APA guidelines and cite any sources accordingly.

Jones calls the office and explains, “It is open enrollment and my employer is offering us a choice between a PPO plan and an HMO plan. Can you tell me the difference between them and which one you would recommend?”

Mary calls the office and asks, “I am so confused. Can you please help me understand the difference between an EPO and a POS plan? Everyone at work is asking, and I know you would be able to tell me.”

John calls the office and asks, “I was laid off and cannot afford the COBRA plan from my employer, but my insurance agent said an indemnity plan would be affordable. Can you tell me about this indemnity plan?”

Thomas calls the office and asks, “My employer is offering us cafeteria plans for next year, and I know this means I basically build my own plan, but could you tell me, of the PPO, HMO, or traditional comprehensive plan, which one or ones will enable me to go out-of-network for care? I do quite a bit of traveling and this concerns me.”