HCMG Exam 3 Lecture 4(100% Solved)
What is the significance of surprise medical bills in each type of insurance model? -
ANSWERSIn public insurance (medicare/medicaid), surprise medical bills are not an
issue here because medicare and medicaid have already negotiated with doctors
across the board.
In private insurance, surprise medical bills show up here. Employer negotiates with
insurance company to determine how much the insurance company will contribute, how
much you will contribute out of paycheck
What are the three types of private insurance models? - ANSWERSHMO - If you go to
out of network doctor, you have to pay whatever doctor charges you → no out of
network care paid for by an insurance company
PPO - If you go to out of network doctor, you will pay a lesser rate than what you have
to pay without insurance, but you have to pay more than what you would if you went to
in network doctor
Full Indemnity - You pay a premium (more than HMO and PPO premium), but you can
see whoever you want
What type of data do researchers look at to determine surprise out of network bill? -
ANSWERSAnalyze the data such as Date, time, Hospital Bill
Type of procedure, the cost of the procedure, code, the insurance company (what they
have contributed, and what expected contribution will be)
So bill will have total cost, cost insurer will pay, cost you have to pay
If a doctor negotiates with an insurance company - they are considered in network
Treatment categories that are used to classify cases by potential surprise medical bill
status - ANSWERSFor ED (inpatient and outpatient) and elective procedures (inpatient)
services:
If the hospital and primary doctor are in network, and other doctor or services is out of
network
If hospital is in network, primary doctor is unidentified in the data, but other doctor or
services are out of network
For ED (inpatient and outpatient):
If hospital is in network, and primary doctor is out of network or there is an ambulance
claim
Percentage of hospital cases with potential surprise medical bills 2007 - 2014 -
ANSWERSIn 2007, 30% of patients who were in the ED as an inpatient encountered a
surprise medical bill
It has decreased as years go on but percentage is still high
There are a lot of mergers, there are less people and less groups for insurance
company to negotiate with, so less time to spend to negotiate with all these small
What is the significance of surprise medical bills in each type of insurance model? -
ANSWERSIn public insurance (medicare/medicaid), surprise medical bills are not an
issue here because medicare and medicaid have already negotiated with doctors
across the board.
In private insurance, surprise medical bills show up here. Employer negotiates with
insurance company to determine how much the insurance company will contribute, how
much you will contribute out of paycheck
What are the three types of private insurance models? - ANSWERSHMO - If you go to
out of network doctor, you have to pay whatever doctor charges you → no out of
network care paid for by an insurance company
PPO - If you go to out of network doctor, you will pay a lesser rate than what you have
to pay without insurance, but you have to pay more than what you would if you went to
in network doctor
Full Indemnity - You pay a premium (more than HMO and PPO premium), but you can
see whoever you want
What type of data do researchers look at to determine surprise out of network bill? -
ANSWERSAnalyze the data such as Date, time, Hospital Bill
Type of procedure, the cost of the procedure, code, the insurance company (what they
have contributed, and what expected contribution will be)
So bill will have total cost, cost insurer will pay, cost you have to pay
If a doctor negotiates with an insurance company - they are considered in network
Treatment categories that are used to classify cases by potential surprise medical bill
status - ANSWERSFor ED (inpatient and outpatient) and elective procedures (inpatient)
services:
If the hospital and primary doctor are in network, and other doctor or services is out of
network
If hospital is in network, primary doctor is unidentified in the data, but other doctor or
services are out of network
For ED (inpatient and outpatient):
If hospital is in network, and primary doctor is out of network or there is an ambulance
claim
Percentage of hospital cases with potential surprise medical bills 2007 - 2014 -
ANSWERSIn 2007, 30% of patients who were in the ED as an inpatient encountered a
surprise medical bill
It has decreased as years go on but percentage is still high
There are a lot of mergers, there are less people and less groups for insurance
company to negotiate with, so less time to spend to negotiate with all these small
