Sunday, February 12, 2012

Intro to Insurance

Many people receive ‘benefits’ to pay for healthcare from their employer or from government agencies. This benefit is called insurance. The company that administers this benefit is called the insurance carrier or just the carrier. There are many carriers but just to give an idea I will name a few of the most popular commercial carriers: Aetna, Blue Cross/Blue Shield, Oxford, Cigna, and United Healthcare.

I referred to these as “commercial” carriers because they are businesses, corporate entities as opposed to government funded agencies. There are also government funded insurance plans such as Medicare, Medicaid and Tricare/Champus. Medicare is a healthcare benefit mostly for people who are over 65 and/or eligible for social security. Medicaid is coverage for the poor. These two insurances are governed by a federal agency called The Centers for Medicare and Medicaid Services [CMS] (www.cms.gov). Tricare/Champus is coverage for those in military service (www.tricare.mil).  

When a patient is treated by a doctor, the doctor sends a request for payment (a medical claim) to the insurance company. Here’s the catch, receiving the payment depends on a lot of factors, such are the patient’s participation status and coverage level with the insurance as well as the physician’s participation status. Other factors involve whether the claim has correct and/or sufficient information contained within. 

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