4 ms·

1) Are there deductibles and co-pays for members who visit an emergency room with an out of network hospital? 2) What is your national payer id? Do you suppor

1) Are there deductibles and co-pays for members who visit an emergency room with an out of network hospital? 2) What is your national payer id? Do you support 837s with electronic attachments, 835, 270/271, and 276/277 transactions to help providers manage claims? What about corrected claims? 3) What kind of contract would an in-network provider expect to get from you all? Some kind of capitated/case rate thing? 4) Are you all using any third party administrators to do the dirty work of negotiations? Edit 5) Who is reinsuring you in the event of big losses?

jstartz26 5y ago
1. There is a $300 copay for an emergency room visit (both in-network and out-of-network). This is actually our only copay period. It is to encourage people to only use emergency rooms for emergencies. There are no deductibles for our primary plan though we do offer a HDHP as well (for employers with HSAs), so for the secondary product a deductible does apply. Emergency care is always covered as an in-network benefit and no copay would apply for inpatient care/admissions. 2. Payor ID is EH001. Yes to all except 276/277 for right now. 3. Naturally, this depends on the type of provider. We work with our providers to contract on a basis that is comfortable for them. Not all physicians are ready to accept something like capitation. We collaborate with physicians on the quality parameters to track. Some agreements are done as bundles for the entire episode of care. Some agreements are case rates or capitation payments. Some are still benchmarked off of Medicare but tied more closely to patient outcomes. For example, with primary care doctors we target avoiding poor control of diabetic A1C levels to be below 15% and to do depression or anxiety screenings for more than 80% (among other metrics). 4. Nope. We contract directly and do all the claims processing ourselves. Sometimes that means negotiations can take awhile (for large health systems) but it almost always means we reach favorable terms with a mutually beneficial structure.
deleted 5y ago
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jstartz26 5y ago

1. There is a $300 copay for an emergency room visit (both in-network and out-of-network). This is actually our only copay period. It is to encourage people to only use emergency rooms for emergencies. There are no deductibles for our primary plan though we do offer a HDHP as well (for employers with HSAs), so for the secondary product a deductible does apply. Emergency care is always covered as an in-network benefit and no copay would apply for inpatient care/admissions. 2. Payor ID is EH001. Yes to all except 276/277 for right now. 3. Naturally, this depends on the type of provider. We work with our providers to contract on a basis that is comfortable for them. Not all physicians are ready to accept something like capitation. We collaborate with physicians on the quality parameters to track. Some agreements are done as bundles for the entire episode of care. Some agreements are case rates or capitation payments. Some are still benchmarked off of Medicare but tied more closely to patient outcomes. For example, with primary care doctors we target avoiding poor control of diabetic A1C levels to be below 15% and to do depression or anxiety screenings for more than 80% (among other metrics). 4. Nope. We contract directly and do all the claims processing ourselves. Sometimes that means negotiations can take awhile (for large health systems) but it almost always means we reach favorable terms with a mutually beneficial structure.

deleted 5y ago

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