Medical Necessity

  Le canal de demande a dépassé le délai imparti en attendant une réponse après 00:01:00. Augmentez la valeur du délai d’expiration transmise à l’appel à Request ou augmentez la valeur SendTimeout sur Binding. Le temps alloué à cette opération fait peut-être partie d’un délai d’attente plus long. Definition: Health insurance companies provide coverage only for health-related serves that they define or determine to be medically necessary. Medicare, for example, defines medically necessary as: “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.”Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.Most health plans will not pay for healthcare services that they deem to be not medically necessary. The most common example is a cosmetic procedure, such as the injection of medications (such as Botox) to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental, or not proven to work.It’s important to remember that what you or your doctor defines as medically necessary may not be consistent with your health plan’s coverage rules. Before you have any procedure, especially one that is potentially expensive, review your benefit handbook to make sure it is covered. If you are not sure, call your health plan’s customer service representative.

Concierge Medical Practice

a Concierge Medical Practice - Is your doctor switching to a practice with a retainer fee?Tom Gill/Getty Images Are you joining a concierge medical practice? The Affordable Care Act, which President Obama signed into law in March 2010, includes mandatory health coverage for people without health insurance. Adding more than 30 million newly insured people into our health system will make the shortage of primary care physicians (PCPs) worse. There will be many more patients and a lot fewer primary care physicians!Faced with the burdens of an aging population and low reimbursement for their services, many PCPs are leaving primary care or changing the way they practice. Some PCPs are switching to concierge practices, a growing trend, also known as retainer, boutique, or direct medical practices. They are controversial and many in the healthcare system think they will make the shortage of PCPs worse, especially in 2014 when many more Americans will have access to affordable health insurance.The concierge practice model, allowing PCPs to offer more personalized care by decreasing the number of patients they care for from about 2000 to less than 1000, first appeared in the 1990’s. In return for these enhanced services, PCPs charge patients a retainer fee, which can range from about $1500 a year to as much as $15,000 per year depending on location and the type and extent of new services.If you are in a retainer practice, your doctor may continue to bill your health plan for covered services, with the retainer (or supplement) you pay being used to pay for the extra services your doctor provides that are not covered by health insurance. Some doctors will not except any health insurance and will use the retained fee to pay for all services; this type of arrangement is known as a “cash-only“ or a “direct primary care” practice.The ability to spend more time with patients, decrease the amount of paperwork and office administration, and make more money, improves physician satisfaction. And, patients who can afford the increased cost are likely to be more satisfied with the attention they get from their doctor.If you are in a retainer practice you will continue to receive basic healthcare services that are traditionally provided by your doctor. Depending on how your doctor has set up the retainer practice (and perhaps how much extra you pay each month), you may receive some of the following additional services:more time with physician during each visitsame day appointments or within 24 hours of callingextended evening and weekend office hoursaround-the-clock access to your physician, including 24-hour availability by pager, cell phone, or home phonepersonalized coordination of hospital carehouse callsaccompanied visits to specialistsprocedures and services that may not be covered by traditional health insurance, such as annual physicals, preventive care, weight loss programs, and wellness advicenicer and less crowded reception and waiting areas and spa-like amenitiesThe main selling points for most patients who decide to join a retainer practice are better and more immediate access to, and more undivided attention from, their physician.Healthcare experts and others opposed to the concept of concierge practices are concerned that these practices promote a two-tiered health system that favors wealthier patients and reduce the number of physicians who are available to care for patients who cannot afford an additional fee.While running a retainer practice may be more lucrative for some physicians and makes healthcare more convenient for their patients, it may make care less available for other patients who cannot afford (or choose not) to pay the required practice membership fees. Since Americans are already coping with a shortage of primary care physicians, the increasing numbers of concierge practices along with health reform changes (millions more with health insurance) may further place a burden on the people trying to find a PCP.People who support retainer practices argue that the practices meet consumer demand, allow physicians to provide the treatment they deem necessary, improve both patient and doctor satisfaction, and improve quality of care by increasing the amount of time that can be spent on prevention and wellness services.Among physicians there is an ongoing debate about the ethics of retainer practices that has become more heated since the passage of the Affordable Care Act and the concern about the worsening shortage of PCPs.In an editorial – Concierge Medicine: A “Regular” Physician's Perspective – published in the Annals of Internal Medicine (a journal of the American College of Physicians) in March 2010, Dr. Michael Stillman, a primary care physician from the Boston University School of Medicine, raised concerns about the ethics and quality of care delivered in retainer practices, and urged the physician community to abandon “the neutrality with which the medical community has addressed” this issue thus far.However, there is a growing interest among internal medicine physicians and family physicians to change their traditional practices to a retainer practice. Seminars are being offered around the country, including at annual meetings of various medical organizations.For example, an affiliate of the American Academy of Family Physicians offers a seminar for physicians (for a fee of $800) “to learn the nuts and bolts of building a concierge practice.” An excerpt from the course description provides an interesting overview of the type of message physicians are getting about retainer practices:Concierge medicine is emerging as the only solution for physicians to escape the failing health care system. Over 1,000,000 patients across the country are in a direct practice and 17,000 primary care doctors intend to transition to a direct practice in the next 5 years. Direct practice is a way to get back to practicing medicine without all of the interference of insurance companies. Physicians simply can no longer increase volume and push patients through an assembly line to survive, and yet practice quality care, while enjoying being a physician healer.

Medical Necessity

aDefinition: Health insurance companies provide coverage only for health-related serves that they define or determine to be medically necessary. Medicare, for example, defines medically necessary as: “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.”Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.Most health plans will not pay for healthcare services that they deem to be not medically necessary. The most common example is a cosmetic procedure, such as the injection of medications (such as Botox) to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental, or not proven to work.It’s important to remember that what you or your doctor defines as medically necessary may not be consistent with your health plan’s coverage rules. Before you have any procedure, especially one that is potentially expensive, review your benefit handbook to make sure it is covered. If you are not sure, call your health plan’s customer service representative.

Beyond Medical Coverage: Vision Care Insurance

aIf you have an eye disease or eye injury your regular health insurance will pay for diagnosis and treatment. However, most regular health insurance policies do not pay for the costs of routine eye exams, corrective lenses, eyeglass frames, or contact lenses. Insurance coverage for such services is known as vision care insurance.Some large employers do provide vision care insurance as a benefit but most do not. According to the U.S. Department of Labor, less than 30% of employees receive vision care coverage.Vision care insurance usually pays for the following basic services:A yearly eye examination, including refraction to check your visionEyeglass lensesEyeglass framesContact lensesLASIK and PRK vision correction procedures at a discounted rateYour specific vision care plan may have a limit (such as every two years) on how often it will pay for lenses and frames.Usually, vision care plans (including those you buy or are provided by your employer) contract with eye care professionals to provide you with vision care services. In some plans you can use any eye care provider and receive a discount on the services offered. However, most plans purchased from a vision care insurance company are PPOs (preferred provider organizations) in which your eye care is managed by a network of eye providers. In a PPO, you also can use out-of-network eye providers, but you will pay a greater share of the cost.Eye care network professionals typically include optometrists and general ophthalmologists. Some networks also may include ophthalmologists who perform refractive surgery and provide LASIK and other vision correction procedures.An optometrist, also known as a doctor of optometry, is licensed to examine your eyes to diagnose vision problems, such as nearsightedness and farsightedness, and prescribe eyeglasses or contact lenses. Your optometrist also can test you for glaucoma and other eye diseases and diagnose eye problems related to diseases such as diabetes and high blood pressure. Optometrists can also diagnose and treat certain types of eye diseases, such as conjunctivitis (pink eye). Ophthalmologists are medical doctors who perform eye surgery, diagnose and treat diseases and injuries of the eye. Ophthalmologists, like optometrists, can also examine your eyes for vision problems and prescribe eyeglasses and contact lenses.Similar to dental insurance, you may be able to purchase vision care coverage through a local business group, college alumni association, fraternal organization, or religious group. If you are over 65, you may have a vision care (including eyeglasses) benefit if you are part of a Medicare Advantage Plan.You also can purchase your own vision benefit plan. For example, two of the larger eye insurance companies in the country that offer individual vision care policies are Vision Service Plan and Humana One. Both companies’ web sites provide access to information about the vision plans available in your state.If you wear corrective lenses and need periodic eye exams and changes in your eye lens prescription, it may be worthwhile to purchase vision care insurance. If you do not currently wear or need glasses, you may be able to get a periodic eye exam through your regular health insurance plan.An individual plan may cost you from $150 to $180 per year depending on where you live. You may also have a copayment for the initial eye examination and for the corrective lens prescription. The typical benefit usually includes:Eye Exam - Covered in fullPrescription Lenses - Covered in fullFrames - Covered up to $120Contact Lenses - $120 allowance for the cost of your contacts and the contact lens examAnother option is to enroll in a discount plan, which provides a specific discount for vision-related services. Although not an insurance policy, these plans can save you up to 30% to 40% off the retail price for exams and corrective lenses. For example, if you are a member of AARP, you can save 30% on eyeglasses and 20% on contact lenses by just presenting your AARP card to a participating vision care provider.