In today's episode I discuss the origins of health insurance in the United States compared to other countries and break down the various modalities of obtaining insurance as well as various insurance sectors. I then discuss the ins and outs of choosing an insurance plan based on HMO, PPO, and EPO and define deductible, coinsurance, copayment, and premium. Finally we briefly discuss the transition from ICD-9 to ICD-10 and summarize how providers can accurately and effectively bill.

• Deductible – the amount you must pay each year before your plan starts to pay for covered medical expenses.
• Coinsurance – cost- sharing requirement where you pay a certain percentage and the insurance company will pay a certain percentage after deductible is met.
• Copayment – a specific flat fee you pay for each medical service; the insurance company will pay remainder of chargers.
• Premium – think of this as a membership, you pay this every month at the same rate (sometimes this can cover your routine screenings).

HMO – Health Maintenance Organization

• You choose a PCP in your area
• If you need a specialist your PCP will make a referral (must be in network and does not cover out of network care)
• More managed type of healthcare plan

PPO – Preferred Provider Organization

• No PCP is required, easier to access specialists
• Network is larger than HMO, giving you statewide, sometimes nationwide care
• PPO allows you to go outside the established network although it won’t cover as much
• Less managed care, more control of available healthcare

EPO – Exclusive Provider Organization

• No primary care physician is required
• Referrals are not required, so it’s easier to gain access to specialists
• Does not cover out of network care
• Ideal for those wanting lower premiums and no PCP

 

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