New Library Materials List Available
The new library materials list for July is available at: http://www.youseemore.com/nhsu/newmaterials.asp
Important Health Care Terms to Understand
Posted on April 17, 2008
In order to get the most out of your health care benefits, you need to understand the terms used by insurance companies, health plans, and health care providers.
Ambulatory care: Health care services that do not require a hospital stay, such as those delivered in a doctor’s office, clinic or day surgery center.
Assignment of benefits: When you assign benefits, you sign a document allowing your hospital or doctor to collect your health insurance benefits directly from your health carrier. Otherwise, you pay for the treatment and the insurance company reimburses you.
Benefits: The amount of money payable by an insurance company to a claimant, assignee or beneficiary under the insurance policy.
Capitation: Capitation represents a set dollar limit that a health maintenance organization (HMO) pays to your primary care physician for providing medical treatment to you and your dependents. This fee is usually paid to the physician on a monthly basis. The physician gets no more or less than this set fee, no matter how much or how little you use her services.
Case management: A technique that insurance companies and HMOs use to ensure that individuals receive appropriate, timely, and reasonable health care services.
Claim: A request by an individual (or his or her provider) to an individual’s insurance company for the insurance company to pay for services obtained from a health care professional.
Coinsurance: The money that an individual is required to pay for services, after a deductible has been paid. In some health plans, coinsurance is called a “copayment.” Coinsurance is often a specified percentage of the charges. For example, the employee pays 20 percent of the charges, and the health plan pays 80 percent.
Copayment: An arrangement where an individual pays a specified amount for various health care services and the health plan or insurance company pays the remainder. The individual must usually pay his share when the service is rendered. This concept is similar to coinsurance, except copayments are usually set dollar amounts (such as $10 per office visit), rather than a percentage of the charges.
Deductible: A set dollar amount that a person must pay before insurance coverage for medical expenses can begin. Deductibles are typically charged on an annual basis.
Denial of claim: Refusal by an insurance company to pay a request submitted by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
Employee assistance program (EAP): Mental health counseling services that are sometimes offered by insurance companies or employers. Typically, individuals or employers do not have to pay directly for services provided through an employee assistance program.
Exclusions and limitations: Specific conditions or circumstances for which an insurance policy or plan will not provide coverage (exclusions), or for which coverage is specifically limited (limitations).
Health Maintenance Organization (HMO): Prepaid, or capitated, health care plans in which individuals pay a monthly fee to be a member of the HMO, as well as small fees or copayments for specified health care services. Services are provided by physicians and allied health care personnel who are employed by or under contract with the HMO. HMOs vary in design, and depending on the model, services may be provided in a central facility, or in an individual physician’s office. HMOs are available to both individuals and employer groups.
Indemnity plans: Indemnity health plans are also called “fee-for-service” plans. These types of plans primarily existed before the rise of HMOs and PPOs. The individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other remaining charges. Fees for services are defined by individual providers, and therefore vary from physician to physician. Indemnity health plans allow individuals to choose their own health care professionals - there are no provider networks from which to choose.
Independent Practice Association (IPA): A group of independent practicing physicians who band together for the purpose of contracting with HMOs, PPOs, and insurance companies for their services.
In-network: Typically refers to physicians, hospitals, or other health care providers who contract with the insurance plan (usually an HMO or PPO) to provide services to its members. Coverage for services received from in-network providers will typically be greater than for services received from out-of-network providers, depending on the plan.
Long-term care insurance: Insurance policies that cover the costs of providing nursing care, home health care services, and custodial care for the aged and infirm.
Managed care: A system of health care delivery that is characterized by arrangements with selected providers, ongoing quality control and utilization review programs, and financial incentives for members to use providers and procedures covered by the plan.
Maximum benefit: The maximum dollar amount that an insurance company will pay for claims, either for a specific service or procedure, or during a specified period of time. Most PPO plans have a lifetime maximum benefit, which is the maximum amount of money an insurance company will pay for treatment of an individual during her lifetime. In addition, many plans have maximum benefits for particular services, for example, limiting coverage for treatment of infertility to $10,000.
Medically necessary: A term used to describe the supplies and services needed to diagnose and treat a medical condition in accordance with the standards of good medical practice. Many health plans will pay only for treatment that is deemed medically necessary. For example, most plans will not cover elective cosmetic surgery.
Out-of-network: Typically refers to physicians, hospitals, or other health care providers who do not contract with the insurance plan (usually an HMO or PPO) to provide services to its members. Depending upon the insurance plan, expenses incurred for services provided by out-of-network providers might not be covered, or coverage may be less than what it would be for in-network providers.
Out-of-pocket maximum: The total amount paid each year by the member for the deductible and coinsurance. After reaching the out-of-pocket maximum, the plan pays 100 percent of the allowable charges for covered services for the rest of that calendar year.
Point-of-service plan: A type of HMO that allows the patient to see either in-network or out-of-network providers. However, the patient pays more out of pocket when she uses an out-of-network provider. In these instances, the patient pays a higher coinsurance percentage, and the charges are often subject to a deductible and copayment.
Pre-admission certification: Also called pre-certification or pre-admission review. Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or inpatient facility granted before admittance. The individual must obtain preadmission certification; however; the physician will sometimes contact the appropriate individual. The goal of preadmission certification is to ensure that individuals are not exposed to inappropriate health care services, or services that are not medically necessary.
Pre-existing condition: Any medical condition that was diagnosed or treated within a specified period immediately before a health insurance policy becomes effective. These conditions may not be covered for a specific period of time under the new policy (usually six to 12 months), however, federal legislation stipulates that an individual only needs to satisfy the pre-existing condition waiting period once, as long as they maintain group health coverage.
Preferred Provider Organization (PPO): A type of managed care plan in which doctors and hospitals agree to provide discounted rates to plan members. PPOs usually do not exercise tight management over medical care and do not use primary care physicians to coordinate care. Patients are typically reimbursed 80 percent to 100 percent for treatment received within the network, versus 50 percent to 70 percent for treatment received outside of the network.
Primary care physician (PCP): A health care professional who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a gatekeeper for an individual’s medical care, referring her to specialists and admitting her to hospitals when needed.
Reasonable and customary charges: The commonly charged or prevailing fees for health services within a geographic area. If charges are higher than what an insurance carrier considers reasonable and customary, the carrier will not pay the full amount and instead will pay what is deemed reasonable and customary for the particular service. The remaining charges are then the responsibility of the patient.
Self-insured: A health benefits plan in which the employer is at risk for the cost of its employees’ health care. Typically, a third party provides administrative services for the plan to the employer group.
Waiting period: A period of time in which your health plan does not provide coverage for a particular pre-existing condition.
Waiver: A rider or amendment to a policy that restricts benefits by excluding certain medical conditions from coverage.
Understanding the American Health Care System
Posted on April 10, 2008
The health care system in the United States can be complex and confusing. A myriad of factors both obvious and subtle contribute to health care products and services that vary in quality, service, and cost from person to person and among geographic areas. By understanding some of the factors that affect the care you receive and knowing how to navigate the increasingly complex health care system, you can make better
decisions and ultimately receive better care.
Usual and Customary Fees
A usual and customary fee is defined as the charge for a medical service or procedure that is in line with the average rate or charge for identical or similar services or procedures in a specific geographical area. Health plans often analyze national fee statistics to determine a usual and customary fee that they will reimburse a provider for a specific medical service. When you submit a claim for a specific treatment or service, the
insurer will pay all or part of the claim, depending on whether the amount of the claim is within the usual and customary range. Health plans are aware that fees charged by providers can vary depending on medical complications and underlying medical factors that may not be apparent by looking at a claim. To appeal a usual and customary
determination, you should ask your provider to provide all pertinent medical records to your health plan along with a letter explaining the circumstances that support their fee. Often health plans will adjust their payment determinations in your favor after they receive additional supporting information.
Understanding Your Explanation of Benefits
An explanation of benefits (EOB) is a form that insurance companies send to their members to explain what part of a claim was paid by insurance, what part was not paid, and why. Many find EOBs difficult to understand because they differ from one insurance company to another. Some insurance companies combine several dates of service or several providers on a single EOB form. Others prepare separate forms for each date of service and provider you see.
Use the EOB to Help You Manage Your Benefits
The main purpose of your EOB is to help you determine if your claim has been paid, how much has been paid by your insurance company, and how much is your responsibility. Then, you will know which invoices to pay and how much. To figure out who has been paid, match the treatment dates and providers from the invoices to the dates of service and providers listed on your EOB. Make sure your provider gives you an itemized invoice so you can effectively match your EOB to your invoices.
Keep in mind that insurance companies rarely pay one hundred percent of a claim. You need to pay your part in applicable deductibles, coinsurance, and copayments.
Below are some common reasons for partial payment of a claim by your insurance company.
• Part or all of the claim was charged to you to satisfy your deductible.
• Part of the claim was charged to you in the form of a copayment.
• Part or all of the claim was charged to you to satisfy your coinsurance requirement.
• The charges for the services exceeded the maximum benefit available for the service.
• Your insurance policy was not in force on the date of service.
• The claim was a duplicate and had been previously paid.
• The charges exceed the insurance company’s reasonable and customary limitation (this happens more frequently when you use out-of-network providers).
• The charges are for a non-covered service (e.g. cosmetic surgery).
• The charge was for a pre-existing medical condition that is excluded from coverage
If you receive an EOB showing that your insurance company did not pay for your entire
claim, first determine the reason why, and then determine if the reason is valid. If you believe there has been an error, contact your health plan’s member services department to ask them to review the claim.
Disputing a Claim
Chances are at some time you will have to dispute a claim that has been denied by your health insurance company. Some issues will be minor and easily resolved simply by calling the health plan’s member services department. Some issues may not be as simple to resolve. In these cases, first talk to your human resources department if you have insurance through your employer, or seek help from your state insurance department, attorney general’s office, or consumer affairs department. You have a right to appeal the way a health insurance claim was paid or a claim denial. Most states have laws that require appeals to be processed within a certain time. Your state’s appeal policy should be clearly written in your benefit summary. Once you have filed an appeal, your insurance company is required to respond within a specified period. Below are some tips for handling more complex claims disputes.
• Any dispute of a claim or benefit denial should clearly indicate that service is a benefit under your medical plan, and that it was medically necessary. Provide any supporting documentation, including copies of your benefit summary or a letter from your provider indicating that it was a medically necessary service.
• If you have been denied service due to medical necessity, you must supply proof that the procedure was medically necessary in order to have a denial overturned. You will need to provide information about your condition, symptoms, previous treatments, and your provider’s recommendation for the treatment in dispute.
• Clearly state the reason for your appeal. Remember that another person is going to read your appeal. Evaluate your written argument and supporting information. Ask yourself if your evidence supports reversing the denial. A well-written appeal with definitive supporting evidence will increase your chances for a reversal.
For more information about disputing a claim decision, visit www.iatrogenic.org/complaint.html.
Employee Resources: Raising Healthy and Safe Children
My child is just starting to walk. What do I need to do to childproof my home? What should I be looking for when choosing a pediatrician? How can I help my child make good decisions in the preteen and teenage years?
Being a parent today can feel more challenging than ever. Whether you have a newborn or a teenager heading to college, you will always have questions. You may be talking about emergency plans with your childcare provider; trying to set appropriate limits for your child’s online activities; or answering your teenager’s questions about drugs and alcohol. No matter what your concern, LifeWorks consultants can provide you with answers and support.
LifeWorks also offers many recordings and publications to help you address health and safety concerns with your children. This month, check out LifeWorks’ “Internet Safety” booklet, which is designed to help parents make sure that their child or teenager’s Internet adventures are safe. Chapters include information about common online activities and how to avoid the associated risks. At the end of the booklet, you’ll find two pullout tip sheets—“Tips for Kids” and “Tips for Teens”—which can be posted next to your home computer.
You can also order the “Keeping Your Teenager Safe” booklet, which was written in collaboration with the Facing History and Ourselves National Foundation. It provides advice and resources for parents on helping teenagers deal with the risks of drinking, drugs, dating violence, peer pressure and violence at school and in their communities.
For additional information, visit http://www.lifeworks.com to read or download informative articles, such as:
• Choosing a Pediatrician;
• Planning for Emergencies with Your Child Care Provider;
• Bullies and Best Friends;
• Kids and Weight Control: The Role of Parents;
• Keeping Your Home Safe for Young Children;
• Outdoor Play Safety for Children;
• Summer Planning for Children with Special Needs;
• Helping Your Teenager Be a Safe Driver; and
• Keeping Your Teenager Healthy During the Risk-Taking Years.
To order your free materials or to speak with a consultant, call LifeWorks at (888)456-1324 anytime. En español: (888)732-9020, TTY/TDD: (800)999-3004. You can also visit the LifeWorks Web site at http://www.lifeworks.com and click on “This Month’s Feature.” Contact the Office of Human Resources for the user name and password. You can also order additional free materials or e-mail a consultant.
There is a new faculty journal available in the Greenawalt Library!
“The Teaching Professor” is a forum for discussion of the best strategies supported by the latest research for effective teaching in the college classroom. From tips for class discussion to mentoring fellow faculty, “The Teaching Professor” stretches from the theoretical to the highly specific. Typical topics include assessment and evaluation, engagement of student interest, faculty time management, and the learner-centered classroom." www.teachingprofessor.com/
New Library Materials List Available
The new library materials list is available at:
http://www.youseemore.com/nhsu/newmaterials.asp#
"Resilience"
Why am I never satisfied with what I have?
Why am I always so stressed?
Will I ever feel really happy?
Life is filled with unexpected surprises and obstacles, and sometimes it can be challenging to keep our spirits up. How can we become happier and adopt a more positive outlook? This month, LifeWorks is featuring the new recording, “60 Minutes to a Better You.” On this new recording, Tal Ben-Shahar, a psychologist, author, and well-known authority on positive psychology, describes four key ways to achieve greater happiness. He talks about:
• accepting your emotions;
• simplifying your life;
• engaging in physical exercise, meditating, and deep breathing; and
• practicing gratitude.
At the end of the recording, Dr. Ben-Shahar shares two brief exercises you can practice again and again to achieve a greater sense of happiness and calm in your life.
You can also go to www.lifeworks.com to read or download these informative articles:
• Four Ways to Achieve Greater Happiness in Your Life;
• Gratitude Exercise;
• Meditation;
• Relaxation;
• Managing Stress;
• Taking Care of Yourself; and
• Quick Tips for Making Time for Yourself.
To order your free materials or to speak with a consultant, call LifeWorks at 888-456-1324 anytime. En español: 888-732-9020, TTY/TDD: 800-999-3004. You can also visit the LifeWorks Web site at www.lifeworks.com.
Contact the Office of Human Resources to get user name and password information.
Library Offers ‘Britannica Online’
The Greenawalt Library at Northwestern Health Sciences University now offers “Britannica Online,” which is more than just an online version of the world’s most authoritative encyclopedia. It includes:
- Full-text journal and magazine articles from EBSCO and Proquest journals;
- “Merriam-Webster's Collegiate Dictionary & Thesaurus”;
- “BBC News” and “New York Times” daily headlines;
- A world atlas; and
- Much more.
The library has purchased access to this useful resource, which is available from the Internet Resources button on the left side of the library’s home page (under General Reference), or just click here.
Nominate A Fellow Employee Today!
Fill out the recognition form that can be found here. Employees who are recognized by co-workers at Northwestern will be noted in Northwestern Today.
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Make a Suggestion
Employees are invited to submit a written idea/proposal on how to improve Northwestern Health Sciences University. Click here to access the Suggestion Form.
Employees Eligible for Many Discounts in Twin Cities
Going to an amusement park, visiting a salon, or buying a car or cell phone? Employees at Northwestern Health Sciences University are eligible to receive discounts on many products and services in the metro area. Visit the Mersc Web site at http://www.mersc.org/ and click on Employee Discounts for more details. Some businesses require a check stub or an employee ID badge in order to receive the discount. Contact Lisa Franczak at ext. 170 with questions.
Lifeworks Offers Helpful Information for Employees
Is someone you love angry or concerned about your use of drugs or alcohol?
Does your Internet use interfere with work or home responsibilities?
Have you tried to stop gambling, but couldn’t?
If any of your habits are having a negative impact on your well-being, you may be struggling with an addiction. LifeWorks has resources available to help with addiction and recovery issues, including help with drug and alcohol addiction and gambling. You can talk to a professionally trained consultant who can help:
- Determine if you may have a drinking or substance abuse problem;
- Develop a plan for dealing with your addiction; and
- Help you understand what treatment option is right for you.
Your LifeWorks program is free and confidential. Contact LifeWorks for an assessment of your situation and referral to a professional who can help. If you’re concerned that a family member or friend may be struggling with an addiction, a consultant can help you understand the warning signs and determine how to best approach the issue.
You can order a free CD, “When Someone You Love Has a Drinking Problem.” A loved one’s drinking problem touches everyone close – spouses and partners, children, extended family, and friends. You may be caught up in patterns of denial, covering up for a loved one’s drinking, or wondering how to find help. No matter what you’re going through, it’s important to remember that help is available both for you and the person you love who is an alcoholic. On this recording, addiction and recovery expert Robert Ackerman, PhD, offers valuable information and reassuring advice about alcoholism and the road to recovery. He talks about how problem drinking affects family, friends, and loved ones:
- Breaking unhealthy patterns;
- Finding support; and
- Helping a problem drinker.
The recording also features stories and advice from people who know what it’s like to love an alcoholic.
You can also visit www.lifeworks.com to read or download informative articles such as:
- Drug and Alcohol Abuse Warning Signs;
- Eating Disorders;
- Addictive Behavior;
- Gambling; and
- Understanding Withdrawal.
To order your free materials or to speak with a consultant, call LifeWorks at (888) 456-1324, en español at (888) 732-9020, and TTY/TDD at (800) 999-3004. You can also visit the LifeWorks Web site at www.lifeworks.com. Contact human resources for the user ID and password. Once you’ve logged in, click on This Month’s Feature. You can also order additional free materials or e-mail a consultant.
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Online Full Text Journal Now Available
The “Evidence Based Complementary and Alternative Medicine” journal is now available: http://ecam.oxfordjournals.org/
The full text of this journal is also available via PubMed Central: www.pubmedcentral.gov/, or by searching Single Citation Matcher on PubMed: http://PubMed.gov/.
Take Advantage of the Minnesota College Savings Plan
What are you doing to save for your child’s future? The Minnesota College Savings Plan is an alternative way to save for your child’s college education.
According to The College Board, in 2003 tuition and fees increased an average of 14 percent a year at public four-year institutions and 6 percent a year at private institutions. Both rates outpaced inflation. The 2002 National Postsecondary Student Aid Study says that nearly two-thirds of undergraduates leave school with some debt. The median student loan debt load of four-year public university graduates is $15,375 and $17,250 for private school graduates.
Money saved through the Minnesota College Savings Plan is free from federal and state income tax, as are withdrawals. The money is also transferable – in case the child receives a scholarship or decides not to go to college, the money can be transferred to another family member. There are no income restrictions, so anyone at any income level can open an account.
You can also choose to enroll in the Automatic Contribution Plan, which allows for a fixed sum to be transferred from a checking or savings account on a regular basis. Only $25 is needed to open an account; if your employer provides payroll deduction, you can contribute automatically from each paycheck.
For more information, or to enroll, visit www.mnsaves.org or contact Lisa Franczak, BA, Northwestern’s benefits specialist, at lfranczak@nwhealth.edu or at ext. 170.
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Employees Eligible for Credit Union Membership
Employees at Northwestern Health Sciences University qualify for membership at the Richfield Bloomington Credit Union, as the University is part of RBCU’s longstanding Select Employees Group.
Like federal banks, credit unions offer a wide array of products and services, including low interest rates on personal and vehicle loans; first mortgage, home improvement and home equity loans; “better than free” checking accounts (monthly fee-free accounts in which a dividend rate is accrued on daily balances of more than $500); quarterly high interest-bearing savings accounts; IRAs; direct deposit; free bill pay; debit and ATM cards; and online access to accounts. The RBCU also has a partnership with Wells Fargo, which allows them to offer surcharge free ATM transactions at any Wells Fargo ATM.
“RBCU is co-operative and therefore is not for profit. Whatever profit we earn we return to our members,” says Andre Thibault, assistant vice president of marketing. “Our goal is to improve the quality of life of their member/owners through new services and technology, better rates on accounts, and few and lower fees.”
RBCU also offers more personal attention to its members, as its 13,000-person membership is smaller than that of a federal bank. In addition, membership is offered to relatives and people living in the same household with RBCU members.
RBCU has two locations: 345 East 77th St., in Richfield, and 4025 West Old Shakopee Road, in Bloomington. For more information, visit http://www.rbcu.org, call (612) 798-7100, or contact Lisa Franczak, BA, Northwestern’s benefits specialist, at lfranczak@nwhealth.edu or at ext. 170.