Third Party Payer Essay

It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical

Tricare Standard - An option that provides flexible coverage for eligible beneficiaries. It allows beneficiaries to choose an authorized Tricare provider they desire. However; this option isn't available for active military members. Eligible participants include: family members of active military, retired military and their family, survivors, authorized past spouses, and Medal of Honor donee and their family. There are no monthly premiums, or fees to enroll but this plan does have an annual deductible and a cost-sharing or copay. If you're a Rank E4 and below the cost is $50 per person, $100 per family. Rank E5 and above the cost is $150 per person, $300 per family.

Tricare Prime is a managed care plan similar to an HMO. This plan has Tricare Prime Remote, Tricare Prime Overseas and Tricare Global Remote Overseas. Tricare Extra is an alternative managed care plan for individuals who want to receive services primarily from civilian facilities and physicians rather than from military treatment facilities. Tricare for Life is a plan for beneficiaries who are both Medicare and Tricare eligible. Tricare Reserve Select is a premium based health plan available for purchase by certain members of the National Guard and Reserve activated on or after September 11,2001. Tricare Young Adult is a plan that can be purchased by qualified adult children after their regular Tricare coverage ends at age of twenty-one. Tricare is a secondary payer in almost all circumstances except Medicaid. The Civilian Health and Medical Program of the Department of Veteran Affairs (CHAMPVA) is the government’s health insurance program for the families of veterans with hundred percent service related disabilities. CHAMPVA provides coverage for most medically necessary services such as surgical procedures, anesthesia, chemotherapy, physical therapy, speech therapy, mental healthcare, prescription medications, maternity care, family planning, immunizations, durable medical equipment, hospice services and much more. CHAMPVA is usually the secondary payer except Medicaid and supplemental policy.

TRICARE is formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and is a health care program of the US Department of Defense Military Health System. Following WWII and the Korean War, access to care in military facilities became less available by civilians and active-duty personnel due to a lack of resources, or a constraint of them, and growing demands on the system, and “space-available basis” was first addressed. As a solution, Congress passed the Dependents Medical Care Act in 1956 and the Military Medical Benefits Amendments in 1966. Such acts allowed the Secretary of Defense to work with civilian health care providers and contract their services. This health civilian health care program became known as the CHAMPUS in 1966. The responsibility of maintaining the health care initiative within the Military lies upon the U.S. Department of Defense Military Health System, which organized the Tricare Management Activity (TMA). The TMA consists of a contract-structure between several large health insurance corporations to provide claims processing, customer service and other administrative functions to the TRICARE

The United States has multiple opportunities for insurance coverage for people. There are many private insurance companies to insure Americans. There are also government assistant agencies such as: Medicare, Medicaid and Children Health Insurance Program (CHIP) (Commonwealth Fund, 2013). Persons must apply and qualify for any government assisted programs for healthcare.

The federal government is involved in all parts of health care at the national, state, and local levels. They have public

Thankfully, health insurance programs such as Tri-Care exist to help these veterans get the drug rehabilitation help that they need. Tri-Care covers any active retired members of all four branches of the armed forces, members of the U.S. Public Health Service, National Oceanic

Military personnel and their family members must participate in the DEERS which is the Defense Enrollment Eligibility Reporting System. It is a database of service members whether they are active duty or retired, their family members and other people who are eligible for military benefits and TRICARE. In order for military personnel to receive benefits they must have current registration in DEERS ("Tricare plans and," 2013). They can enroll online and keep everything up to date via the internet. Claims and reimbursement may also be made through multiple website affiliated with TRICARE.

What is TRICARE? A question that many of us really do not know how to answer. TRICARE is a major part of the Military Health System, its purpose is to combine the resources of military hospitals and clinics with civilian health care networks, provides access to high-quality health care, supports military operations and readiness. In order to participate in TRICARE benefits, beneficiaries must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS) before you can reap these benefits.

Tricare, which was formerly known as the Civilian Health and Medical Program of the Uniformed Services, is a health care program of the United States Department of Defense Military Health System. Tricare provides civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. There are three types of medical plans with Tricare: Standard, Extra, and Prime.

For Americans, health care coverage depends primarily on whether health insurance is provided by their employer or through two major public programs, Medicaid for the poor and Medicare for the elderly.

Understanding the classification of healthcare services in terms of acute and long term care enable us to plan for services, to describe institutions, and to allocate funding and reimbursement. In the United States, healthcare services provided by health care providers (such as doctors and hospitals) are paid for by the following including, private insurance, Government insurance programs, people themselves (personal, out-of-pocket funds). Additionally, the government directly provides some health care in government hospitals and clinics staffed by government employees. Examples are the Veteran’s Health Administration and the Indian Health Service.

A third party payer is an organization(s) that reimburses money to physician according to the level of care and treatment that was rendered to the insured member. This payment system represent cost sharing they individuals, about 84.6% of Americans, who elected to pay a set rate in exchange for the access to medical care and service (Buchbinder & Shanks, 2012). Well, the healthcare (HA) system is not longer that simple. The HC system is mandate that legislative and mandates t and most will agree there are that I have HC

In the United States, premiums may be split between enrollees and employers, but the employer rarely pays 100% of the premiums. Patients usually must pay a co-pay at the time of the service which goes directly to the provider, and the insurance will later pay the remainder. In government insurance plans, such as Medicare and Medicaid, tax revenues are used to pay providers.

Integrity and fairness are very important in all proposal evaluations, especially in the medical community. Tricare health care program was created for all service members of the military, especially retired and their families. The purpose of Tricare is to provide quality and cost-effective care for their members and for the government. Tricare unitizes military insulations that have a medical treatment center on site to be able to provide cost effective quality care to their members and have a network of contracted medical civilian providers off base. Members are encouraged to seek medical care on military insulations. But when no providers are available members are able to find a local medical provider that is in the Tricare network. If you do not conduct your business in an integrity and fairness manner then you as a medical insurance provider will not be able to help your members get care. Since your company cannot provide any willing medical providers to take your insurance.