Payers

Payer or insurance:

Payers are not but insurance.

Insurance

Insurance: It is an entity which covers the loss of a product that is insured, at the time of emergency.

                    One should pay the premium to avail the Insurance policy and enjoy the benefits. So, premium is directly proportional to the benefits which patient receives.

                    Every insurance has a validity period: Effective date & Termination date. This can either fiscal year or year to year plan. 

Types of Payers (Insurance):

Self funded: It is where the premium is paid by the individual from his/her own expenses.

Group Health Plan: It is where the premium is funded by a 3rd party/organization.

                                                                     

Types of Insurances

Traditional Indemnity Plan: Covers only illness.

                                              Does not cover wellness.

                                              No par and non-par Concept applies here.

                                              Known as "Fee for Service Plan".

Managed Care Plan: Both illness & wellness are covered.

                                    It is where the insurance enters into the contract with providers.

                                    Par and non-par Concept applies here.

Major types of Managed Care Plans:

HMO: (Health Maintenance Organization)

            They are group of General physicians.

            Patient is assigned to a dental office at the time of enrolment.

            Rules:

For any health related issue patient must visit the assigned office first.

Patient can not visit a specialist without a referral authorization from the assigned Dental office (except emergency).

The assigned Dental office is considered to be the one point of contact for the patient.

Patient cannot visit a non-participating provider (except in case of emergency).

The assigned Dental office is considered to be the "Gate Keeper" in HMO plans.

PPO: (Preferred Physician Organization)

           They are Group of Specialists.

           No concept to assign to gate keeper office.

           Patient has both in-network and out of network benefits.

POS: (Point of Service)

          It is known as Hybrid plan: Combination of HMO + PPO

          Also known as Open Ended HMO.

          Patient is assigned to office/PCP but there is no restriction for the patient to go to any provider of their choice.

          Referral Authorization is not mandatory.

          

PCP: Primary Care Physician

EPO: (Exclusive Provider Organization)

          It is high paid premium. PPO acts as HMO once choosen the provider for a particular area. It is limited account.