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| Estimating Group Health Plans |  Policies and Reimbursement
Some health plans fix artificially low limits on the maximum payment. Firstly, you have to make sure the plan you choose offers at least $1 million of coverage, since costs for treating catastrophic sickness can easily run up to these astronomical amounts.
You also have to be on the watch for low reimbursement levels. Some plans pay a specified maximum per procedure, which can be far less than what doctors in your area in fact charge. If the claim payment falls short of the bill, the patient can pay the difference. To prevent this, you may want to check with a doctor to see if reimbursement levels are in the normal billing range.
If you are estimating PPOs or POSs, shun overpaying for the flexibility they offer through high deductibles and co-insurance. Watch out for plans that require patients to co-insure more than 25 percent of the cost of cure or that continue to charge co-insurance for costs in excess of $10,000.
Coverage and Features
In fact, all group health plans cover emergency care and hospital care. Most of them also cover out-patient care, including routine exams, office visits, and lab work. But different group health plans can have some significant distinctions. Some of them do not include treatments like prenatal and postpartum maternity care, ambulance service, and prescription drugs, or have very different co-payment or co-insurance fees in other areas.
Devote your especial attention to provisions for long-term treatments like mental health or substance abuse: some group health plans offer insufficient coverage in these areas. Also check provisions for long-term diseases and restrictions for pre-existing health conditions like diabetes or asthma.
Physicians
It is very difficult to assess the quality of physicians participating in the network, although it is probably the most important thing.
Find out the selection process during which network physicians are selected. A selection process in ideality should include inspections of the doctor's background, including analysis of any previous malpractice issues.
Grievances
Save your employees many potential problems by researching how the insurers solve grievances from plan members. Quality organizations should have a specified procedure in place for airing disagreements before a grievance board. A clearly outlined appeals process gives members a way to protest unfair reimbursement levels or other problems.
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