Introduction to Business Analysis with Healthcare Domain | ZaranTech

alright so good evening everyone welcome to the first session on the healthiest
cities of this webinar and what again is in the introduction session or in the
previous session what we covered was we talked about what is going to be
coverage for this particular training course what are we going to cover how
are we structured what are the modules that we cover all right so um let’s move
forward let’s start the concept of the health care okay so what we’re going to
look at is some of the concepts like what is health care insurance even
before that will first try to understand what is an insurance how does it work
and then we’ll move on to what is a tilt care insurance then what are the
different components of the health care insurance and similarly what we would be
looking at is the components or the pillars of the any health care industry
so beat any geographical area beat any geography the pillars of the health care
would remain the same so we would be talking about those pillars as well and
then we would be looking at the health insurance coverages types of health
insurances and some other key terms in the health insurance er I may not be
able to cover all these agenda items that I’ve listed down today we’ll go a
little slow today and then just bill the concepts and then
probably in the next class I would be able to finish it they and I read in the
bottom that I have for the day one okay so let’s begin let me just open minded
sheet all right so let’s begin with the concept of insurance what before and
bust one more thing before I move forward let’s make this session more and
more interactive I know every training you must be joining or you have attended
probably the trainer would have said let’s make this training more
interactive now let’s ask questions so please do so as well here ask questions
ask whatever you do doesn’t silly question so please ask whatever
question you have okay and please participate in a discussion so let’s
begin with the first question what is your understanding of the term insurance
well anyone go ahead you can raise your hand I’ll unmute you so or you can write
in the chat box but let’s start with the first question
since you’ve invested your time money and resources into the session what is
your understanding of the term insurance okay services security okay so by L are new
to you can you talk know it Sarah yes it’s like my understanding says it’s
like security your health security you’re trying you’re planning to get
something to secure your salt security against what yeah something okay help
financially and yeah financially financially okay all right anyone is all
right so you are right so basically an
insurance is the protection against encourage no financial gosh you talk
about any insurance it is mainly about protection against incurring of initial
loss now you can take example of any insurance with health insurance auto
insurance little insurance fire insurance why do we take insurance we
take insurance to protect ourselves from those unforeseen events the events which
we cannot probably see coming in the future or we can not see or we don’t
expect those events to occur so to protect ourselves from those unwanted
events or unforeseen events we buy insurance because when those unforeseen
events occur or they cost us heavy if let’s say we have
been to a hospital definitely there would be a bill that we have to pay to
the insurance company so to the to the hospital that is why we buy insurance to
protect ourselves from our risk of incurring a financial loss any idea how
does this insurance concept came in how does this ensure how was this insert
insurance concept introduced so there’s an interesting anecdote let me see I see
someone else writing in the chat box it’s Branham pronounces health insurance
is the type of insurance coverage that covers the cost of the insured
individuals medical and surgical expenses bang-on right so any expenses
that you incur in detailed here definitely your medical expense your
insurance is going to cover it so I was talking about and any growth factors for
the insurance how does insurance came into existence
they’re usually merchants in the seventies in the 18th century who used
to travel across the sea to sell their spices now because they were not able to
predict that at that point of time they used to in case of bad weather they used
to lose all their spices and then probably they would go bankrupt so in
order to protect themselves in order to protect their eternity what did it was
they came together and started pulling in some money so let’s say there are 10
merchants every merchant would cool inlet at $10 each now they would have
hundred dollars now any all the 10 merchants are selling in 10 different
directions if any of the one loses his losses with spices probably they can
give some portion of the money from that pool that they have collected with the
particular merchants to serve well and that is how this concept of insurance
was introduced and till late the concept remains you see so insurance how do we
get insured ourselves it is all about pooling a certain sum of money have you
ever wondered you pay a premium of how much money you pay somewhere between 250
to 400 $450 that’s the average range are today an
american-based words and be held in Germany somewhere around 250 275 to
somewhere around 450 now you pay a small premium but you get a coverage of let’s
say $100,000 how is it possible you just paying month monthly $300 LexA feel it
so you’re paying annually somewhere around $3500 but you get a coverage of
$100,000 how is it possible as you ever wonder it is possible because insurance
company in your graphic area with all the money from several people so it is
not you who is only paying $3500 there are 100 of the people in the odd area
who would be paying thirty five hundred dollars annually which means now they
have a insurance company has a pool whenever you go to a hospital an
insurance company will dig into that pool and we give you our or will
reimburse super-useful it it can be any insurance company it can be your fire
insurance company for whatever insurances you have taken the concept
remains the same you come together you pay a small portion now everybody is
paying a small portion it forms a larger pool and then people attention able dig
into that pool to get the money what is the basic assumption here that the
insurance company is making the assumption that the insurance company is
making here is not everybody is going to fall sick at the same point of time
right if there are hundred people the assumption is hardly 203 people would
require money at a given point of time not all the 100 people would come
together to the insurance only and demand the money if that becomes the
case probably 10 she runs coming able to go back and that is why AIG was on the
bank of on the verge of bankruptcy after 9/11 because many people were having
their life insurances from the AIG after 9/11 happen if 9/11 happened everybody
reached out to aah and that is why they were on the verge of bankruptcy
right so the basic premise or the concept from which the insurance has
been well is not if everybody has to pull in the
money but not everybody would be reaching out to the insurance company at
the same point of time okay I’ll take a pause here any questions on the
insurance or any thoughts you want to share renessa is how can I come oka panel and
new to you so premise is how can a company manage
such a situation unfortunately Pranay it’s not manageable either you have to
borrow the money or you go bankrupt but you cannot honor all the claims that if
every claim comes to you you know at one point of time if everybody to whom
you’re giving insurance comes to you at one point of time
you cannot honor everyone’s claim and in that case probably you have to borrow
from the government or you have to borrow from the from your peers or you
go bankrupt but I think they can prevent larger claims before they even get close
to them do they take any prevention measures before the claims come to them
like their concepts yes there are concepts which insurance company
practices which is known as the reinsurance which happens lets you
getting insurance on the insurance reinsurance simply means insurance on
the insurance so for about if I’ll I’ll give you an example let’s say our claim
comes with a $50,000 right now the insurance company has insured itself
it’s none other insurance company saying if any claim comes beyond $50,000 that
is my stop-loss limit anything beyond that that other insurance company has to
pay token in its there are multiple regional incision I’m sorry can an
insurance company does a company takes measures like well if you’re keeping
your health into progress and if you go for constant checkups do we have any
premiums in that case which should also have the company to cover the loss of
this not expect a lot of Ptolemy’s so you are asking about is how the
insurance companies can keep people healthy right and not in a volatile
value there I definitely see the insurance companies
as though taking measures to ensure that people remain healthy and that is how
they stay in profits or that is how the on demand because of the lesser you go
to hospital are the more profit cynic and get remote and that is why they
promote wellness programs but I am talking about a situation let’s say any
unforeseen even happen in that case how would insurance company on a rocky I
mean that is probably everything would go for a toss right just like an angle
women nobody even thought of 911 but what did happen everybody who was having
an insurance with AIG they went out there for the asking the claim for the
hit from the AIG he was not able to own or eat anyone’s claim they’d reach out
to the government for help because he the ID being the largest insurance
company in the u.s. they reach over the government and government then supported
it and that is how they survived that particular moment of 98
otherwise had they been both working above a half they’ve been trying to
honor everyone scream they would have known I see one more question from Sabah
so I’ll unmute you can you please explain your question yes my first
question you already have explained it was about the war what if it’s more and
the resumption goes wrong that they not everybody gonna fall say and now the
question was the birth of babies the pregnant women for example this is their
assumption correct in that case because there is always a baby born for example
every day or every month or something so that is an assumption that assumption
still stands correct generally see it is not that the insurance company from day
one would be profitable there there is a certain number of period from in which
an insurance and me a fee so break even so they operate in losses they have to
have these workers to operate in losses and then they come in property right so
it is not that is one of the factors or no it is a
factor that is that they already consider it and given the number of
members that they serve it is huge it is each ok so let’s take an example let’s
say today the population of the Inuits is close to 330 million you agree alone
stirs approximately 70 million people almost 25,000 of the population you eat
these herbs or more than 25% of the population let’s say let’s assume that
they have such a big chunk of the population that they’re serving
that they’re they have deep pockets they would be able to sustain themselves for
a pretty long period of time right so because they have been into existence
for almost 50 years now so that is how they build the money over a period of
time it is not that table to top table from day or they were profitable from
day one all right so that was the concept of insurance and that is how we
can extend the same concept to the health insurance because as I said it is
a protection against the risk and the definition that were negative somebody
who can care or who can cover for your expenses that is incurred willingly
get-ups and misogyny next is let’s talk about the health insurance sorry our
health care components now if you have to explain a health care to anyone or
any layman pose and how would you go about it what are the things you
consider as a part of health care and it can be it is not legitimate it will be
specific to us no you go to any geography and you will always find those
components as a part of a yeah what do you think
are those components okay um Lakshmi
let me mute you Lakshmi go ahead let me can you talk I’m not sure if I’m correct
it considers of doctors okay and read where VP copy ok copy is a concept like
it is not a lot of the industry it may exist somewhere it may not exist
somewhere but doctors will be everywhere all right it can be any healthy system
you take you have to her doctor right similarly you do wrote insurance and
insurance is another example of the health care pillar because without an
insurance probably a health care was not exist so we have one of the pillars as
doctors we have another pillar has insurance what else patients payers and the pharmacist
excellent so Sabah says otherwise another component is the patient on door
pillar is the pharmacy and then there has to be one more government awesome government now if you look at any of
these pillars and pick any geography for consideration let’s say sushumna has
come from UK right she was practicing often missing the UK she would find
these five pillars in Indy duty doctors definitely would be their insurance
definitely would be here in the form of NHS patients definitely we are the
patients we have the pharmacies and then we have the government regulating the
entire land of the area right let’s say path who was studying pharmacy in India
again you can find these five pillars there as well doctors insurance patients
the formation and government so you take any healthcare landscape in each over of
e across the globe these are the basic five
those of the healthcare you you pull out any of the pillar and probably the
health care would not exist so this is what forms the entire landscape of the
healthcare now to give you the key terms here what we call them doctors are known
as providers because they provide the medical attention and it is not only
doctors who are called as providers anybody who can provide you a medical
attention is a doc it is a provider it can be a nurse it can be in a hospital
is known as a provider okay so anybody who can provide you a medical attention
then sometimes even the pharmacists are known as the provider because they
provide medical attention to you when I say medical attention it is not that
let’s say five fall sick and my parents providing my medical attention they
would be known as doctors or they would be known as providers know the
completely definition I would say anybody who is authorized to provide the
medical attention okay those are known as providers then we have insurance
insurance companies are known as fierce payers means we call them experience
because they pay for our expenses then we have patients which is us Center of the hill here without a
patient none of them will exist then we have pharmacies and then we have
government let me call them as policymakers so if I have to now
remember the key components of the healthcare system I can’t remember him
by five piece which would be providers payers patients pharmacies in the policy
makers okay so I will get it on we have providers we’re finishing policymakers
and the pharmacists these are our fibrous so let’s move forward
this is econ this is the definition of the health insurance that you just
discussed I will quickly go through this okay against the risk of incurring new
medical expenses by submitting the overall risk of the healthcare expenses
an insurer can develop a routine financial structure this is something L
highlight such as a monthly premium or a payroll tax to ensure that the monies
available to pay for the healthcare benefits specialist and the insurance
agreement now what is this routine and infrastructure what is a premium premium
is the money that we pay to the insurance company right we pay it
regularly it can be any interval it can be a monthly premium it can be a
quarterly premium it can be your annual premium it can be any frequency can be
any but it has to be as and definitely frequency and how does insurance company
calculate the premiums there are certain parameters that they consider for a
given geographical area let’s see for for let’s say if somebody is residing in
Texas now what’ll parameters an insurance company would consider in four
to decide the premiums in the taxes they will consider first of all the the age
we gender the zip code the smoking status them and they may not tell you
out front that we are considering these statuses or these parameters but they do
consider it right so they because I work in insurance something I know that the
parameters at they consider they even consider the race ethnicity as well to
calculate the premiums all these parameters act as available in their
equations when they do the calculations for the payment so eight smoking status
gender the zip code where you’re residing then probably your race
ethnicity all those parameters they consider okay I see some comment long
real moment income definitely definitely income and the family size based on
which you would get a insurance income is generally as the it is not used as a
parameter to calculate the premium it is used as a parameter by the government to
calculate your subsidies okay so if you’re buying an insurance from the
healthcare or govt which is an exchange you have to and if you have to key in
your income as well as the family members to get the subsidies or the tax
credits from the government per se income is not a direct variable in
calculation of the premiums for your for you irrespective of the income that you
have the premium remains fixed for you okay it mainly depends on the services
that you are taking from the insurance company what is your age status gender
and other details yes they have but that is see what I’m saying is they
consider your credit his feet but it is not acting as a director variable or a
direct it does not have a direct relationship with dipping on calculation okay
the benefit is administered by the central organization that is a
government agency private business or not-for-profit entity so basically this
talks about the bodies who can deliver the insurance services to you so it can
be the government in the form of Medicare or Medicaid it can be a private
business like you eg8 nursing Mayu mana or
it can be any not-for-profit entity okay now these are some of their very basic
concepts of the health insurance overview what is the need for an
insurance definitely we understand to control the cost of the medical expenses
proper and timely medical care in case of an emergency and stay healthy so
basically mostly towards the preventive medications and to cover the cost of the
exchanges I will come to this later on probably will not talk about this HMO
PPO in the POS plans we will talk about this in the next class
what are these plans okay this is important so whenever you’re buying for
any insurance right there are certain points you should consider and from here
we’ll pick up on the key terms that we would be looking at today the first is
your must-haves this means let’s say I’m buying a policy insurance policy or
health insurance policy thus that health insurance policy covers what my needs
are assume only or assume I need I need
services related to garlic or am i called
equation and I need services related to art does my insurance company cover
those services or not so anything or any specific service if
you are looking for you should buy a plan which covers that the second is the
cost of the basics simply means the premiums that you have to pay for these
services what is the premium that you are paying
provider network network means the providers providers means doctors and
with whom your insurance company has signed an agreement to provide the
services at a lower cost so since you all must be buying an insurance you must
have seen a network a list of hospitals that you must be receiving from an
insurance company having the network details as to who your network of us who
are doctors that you can go to where treatment
reason being and if you go to a specific doctor with your insurance company
assigned up with you get a lower price if you choose to go out of network then
your insurance company will charge you a higher price because they have not
signed a contract with the specific provider in network and out of network
okay so there’s a term that Laxmi has used in network and out of network yes
that is correct I will be talking about those two terms after this slide then we
have out-of-pocket maximum which means how much you have to pay from your
pocket prescriptions definitely what prescriptions or medications does your
insurance company cover or your plan covers annual limits on the coverage and
services for example let’s say you can go to
physiotherapist only 10 times in a year so that’s a coverage limit I have right
so in case if you are looking for a specific service does that company or
does that plan cover that service or not if it covers what is that your insurance
companies covering I can take another example let’s say a maternity benefit
will only be covered for the first two children that is one of the scenarios we
have in India it will only cover the medical expenses for the pregnancy for
the first two cases so there is a there’s a limit on mine inch on my
service that I can avail now from my insurance plan right similarly I can
only go to a doctor let’s say thrice a month in case I go to a doctor more than
twice a month I probably mentioned income will charge a higher limit or a
high a high dollar value so those are some of the limits that they can impose
on you and then the dependents how many dependents does my policy cover what is
the extra premium that I am paying for them so those are some of the basics
that we must look at while we are while we are buying an insurance policy now
which brings us to some of the key terms I will come to the slide later on let me
first discuss okay let’s cover this internal computing key
terms so this is these are some of the examples of the insurance companies in
the US and these are their banks I would need your help here because the slide
that you’re currently seeing on the screen is not up to date okay what you
need to do is and this will be probably a first assignment what you need to do
is you need to list down the top ten insurance companies in the US health
insurance companies in order of their revenue right while you
looking for that so that is the first activity that you have and I’ll upload
them on let me quickly take this so I am hoping that you somebody from the
serenity support team would have done a walkthrough of this block with you in
case if they have not please reach out to the support team for this particular
blog link that will be shared with you and we’ll do a walk-through as well with
you so in this blog this is a tab which is assignment I’ll upload the assignment
in this particular blog which would be first of all you need to list down the
top 10 health insurance companies in the u.s. in order of their revenue and the
second question is while you’re working on this activity you would see various
consolidations happening in the market in the u.s. healthy landscape app I’m
specifically more interested in Dee towards the insurance item the
consolidations that are happening towards the health insurance side right
let’s down some of the consolidations that has happened that have happened in
the recent past and your point of view as to why do you think those
consolidations are happening right some consolidations have failed and some
consolidations have been successful you can call them as mergers and
acquisitions or you can call them as consolidations you can call them as
takeovers there are different consolidations that have happened in the
healthcare lamp in the impair in a pair a landscape
what are those consolidations and your point of view on why those
consolidations are happening okay any question on the assignment before we
move forward yeah as it’s only the hrivnas of not see
the only intent of this exercise is to get you start reading on the health care
insurance are doing because when you start browsing for it
you will see different articles you’ll read different articles that is the only
intent behind this exercise okay so I’ll put up on the assignment on the
assignment board and you will even submit it there itself whatever
assignment you have done you can submit it here itself alright so let’s move forward now so I
have already covered this but I will cover this once again different types of
insurance that we can lie one is your individual insurance I’ll explain what
is an individual insurance then another one is an employer insurance so people
who are working in the US would be getting a coverage from their employer
right if you are not working then probably you would have bought an
insurance on your own then there are certain other insurances
which you get from the government like you will get a Medicare Medicaid then we
have chip we have TRICARE there are certain government insurances which we
get from the government which means everybody is covered in some way or the
other if I am not working I’ll buy insurance on my own if I am
working probably my employer will provide me insurance if let’s say I am
my if my employer is not providing me an insurance and I am NOT I don’t have
decent money to buy an insurance probably government will help in here or
if I am retired I’m always I’m not able to work even then the government will
help me or if I’m a government servant or I’m a
military person again the government will help me there so everybody is
covered in some form of theater form through these kind of insurances it can
be an individual insurance which you buy on your own for yourself and for your
family then we have the employer provided generally known as the employ
or the group coverage provided to you or her employer not only your employer
group coverage can be in any form let’s say if you’re a college student even
then your university or your college is going to provide you some certain
student insurance that is also an example of a group insurance and then
there are other plans these are the add-ons on your individual or your
employer like your vision your dental your cosmetic surgeries let’s say you
want to under when you want to cover them by your insurance is given by other
plans has the pharmacy insurance so there are different plans reckon they
are different riders on your plan that you can buy to cover your health
expenses all right now let’s move on to the key terms before this any thoughts
any questions any feedback is the speed okay do you want me to slow down do you
want me to go a little fast what do you think okay okay I see a comment all
right thanks for that Renee all right so let’s
go with some of the key terms here the first key term is the premium let me
know nice bed sheet freedom is the premium okay
I believe everybody of you must be knowing this Tom that is about payment
to the insurance company at a fixed interval to cover for you right and that
is what is known as a premium then comes the another key term in the
and the key terms now that we are discussing they are specific to the US
healthcare it’s Vic to thee please note this that is not not that these are
generic in nature they may be but as of now the definition that I am going to
give you they are specific to the US healthcare so let’s say for example
premium one difference I can tell you I talk way between for the u.s. the
frequency payment is monthly right if you compare it with India the frequency
is this is for the u.s. if you compare it with India it is your rate in India
so that is I am saying all the definitions that I would be giving you
would be specific to the u.s. altogether okay I see this there’s a poll so I need
to pay a support team hello because I’m hoping you’re able to see my
screen because I got a prompt that while the poll is going on my screen sure
would be disabled right I’m currently on a spreadsheet with which is e term
specific to the US healthcare all right so this is a term that I was talking
about cleaning the next term is the cochlea now copay is a fixed payment you
I’ll say member me to be provider a fixed payment for example let’s say in
lucid one this is my first visit in this entire year let’s assume that and my
total bill is $400 okay in my visit to my belly’s gets a 150 dollars so and so
forth let me means the and B the certain widgets that I’ve made in this year and
accordingly my prices or my total will has buried my copay as per my insurance
policy is $20 okay how much would I be paying for every visit
it says copay is a fixed payment the remember has to say – irrespective of
your bill amount you would always be paying $20 that is a copia it’s a fixed
amount okay then we have the quencher now another key term is then
– Thomas coinsurance it’s a percentage of the payment remember has to be let’s
take the same example okay now my coinsurance is 24 how much would I have
to pay every time it’s the ocean tidge of the amount so let’s this into 24
instead this would have vary based on the bill that I’m paying or the bill
that the doctor has to submit to the insurance company so if my village for
350 dollars and the coinsurance is 20 percent I have to pay $70 if the bill is
$300 and the coinsurance is 20 percent I have to pay $60 now if had been at a
copay I would have paid a fixed fee of $20 derivative of the bill cost okay so
that is the difference between copay and coinsurance one is the fixed amount and
the second one is the percentage of the team the third key term is deducted
deductible detectable means the money you have to
pay from your own pocket before the insurance company starts covering your
expansion starts covering your expenses this is pretty important and the key
term here is from before before the insurance company starts covering your
expenses let’s look at the example let us take the same example again this is
my widget and this is the let’s say my plan says I have a copay of $20 okay and
a deductible of $500 which means let’s say member pays insurance company now
this is the grid that I have made my deductible is $500 and this is the first
widget in the air definition says the money I have to pay from my pocket
before the insurance company starts covering my expenses okay so what is man
electable $500 how much is the bill for $100 have a mathematical table No so I
have to pay $200 in total okay I see your common right let me say is hundred
now let’s go back the second one is 150 again every 100 people know so how much
I would have to pay 150 how much sensual swimming would pay zero let’s go to the
third one again how much I have to pay 200
insurance money would be zero now have a madman deductible
I’m still at 450 I have to still spend another $50 before my insurance company
stops covering my expenses so how much a member has to pay member has to pay $50
right and then the remaining okay I’ll write a note here assume deductible is
inclusive of okay so how much I have to pay $50 and then the remaining $200
groupid by the insurance company why because now I have met my deductible of
$500 the threshold was $500 I have already spent the $500 from my pocket
which is when the insurance company would start covering my expenses in the
next visit how much I have to pay I only have to pay the copay and the remaining
would be paid by the insurance company similarly again $20 and the remaining
330 dollars would be paid by the insurance company I will take apology at
any questions on these calculations why don’t you follow what the deductible is okay it’s also unlikely okay a comment
let me unmute your name how can you explain me a question can we change or
alter the detectable so during the plant soon as we take it and then we realize
no this is not the plan then we make it so how would the paying structure does
it affect no so basically once you have taken a plan
the plan comes with certain limitations I said you cannot get an altered a plan
you cannot change the copay or deductible of the plan you can add on
most services in the form of providers but you cannot change the basic
components of the plan like copay deductible or coinsurance okay
okay what you can do is there are different plans that are available let’s
say let’s say why you are even young and healthy and you don’t go to a doctor
very frequent or you go to a doctor really what you can do is there are
different plans in the u.s. known as pdh peace plan I will cover them later on
but just to raise this question or which means higher if people health plan or
HDHP let’s say it’s bitch talk about hbh high deductible plan this means the
deductible that you’ve opted for is very high somewhere in the range of six
thousand seven thousand dollars why because you’re willing to take that risk
that okay I will pay this lip this amount from my pocket or this is what my
threshold should be and why are you willing to take that risk because you
know the you don’t go to doctor very often or
your foot and find you’re healthy and you don’t you will not know doctor in
this specific here right so that is why and this high deductible
health plan would substantially lowdown your premium what’s substantially load
on your premium you for going for high deductible whereas there are other plans
where the deductible would be low but the premium should be higher so higher
the deductible lower the premium lower are lower than durable higher the
premium yes right because that is it threshold that you have to make the
phasing make the payments from your own pocket
yes so higher the payments you make from my pocket definitely insurance when they
will charge you a lower price okay okay and one thing you said the deductibles
would I mean yeah the copay would kick in after the five hundred dollars have
been spent that’s the deductible as per the examples so let’s say this is the
definition see that is why I put this assumption as use the deductible is
inclusive of your pocket what does this mean this means if I have
to further drill down how would I break this hundred dollars in the first visit
I would allocate 20 to the copay 80 and 82 versi deductible but still how much
the member is paying from the pocket hundred dollars so that is why I have
put hundred dollars as the member base and I have said assume deductible is
inclusive of coping there are certain plans
it depends on plan to plan which may say deductible or co-pays exclusive of
deductible which means you pay a copay separate and you pay a deductible
circuit let me take that example it could be a complex one but let us take
this example so I am assume copy is exclusive of deductible okay yeah it does not intrude
elastically so now let me put this one more this is my copay and this is my
deductible how much would I pay the copay $20 copay is a must I have to pay
every time irrespective of this visit irrespective of anything I have to pay a
copay how much I contribute to what’s my deductible $80 okay
how much I contribute towards Mandira table 130 dollars how much again 20 and
this would be a 180 180 if I went my deductible no right again this is 20 and
this would be how much – 30 so okay now if you see I exceed this right how much
I am short with here I am total at 390 are you following me till now
yeah how much I have to pay more delectable I have to pay $110 extra
right now I have hit the threshold of 500 how much a member has paid from the
pocket copay 20 hundred and ten hundred and thirty how much the insurance only
would pay 120 so the total comes to be 250 dollars so this is how the
calculations change depending on what the notice whether it is inclusive other
than it is out of deductible and this makes this calculation little more
complex but I hope we note helps you in understanding what is inclusive what is
exclusion oh yes if I’m keeping the co-pays always out and then fee I cannot
be more than the bill right if the bill is under dollars I cannot
million candle alternator $20 right so this is the maximum that I can play with
is hundred dollars okay the twenty goes to mercy copay and eighty course what’s
a deductible so for instance hotel with three I have contributed Mac I’ve
reached my limit of three ninety my threshold is 500 so another 110 I have
to pay before insurance only covers me so Hanan and then in the next visit I
pay and then I pay 20 towards the copay which means one hundred and thirty
dollars has been paid out of 250 remaining would be paid by the insurance
so that is 120 dollars only privately insurance um okay let me be it’s a
lengthy question let me Anu to you I believe let yourself muted this question
like we were talking about the group insurance right earlier before the
deductible like we choose from our employer and we have certain number of
months that we should be in the same plan so you were just talking what you
know changing the plans in the middle but see that anywhere because with my
current employer there’s like trying couple of month option so I would like
to hear you were talking some people using the first in the middle see I said
you cannot change the property of the plan like cooperator cripple or
coinsurance you cannot change them in the middle all right the second is
you’re talking about changing of the plan in the middle it entirely depends
on you how you can do that probably see from an employer perspective you cannot
change a plan because there’s just one time of the year when they would enroll
you or they would probably reach out to you and then the plan remains which they
deduct from a salary or they later from your pay stubs and then your plan keeps
on continuing let’s say if you are an individual and you want to change the
plan what will you do I can you can write you can change the
plan I’ll probably even stop making the
payment will be existing plan that you haven’t even buy a new plan okay
watching had on writers but you cannot change the property of the in policy
itself like you can you can change the coverage limit or the coinsurance or the
deductible or the Copa you cannot change that property of the plan okay what
happens alright so any questions on this calculation no okay let me make it more
complex let’s add coinsurance to this now what do you think how would this
look like so this is what my insurance company and this is what my coinsurance
okay again my coinsurance is 20 bullshit now what do you think is going to this
gonna look like coinsurance is always calculated last let me just write that
comment always what you don’t know so you have
force calculated to the copy you will first have to panic okay always then you
have to make a deductible so let’s say rest all assumptions apply which means
the copay is exclusive and then you have to create the variable and then you have
to pay the coinsurance okay so these two assumptions are still valid co-pays
actresses and the coinsurance the coinsurance is 24 so now you have to
first pay your deductible let’s say you will be paying this in entitled right so
as of now you will be not be paying any coinsurance it is all CEO now let’s come
to this visit how much is the deductible left one hundred and ten dollars okay so
all I have met my threshold of five hundred dollars as a deductible how much
I have paid as a copay twenty dollars how much I have paid in total one thirty
dollars what is the remaining out of 250 130 having paid how much is the meaning
120 is the thing on let me write the math here so 250 is the full – 20 I paid
as a copay and 110 I Paris injectable this would be equal to 120 which is
remaining now out of this remaining balance my coinsurance is calculated so
20% of this 120 is $24 so I have to pay an additional of $24 at a coinsurance
and then the remaining would be paid by the insurance company fifteen – now one this is what the
insurance company with them I’ve made it more complex but just to help you
understand that coinsurance is always calculated last you first contribute
towards your copay then you contribute towards your deductible and then you
continue towards your coinsurance so if wait twenty dollars first then to
meet your deductible you have to pay a hundred and ten dollars extra you did
that how much is the remaining 123 getting out of that 120 now you have to
pay the coinsurance which is twenty four dollars and then the rest would pay for
the entry let’s say in the next visit what would happen since I have met my
deductible what would be the scenario twenty cause what’s the copay deductible
is zero because nothing is being contributed to my deductible and then
copay what would be the coinsurance twenty I have paid 280 is the remaining
which is twenty percent of the two it is $56 and then the remaining this comes to
be seventy six to twenty four dollars have to provide insurance so you first
pay the copay deductible the table is zero so you don’t have to pay anything
then the remaining is 280 out of 280 you have to pay another twenty percent that
is separated solos you pay and then the rest or the paper be insurance car okay any questions on the calculations I
know this little complex calculation so any question any questions thoughts on
this or are we good here the whole process of this calculation what do we
term it as hydrogen occasion excellent question we call this as aggregation this is the term that we used will spend
good of a good amount of time discussing this adjudication one of the parameters
in the adjudication so there are three steps with three electrification
interrogation and the ocean delegation does the check that we need to do the
whole performance calculation then we perform this calculation what all things
we need to look at and then what happens once the calculations have been done so
three steps or three phases for your dedication the checks that we have to
increment irrigation these calculations are to look in debt and the core
certification owes the calculations are done what we need to do okay all right
so many people have been silent now so some any questions from us are any
questions from you or you are all good okay
I don’t would you be able to share this sheet with us or soon appstore oh you
want to save your feet oh yes let me save this in because I haven’t saved the
sheet so let me save it alright I’ll share this sheet okay all right so let’s
move on to other terms so we have talked about premiums Oh pay coinsurance and we
have talked about adaptable the another term that we would be looking at is
out-of-pocket maximum now what do we mean by out-of-pocket
maximum let’s look let’s compare the definition deductible little bit this is
this is in deductible and now out of out of pocket maximum names the money you
have to pay from your pocket sorry before the insurance company starts
traveling hundred percent of the instance that is the difference between
deductible and out-of-pocket maximum little Delta difference what the
difference is money you have to pay from a pocket before the insurance company
starts covering 100 percent of your expenses what would the heart be still
you have to pay the copay but other than that you don’t have to pay anything let
me take an example I know this is a little confusing so let me take an
example and as of now for this calculation I will not keep okay okay
sorry coinsurance so all I’m saying is this is what I have and let’s say there
have to be multiple digits which would be I would expand this would tell and
this is Amy and this copay is again this magic table and then assume we are not
assuming the coinsurance but the out-of-pocket expenses generally would
come when we have a coinsurance so copay you still have to pay okay
so let’s say your deductible is $500 I’ll write it down
copay is 20 dollars deductible is $500 and let’s say out-of-pocket max is $600
let’s make it 5 $60 so this is 80 this is 130 this is 180 how much it is 90
this is 110 right now I have met the deductible of $500 now my insurance
company starts covering my expenses so let us say this would be my 20 and 280 this would be another 20 and 330 this
would be another 20 m33 right now consider as of now just to explain you
the concept of out-of-pocket maximum or this definition the money you have to
pay from your pocket before the insurance company starts covering 100%
of your expense how much you have paid from the pocket till now including the
co-pays let’s count this what is this 640 the deductible was 500 okay let’s
make it six forty now assume this scenario you have paid a total of 640
dollars till now from a pocket and your out-of-pocket maximum is 640 dollars
what would happen in the next visit this entire 450 dollars goes towards the
out-of-pocket maximum I have made several assumptions in here but assume
that the copay is inclusive of out-of-pocket maximum with inclusive in
everywhere and that is why I am saying the hundred percent of the expenses that
you are going good goes towards your out-of-pocket okay generally it is not
so much it is not that assumption generally the co-pays exclusive but for
this for this mission of this definition I have assumed even the cooperating post
now you have failed or you have freeze the threshold of your out-of-pocket
maximum fix what did others the remaining everything now would be done
by the insurance will be P net written by the insurance that is the concept of
out-of-pocket much in the order of pocket like you said after the 640 like
everything goes out of pocket so but still we have to pay the corporate you
still have to pay see if I write $20 here you will not be able to understand
the difference between the visit 5 6 7 and we after 8 9 10 11
8 onwards by assuming that you’re not doing anything towards the copay
everything goes to the insurance company okay
once we spend few classes I will give you the actual calculations of how this
happens but this being the first class I don’t want to confuse you and that is
why I am making various assumptions of how these payments are okay go ahead I’d
also like could you please explain the the out-of-pocket part once again after
as soon as we pitch in 640 chip in six forty dollars then like you said that
the insurance would be taken care of excluding the copay which is like all
wasted all right so see if I do this calculation what I have let’s take this
calculation okay let me include so let me give you the actual calculations of
how this happened do you have to take a coinsurance
for your on this one okay how much I have paid from my pocket till date is
six it okay little visits five I have paid six eighty dollars and these limits
apply this is my scenario okay out-of-pocket maximum mystics eighty
dollars now tell me how much would you pay from your pocket in visit sixty you
have already paid six eighty dollars from your pocket right so far so good
okay how much would you pay in budget six the actually you would be paying $20
only is a copay you would be paying zero as a deductible
zero coinsurance because you don’t pay anything everything is you have
everything has to be by the insurance company and the insurance company pays
the three particles that is how the calculation okay and the only thing
which came in between was the coinsurance so that includes of analyzer
but rest of the plan remain I same they means you say correct alright let’s move
to few other terms so we have talked about premiums we have talked about
deductibles we have talked about co-payments coinsurance is we have
talked about all right exclusions we have taught about
out-of-pocket maximum so now just look at the exclusions there
are certain things that your insurance company does not include on your plan
let’s say you have gotten made can plan okay things like vision dental
your company will not including you have to buy these riders from your insurance
company to be included on your medical plan or you have to buy them separate
you have to buy a separate plan so these things which are not included in your
body you see they are known as exclusion like cosmetic surgeries like fat removal
process I see a note okay so these are not included there are various other
things that are not included let’s say donaga egg retrieval now let’s say you
make a phone call from your hospital or let’s say cotton garden I’m spending off
the couch but it’s a cotton gauze let’s say needles syringe these are some of
the things that are there say the medical supplies certain medical
supplies like we have cotton we have band-aids we have needles syringes various other
things that are not covered so these things we call it my bad these things
are known as not covered and these things are known as exclusions which
means your insurance company will not pay for them exclusions and not code not
covered again means the same thing you have to pay
for these 100% at cost and then these are the exclusions these can be covered
in the plan if you pay extra out you can buy a separate plan from your insurance
okay so we have not covering we have extinctions none of these none of the
policies that will buy will cover these things all these things and would be
generally covered by a would not become a copy okay this is what we have
exclusions and so the surgical needs everything goes out of the pocket little
what I’m in the court in those ones not covered which means they are going out
at Sepang right right right they are going out of the pocket which means you
have to buy or you have to pay for them okay let’s say mmm the big band that
Avenue when a person get admitted to a hospital they put a band around your
wrist that band even cost you let’s say the band cost you $5 angels come they
will not pay for the band wristband you have to pay from your pocket so these
are certain not cover items for which the companies do not be okay coverage
limits we talked about the coverage limits like the number of visits we can
make to a doctor the number of visits we can make to a physiotherapist the number
of let’s say visits we can make to a lab so those are the coverage limits what we
have all right these are the two terms that I will probably not be talking
today this is the payment model to the provider I would be talking about these
terms when we will discuss the provider okay when we learn about
does a provider get the money from the insurance company these are the two
models to which they provide and there are videos of the models these are one
of those two models through which the provider gets the money from the
insurance company okay just like understand if you want to have
an analogy let’s say you’re working with one of the organizations there are there
can be various arrangements through which you can get the money from the
company in view of your services it can be in the form of a salary you can be it
can be on an hourly basis it can be a fixed contract right so those are three
or four terms which you can enter into a contract with a company
similarly there are different models through which provider gets reimbursed
from insurance so these two are one of those models so we would be talking
about these models when we would talk about or the provider compensation body so these are some of the examples of the
exclusions like cosmetic surgery do not be able to read custodial clear
infertility services weight control solutions never waste exclusion so read
whenever your point of policy leave the fine print which generally covers
exclusions what are the exclusions on your part one more thing one last is the
so okay let me first cover the in-network and out-of-network and then I
will come to the pre-existing now in network in network means whenever you
buy a policy along with the policy comes the network lists hospitals clinics
physicians office you go to seek medical attention or a
medical care right that is a network list generally known as in-network means
these are the hospitals or these are the people who have signed a contract with
the insurance company to provide you these services okay these are the people
who have signed a contract with your insurance company to provide you the
services then comes the out-of-network which means were not on your network
which means with not signed a contract with your insurance company you can
still go to them but at a higher price so let us say let us take an example for
a check-up or a routine checkup I go to an in-network Hospital who
charges me 100 dollars or who says a total bill is $100 okay
insurance commonly since my insurance and let’s say I have an insurance from
AVG since my insurance company has an contract what has a contract with this
particular hospital I finally contract it has been mentioned that for a routine
checkup the price that or the price that this hospital is going to see here is
$70 how much I am going to power how much the total the hospital is going to
receive it is only $70 only $70 what happens to the remaining $30 they have
to write it off in fact I would say the hospital has to write this happens
in an in-network scenario okay and so let’s say your copay was 20 so you pay a
20 and the remaining 50 would be pay 20 in shut-ins come let’s look at
out-of-network hospital because they do not have a contract with the insurance
company first of all insurance company would say
okay you have to pay a higher cost because you choose to go out of network
I have designated you on it but you did not respect my decision so you are going
out of network so you have to pay a higher cost which means insurance
company is first of all going to charge you a higher peg let’s say for them the
co-pays for out-of-network the copay is $30 now because they do not have a
contract how much the hospital is seeing the hospital is seeking hundred dollars
you have already paid $30 the insurance company is not going to pay the
remaining 70 insurance company would pay let’s say another $50 and the remaining
$20 hospital will reach out to the members for the payment right so you end up paying a higher
money in case you go out of neck now you can ask me a question as to why the
insurance company is not paying these $70 why to spin $50 there’s a term which
is known as you see here stands for usual and customary reimbursement go
ahead see like you said a network and nod nod for doctors technically network
doctors are tight this care providers are tied with insurance conference
migrate ride up with the insurance companies right yeah my profession is
what they go what if particular person does how the patient is going through an
emergency like an accident or some terrible things like emergencies always
an exception always okay any pro any course any plan any plan any policy you
buy in the healthcare emergency is always an exception okay okay we are
talking about in honorable inches or so okay so I was talking about it on use
here it stands for usually and customary rate what happens is the insurance
company calculates the average all insurance company calculates the average
rate of the service okay that okay this is the average rate of the service or
have this in my in network how much would I have paid so usually what other
companies are paying and what what the other hospitals are charging for this
particular service the calculate an average of payment what Couture is then
they will see okay how much your coinsurance co-pays they deduct that
from the usual and customary rate and the rest they pay
so that is why alex is a calculated that okay you need they do see a rate for
this is $50 or $80 the use here is $80 you have already paid 30 so the
remaining would be paid by them 50 and then for the remaining $20 Hospital will
not write it up also tells it may reach out to the member for the remaining $20
in an in-network Hospital cannot reach out of the member because there’s an
agreement with the insurance company that they will only get $70 for this
particular service a little complex but is it clear what do you want to repeat
it I want Jennifer to be repeated okay all
right let us say there are 10 hospitals in an area okay now let’s say for a
routine checkup one huncle is charting hundred dollars another surgeon hundred
ten dollars somebody’s charting $80 somebody
starting $90 what a given area or a for a given zip code what an insurance
company will do is insurance company will take the average of all those
prices and then calculate the UCR let’s say use here for the two team checkup
comes to be $80 okay this is what the insurance company has calculated and we
use as the UCR rate for a routine checkup now concept of UCR comes into
picture when you go out of network if you choose to go out of network first of
all your copay is higher which means you have to pay a $30 of the copay now you
went out for a routine checkup so the insurance only would say okay the usual
rate for the routine checkup is $80 you have already paid with $30 so I would
pay the remaining $50 okay now for the remaining because the also
provided you the service for the $100 they are seeking another $20 home or
Hospital each other hospitals will not reach out to the insurance company
because insurance only will simply say no I have done I have covered everything
that is the member has to pay no because he chose to go out of network and that
is why Hospital will reach out to you for the remaining 20 doctors so how much
at the end member ends up paying member ends up paying $50 for this QCs over
1200 going out of network okay that is if you have chose to go in
network you would have only paid $20 it is always suggested to go in network
never go out of network it would be very costly for you out of network is always
very costly all right I’ll take a pause here any questions thoughts comments
I’ve been talking from long so any thoughts here so in network and out of
network I understand completely but as far as what I’m understanding against
even an in-network I’m choosing an in-network doctor it’s not always
mandatory that all the I mean services that I would expect a fee would be
coming on to this network hospitals always and except emergency but could
you please repeat information oh yes like you said before this there are a
few services which can’t which are excluded and which are not covered okay
for get up worth it not covered and those about not excluded once okay what
excluded ones and now here you say in network and out network there are two
different things in a network let’s say I got some problem but again I see that
that is not covered in the prescribed plan that I have taken
does the any such situations arrive xmn keeping the keeping the list of those
services which are not excluded and they’re not included in the plan like
you discover so probably if I understand your
question correctly let’s say you are looking for a allergy treatment okay
let’s take an example you are looking for somebody treatment now your plan
does not cover any Hospital who provide you that treatment all your plan does
not have any hospital that will provide or that can provided that particular
treatment right in that case you choose to go out of network who would be
responsible is that your question yes who would be responsible for it and
utilizing console by it’s not covered because huge was that plan because you
it was you in the first place who chose a specific plan oh right remember the
first light that we talked about yeah how to choose a plan your must-haves
that is what you’re missing here because you were the one who chose that plan you
see okay you did not see that coming and that is why you did not choose a plan
which would you do not have a particular service no but it’s it’s a general
question that I put because I can’t guess what happens with my body right so
investigators quickly like terrific I can see generally these services are
covered most of the services in most of the policies are covered there may be a
certain services or they may be certain things which may not recover and for
that case you have to go out of network but it is generally the member who has
to member would be held responsible it is not the fault of the insurance
company who’s designing a network they design the network in such a way to
provide you the maximum coverage even then it is not that you would be getting
100% of the coverage yeah can I get an example because I’ve worked on this
issue before from a medical perspective we’ll give me a day I will probably look
at what particular service cannot be caught in a plan or what is not caught
in a plan okay but let me give me a day likely thing from a clinical perspective
I will probably contact some of my friends who
understand the clinical background and then I can come back to you on that know
why I was what I’m trying to say is like I had control situation I said I wanted
to discuss it in the class it should be helpful and it’s a napkin please quick
you have bill feet people I was working on a capitation process so I was not so
keen about I was not aware of the claims and adjudication process clearly that’s
when it took me a lot of time to understand these syllables so that’s
when what happens is this is with the shark insurance so there was one of the
services I mean one of the diseases which has been recorded like pretty
common in that particular year so they see a lot of patients coming in for that
particular I wanted to I mean to get treated for that particular disease
since it was not covered in the plan we see a lot of people switching plans and
they had alternatives or maybe depending on somebody else’s plan and to get it
treated because it was costing them a lot
so what shark has done at that point of time is they have included a special say
as a special processing that okay you get you if you could pay like ten or
twenty dollars or something like that just to make sure like you can get rid
of this particular thing which has been frequently found this year and so yeah
that what they did it and we added and or the we use capitation to do that so
that’s when that reminded me and I was taking the point because it was like
highly recorded disease that particularly and that particular state
and that’s that’s specific right to that particular state itself what I’m talking
about so since they have a lot of issues recorded they came up with an
alternative policy and added like fifteen dollars or some something in
there Paul existing policy according to the policy and then that could help them
to get out of that disease I mean mmm and what also exactly what child it was
they put it as a rider all right so any specific piece that you’re talking about
the book it is a rider on their plan and they said okay we’ll cover you for the
particular problem for another 15 dollars oh yes it’s a CD I don’t
remember the name at all right correct right it’s not a problem but they
covered it as a the the concept here is that some surfaces which are not covered
you and we covered for those services as a
rider plan like vision dental and all those accel exclusion that we talked
about in the exclusion you can get yourself covered by paying some extra
money writer plans right all right so we’ll stop here for today I think we
have been going for long it’s almost one hour 45 minutes I just wanted to discuss
one thing with you guys is it a possibility that we can pre bone the
timings for this particular glass if it all suits you let me unmute everyone let
me just figure both each and everyone associate or timings laxmi cells mutates
a vice mutate so should I let me okay you are also self muted and Sapna
you’re also okay you’re on on you so guys were on self you can unmute
yourself in can we discuss the timings is it a possibility that we can pull up
on this session people how much what do you suggest I suggest brief on it we
currently are having it at 7:30 right can leap upon this session – let’s say
7:30 what do you suggest 6:30 by one our 6:30 CFC sure
election oh this is lachemann definitely you hang with 6:30 right yeah I’m fine
with 6:30 because it’s getting too late for us actually right right right right
I completely understand somebody who is based out in the EFT are going to be
very late for the est guys yeah I’m in California so I think I’m good even see
also I’m fine flexible okay okay somehow what do you suggest is 6:30 fine
with you okay okay all right brunette is 6:30 good with you 6:30 CST I’m good but
one more question of you have any knowledge like how long is the sessions
going to be on an average terms because similar
hormones like similarly it would be our and-a-half 9290 200 minutes we keep I
generally keep the session duration as 90 to 100 minutes
oh no I’m talking about how many days it’s gonna take probably six weeks five
to six weeks thank you not 506 of the five would be if we go if
we extend the length of the session by another 20 25 minutes then it will take
five weeks otherwise it would be minimum of six minutes okay so now how you find
at 6:30 PST um yeah yeah okay what about you I’m
sorry that is a look right so next class onwards we’ll all meet at 6:30 we’ll do
a round one second to see if we can still keep on it or is it is the time
okay with everyone okay and then if we can still be point with another you keep
on it by another half an hour but let’s meet at 6:30 in the next class okay 6:30
CST so what I will do is I will upload that excel sheet I will upload the
assignment and I’ll upload this particular take for your review or for
your reading okay okay and one more thing any questions you may have while
you’re going through the recordings there’s a discussion board put your
questions on the discussion board let me show you the discussion board once again
so this is the block you see this meal next to need assignment is a discussion
board in case you have any questions you can put on that discussion board and
then probably everybody would be able to see that question and we and you can
even post responses to the questions that the group may have all right
anything else before we close the call of those I’m good – I’m good thank you
all right so then we’ll stop here and then we’ll meet on Grace when I state
right so we’ll meet on Friday then all right people
good bye everyone then take care thank you good night good night

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