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Managing Evidence-Based Self-Insurance Plans
by: AllMed Healthcare Management
Instead of contracting with a traditional
health insurer to provide group health insurance, many organizations are turning
to self-funded insurance plans that are managed by third-party administrators
or an outside health management company. According to the Employee Benefit Research
Institute (EBRI), about 50 million workers are covered with self-insured group
health plans. To help reduce costs and errors associated with these plans, many
of these entities are now evolving into "evidence-based" self-insurance plans.
Because self-insured plans are subject to
the Employee Retirement Income Security Act (ERISA)-the federal law that protects employees' retirement income and benefits-the
same rights that are available to insureds with traditional healthcare plans
are available to individuals on a self-insured corporate plan. This means that
when treatments are denied, for whatever reason, the patient has a right to appeal
the decision and have it reviewed by a like specialist not involved in the original
claims decision. When such a dispute arises, TPAs and self-funded insurance managers
are required, by ERISA and state laws, to have questionable cases reviewed by
non-biased specialists within specific timeframes.
The primary issue here is how do the management companies, without a full
medical panel on staff, decide that treatment decisions are based on proven medical
evidence each and every time? How do these companies ensure that they are staying
up-to-date with the latest medically approved treatment options?
While some cases are obvious, partnering with an Independent Review Organization
(IRO), such as AllMed Healthcare Management, may be just the answer to this issue.
An IRO can provide access to the broadest panel of specialists that can make
sure decisions are based on proven medical evidence. And, an IRO can also help
guarantee state and federal deadlines are met by turning around review decisions
within 48 hours or less. For more information on how an IRO can help your organization,
please contact AllMed at 800-400-9916.
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About The Author
AllMed Healthcare Management Founded in 1995, AllMed (http://www.allmedmd.com, http://www.allmedmd.com/blog/index.htm)
is a URAC-accredited Independent Review Organization (IRO) serving insurance
payers, providers, TPAs and claims managers nationwide. Reviews are conducted
by board-certified physicians in active practice. AllMed's growing customer base
includes premier organizations, such as Educator's Mutual Life, IMS Managed Care,
Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations,
TriWest Healthcare Alliance, Allianz and many other leading healthcare payers.
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This article was posted on January 13, 2006 |
