It's common knowledge that litigation has exploded over the past few years. This is particularly true with respect to malpractice suits against licensed professionals. This category of risk generally applies to: ·
Doctors Nurses Other medical practitioners Hospitals
What Is Medical Malpractice?
Medical malpractice occurs where a medical practitioner acts in a negligent manner when treating a medical condition. Malpractice can occur from an action taken by the medical practitioner, or by the failure to take a medically appropriate action. Examples of medical malpractice include:
Failure to diagnose, or misdiagnosis of a disease or medical condition; Failure to provide appropriate treatment for a medical condition; Unreasonable delay in treating a diagnosed medical condition; Failure due to faulty equipments, negligence in maintenance of the hospital facility or non-conformance to standards also result in medical malpractice.
To prove a medical malpractice claim, the patient must prove the health care provider did not comply with an acceptable and reasonable standard of medical care in their specialty, and that this failure was the cause of the patient's harm.
When a medical malpractice claim is placed, there need to be four basic elements for a successful claim and compensation. The patient needs to show that a duty was owed when the hospital took on the patient. Next, they must show that the duty was performed incorrectly and there were obvious errors. They should show that this breach in duty caused an injury and damages (which can be emotional) for which the hospital, physician or practice must pay financial compensation. The majority of medical malpractice claims are due to medical error and 73% of these settle for compensation
How to Choose Medical Malpractice Insurance
Medical malpractice insurance falls into three categories: claims-made, occurrence and claims-paid coverage. The most common type of policy is claims-made coverage.
Claims-Made Coverage
Claims-made policies cover policyholders for alleged acts of malpractice that take place and are reported to the carrier during the policy period. Claims-made policy premiums are relatively low for the first few years due to the fact that there is often a significant lag between when a treatment is administered and the filing of a claim resulting from that treatment. Because of this, claims-made premiums are structured to increase each year
that the coverage is in continuous force until the risk presented approximates a "mature" risk. This is usually in years 5, 6, or 7 for individual physicians.
As a result, one advantage of claims-made coverage is that premiums are based on actual past and current experience. Policyholders therefore do not pay premiums for future liability that is difficult to project.
Another advantage of claims-made coverage is that it enables physicians to increase liability limits when necessary. For example, the limits of liability in effect at a policy's inception may not be enough to cover a settlement incurred today. In this case, the physician may wish to increase his or her limits of liability. Claims-made policies only cover claims reported, and arising from, incidents that occurred while that policy is in effect, policyholders must be wary when switching carriers or otherwise terminating coverage.
For Example, assume you purchase a claims-made policy with an effective date of 7/1/2003. Assume you hold this policy with no interruption in coverage for 10 years. In 2013, you submit a claim for an event that occurred in 2004. The policy in force in 2013 will respond, meaning that you will be covered up to the full limits of the 2013 policy.
Occurrence Coverage
An occurrence policy insures for any incident that occurs while the policy is in effect, regardless of when a claim is filed. Under an occurrence policy, insureds pay premiums that take into account not current experience, but future projections as well. Such claims are called "incurred but not reported" (IBNR). Occurrence insurance rates can vary significantly because of the difficulty in projecting future claims expenses. Under an occurrence policy, the limits of liability are those in effect when the incident occurred.
The advantage of an occurrence policy is that neither retroactive (prior acts) nor tail coverage is needed when terminating coverage.
Tail Coverage
Tail coverage is offered when the physician is terminated from the current policy due to retirement, change in employment, disability, etc. Every physician has a retroactive date within the policy. The retroactive date indicates the physician's entry date in the policy. Claims will be entertained for any losses that occur during the retroactive date and end date of the policy that is active as of the reporting date of claim. Tail coverage ensures that the reporting period of the policy continues even after the expiry of the policy or termination of the physician from the policy. Tail coverage is also known as Reporting Endorsement Coverage.
Every Physician has separate limits within the policy. If the physician is covered for their individual limit and opts to get covered for Tail coverage, then either the physician continues with the same limits or opts for lower limits. If the physician opts for lower limits there would be a discount that the physician can benefit on the tail premium. Any claim registered hence forth on the policy will only be valid for the reduced limits. Physician can opt for tail coverage within 30 days from the expiry of the policy or the termination date of the physician.
Premiums for tail coverage are determined by a doctor's specialty, territory, limits of liability and length of continuous claims-made coverage. Tail coverage gets more expensive the further back in time it must provide coverage since the liability assumed by the carrier becomes greater. It is usually a percentage of the insured's prior years premium.
Prior Acts ("Nose") Coverage
Prior acts coverage provides similar protection as reporting endorsement coverage. However, unlike a "tail," nose coverage is purchased through the new insurer.
Claims-Paid Coverage
Claims-paid coverage is often used by Trusts. Under a claims-paid policy, premiums are based only on claims settled during the previous year and projected for the current year. Claims-paid policies are generally assessable for a number of years after the policy has been terminated. In addition, claims-paid policies usually have restrictive claims "triggers," under which a claim is not considered formally made until a "Summons and Complaint" is received. As a result, policyholders changing from claims-paid coverage to claims-made coverage might find it difficult to obtain retroactive (prior acts) coverage from the new carrier. Physicians leaving a claims-paid carrier will most likely have to purchase expensive tail coverage from that claims-paid carrier.
Common Exclusions
• Contractual Liability
• Clinical Trials however Research Projects may be covered, the insurer will require information on these.
• Genetic damage or manipulation
• IVF treatment
• Dishonest, Fraudulent, Malicious or Illegal acts or omissions.
Risk Management & Assessment
Implementing a risk management program can help improve patient care, prevent malpractice claims and reduce costs. Physician-led research shows "risk appears related to patients' dissatisfaction with their physicians' ability to establish rapport, provide access, administer care and treatment consistent with expectations, and communicate effectively."
Insurance Company offers risk management courses to its insured. Similarly they also conducts risk management seminars periodically. By attending these seminars the physicians are eligible for risk management credits in the renewal. A Risk Assessment can be requested by the Underwriting or Risk Management Departments, Claims Committee or an insured.

While you are traveling many of the health insurance companies will offer you a limited coverage mainly if you have abroad trip. You may require a holiday medical insurance if your health insurance is covering from specific providers only care of your immediate area. Such policies may cover hospital stays, medical care, and also to a perfect medical facility or a transportation home.
How Do I know If I Need Holiday Medical Insurance?
Several reasons are there to have a holiday medical insurance very important for you. While traveling abroad you will definitely require to have an insurance for yourself against the potential health problems specially if you belong from a country, which gives managed health care and that too within the country only. In the same way if you are having the private health insurance, which only has coverage to specific regional facilities then the holiday medical insurance can be a must for you to save yourself from the grave medical problems.
An extra insurance may help you to have better care with a guarantee to be able to have immediate care if you already have a medical condition like diabetes or asthma that may likely act up while you are traveling.
The holiday medical insurance can be a very good investment if you are planning to travel such an area in the world that normally has overall poor medical care. For the regional medical care even if you manage to get the coverage but still your health insurance company might not cover the transportation or the evacuation to the medical facility will no way near you.
Where Can I Purchase Holiday Medical Insurance?
You can buy holiday medical insurance from various independent insurance agents as well as companies. Buying the insurance from a tour company or a travel agent is not a good idea always because some where else you may often get better coverage and rates. To find a good rate shop around and surely read every detail given on your policy so that everything that you will need is covered by your policy. The small print often will include the crucial exceptions as well as exclusions.
What Should I Look For In a Holiday Medical Insurance Policy?
The policy that you are purchasing must cover all your existing health conditions, transportation to and from the medical facilities and also the major medical expenditures. Make sure that your policy covers the transportation while you are traveling abroad mainly to an impoverished area.

Health care spending continues to rise at the fastest rate in our history. In 2005, total national health costs rose 6.9 percent -- twice the rate of inflation - reaching $2 trillion, or $6,700 per person [Catlin, Cowan, Heffler, et al, 2006]. Currently, total health care spending represents 16 percent of the gross domestic product (GDP). In the next decade, U.S. health care spending is expected to increase at similar levels, reaching $4 trillion in 2015 [Borger et al, 2006].
While some experts maintain that our health care system is costly because it is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, waste, inappropriate care, and fraud [Health Insurance Cost, National Coalition on Health Care, 2008], at least three remaining key factors, namely, aging population, expensive medical innovation, and defensive care, contribute substantially, to the overall cost picture.

Aging populationIn the United States, the proportion of the population aged >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons aged >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons aged >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030 [Public Health and Aging: Trends in Aging --- United States and Worldwide, 2008; Kaiser Family Foundation, 2006].
"The growing number of older adults increases demands on the public health system and on medical and social services. Chronic diseases, which affect older adults disproportionately, contribute to disability, diminish quality of life, and increased health- and long-term--care costs." [UN, 2002] 125 million Americans have one or more chronic conditions (e.g. congestive heart failure, diabetes.) Chronic diseases account for 75% of all health care expenditures. Source: Burrill & Company, 2006
Expensive innovation
The American biotechnology industry has surpassed pharmaceutical companies for the third straight year as the primary source of new medicines, and biotech revenue jumped nearly 16 percent to a record $50.7 billion in 2005. Source: Ernst & Young LLP, 2006
The USA is the world's largest and wealthiest pharmaceutical market, accounting for around 48% of the world total. Per capita expenditure on drugs is US $1,069 in 2006, nearly double the level found in the rest of the world. Source: Espicom Business Intelligence, 2006
...an estimated 30% of new products under development are "combo products" - involving medical devices embedded with pharmaceutical or biologics components. [Combination Products- Navigating Two FDA Quality Systems, Microtest White Paper, 2007]. The combination products market is estimated at $5.9B in 2004, and will continue to grow at a compound annual rate of 10% through 2009. By 2009, the market is expected to reach approximately $9.5B worldwide with a majority of these revenues from drug-eluting stents and steroid-eluting electrodes. Source: Navigant Consulting, Inc. In 2004, the US held approximately 65% of the drug-device combination product market. By 2010, the US is projected to hold 57%. Source: Business Communications Inc.

"Defensive" Medicine"One of the major cost drivers in the delivery of health care are these junk and frivolous lawsuits. The risk of frivolous litigation drives doctors -- and hear me out on this -- they drive doctors to prescribe drugs and procedures that may not be necessary, just to avoid lawsuits. That's called the defensive practice of medicine.. . . . See, lawsuits not only drive up premiums, which drives up the cost to the patient or the employer of the patient, but lawsuits cause docs to practice medicine in an expensive way in order to protect themselves in the courthouse. The defensive practice of medicine affects the federal budget. The direct cost of liability insurance and the indirect cost from unnecessary medical procedures raise the federal government's health care costs by at least $28 billion a year." [US President George Bush, Arkansas, January 26, 2004]

Now let us observe the paradox:

On one hand, the participants of every ancillary industry to health care, including insurance companies, hi-tech and pharmaceutical engineers and scientists, as well as lawyers, have increased their profits in step with the rising costs of health care at ever accelerating pace.
On the other hand, the medical and chiropractic office owners - the actual health care providers - have not only failed to keep up with raising costs but have lost a significant part of their income. In fact, between 1995 and 1999, at a time when most wages and salaries in the United States rose 3.5 percent after adjusting for inflation, average physician net income from the practice of medicine, adjusted for inflation, dropped 5 percent [Reed and Ginsburg, 2003]. In 2006, the median compensation for specialty and primary physicians grew only 1.7 ($322,259) and 2 ($171,519) percent respectively, slower than consumer price index of 3.2 percent [MGMA Physician Compensation and Production Survey: 2007 Report]. In comparison, health care costs beat the inflation by 3.5% reaching the annual growth rate of 6.7 [Health Care Spending, 2008]
Diverting our focus away from trying to find solutions to the problem of rising health care costs, we ask a different question: How such a paradoxical situation is possible without a deliberate and systematic strategy against health care providers?

A Sacramento-area surgeon couldn't schedule surgeries for more than six months because his contract was not loaded in the insurer's computer system. More than 200 of Dr. Watson's patients received letters indicating incorrectly that he was no longer participating in the network. Watson lost about 25 percent of these patients and was not paid for about eight months. Another insured spent eleven months trying to get claims paid for his family, including an autistic child. The insurer never specified what information was needed to make the denied claims eligible for payment.

Are these three isolated incidents or are they three symptoms of a growing problem with the entire provider's reimbursement system? The owners of health care practices easily recognize these painfully familiar symptoms. The better questions are: how are they related to the rising healthcare costs and what can a provider do to help?

In 2005, national healthcare costs rose 6.9 percent - twice the rate of inflation, reaching $2 trillion. National healthcare costs are predicted to double to $4 trillion by 2015. While key health care cost factors include aging US population, the arrival of new and expensive drugs and bio-tech devices, and the defensive medicine, the insurance costs alone stand out as a key contributor to rising healthcare costs. Exorbitant executive compensation became a hallmark of healthcare insurance industry, where William McGuire, CEO of UnitedHealth Group, has reportedly received over $500 million since 1992, more than $1 billion worth of options, a lump sum payout of $6.4 million upon leaving the company, and an annual pension of $5.1 million. But such compensation can be easily justified on Wall Street, when comparing it to outstanding insurance industry profits, such as 38 percent growth in earnings in the 3rd quarter of 2006.

The problem for any successful insurance company is how to make such growth sustainable? This question is difficult because the premium growth (68.4 percent) has disproportionally outpaced both inflation (16.4 percent) and workers earnings (18.2 percent) during the same period (2001-2006), making it impossible to continue to rise the premiums without losing major segments of insured population.

Without the ability to attract new clients or to further raise insurance premiums, cost reduction becomes the next most important approach to enhance profitability. Such cost reduction can be done in a variety of ways, which we conveniently divide into strategic and tactical or opportunistic approaches.

Strategic insurer's arsenal

The creation of an oligopsony through consolidation is the main weapon in the strategic arsenal of insurance companies. Oligopsony exists when providers significantly outnumber buyers, enabling them to dictate prices. Take for example, the PacifiCare's $9.2 billion merger with United Health Group Inc. in late 2005, which created a vast network of HMO and PPO plans covering more than 3 million Californians. Today, three plans alone (UnitedHealthcare, WellPoint and Aetna) cover 77.7 million insured lives. Oligopsony allows the systematic and continuous cost reduction without extra investment, e.g., annual cut of allowed rates (such as the average reimbursement for E&M allowable dropped 10 percent in 2006 and another 6.5 percent in 2007), payment suspension for specific procedures (such as EKG tests for routine physicals), offering "all or none" participation alternatives, or the creation of "tiered networks" that profile providers and incentivize patients to see lower cost providers.

Tactical insurer's weapons

Increasing billing process complexity and inventing new denial reasons through arcane terminology, disparate data formats, and modifications of CPT/ICD codes and medical necessity rules - these are all examples of tactical methods designed to increase providers costs for both billing and follow up and reduce the payments at the expense of practice owners. These methods need continuous investment in personnel training, better process management, and improved technology to keep them effective as the providers begin building more sophisticated systems to scrub and analyze claims and discover payment discrepancies and irregularities.

Provider's Response

Returning to the three incidents mentioned at the outset of this article, the joint Department of Managed Health Care and Insurance Department determined that these are not isolated cases. It analyzed 1.1 million paid claims from June 2005 to May 2007 that covered about 190,000 members in PacifiCare's HMO plans and PPO coverage [Gilbert Chan , "PacifiCare fined record $3.5 million," www.sacbee.com , January 30, 2008] and discovered 30 percent of the HMO claims wrongly denied and 29 percent of the disputes with doctors were handled incorrectly. PacifiCare paid out over $1 million and was fined additional $3.5 million.

In summary, providers need new and effective approaches to mobilize both legal and organizational talent to reverse their revenue decline. Legal methods battle market conditions like oligopsony while large-scale medical billing networks aggregate claim volumes and create resulting economies of scale to enable analytical discovery of under-payments.

The only small and home business owners who are not worried about health insurance, usually have some other form of coverage. Some are covered through a spouse's group health plan, and some already have a retirement plan from earlier employment or military service. However many small business owners have made their career out of what they do now, and so they must rely on themselves to provide a medical plan for themselves, and their family.

If you do not have employees, you need to look at individual coverage. If you have a couple of employees then you have a choice to make. A small business group plan is a great benefit, and it tends to attract and retain qualify people. However, premiums for small groups are expensive and risky. Since their is only a small pool of people to spread the risk, and since federal law mandates that insurance companies have to accept everybody, expect to pay for a policy!

Now you will be able to deduct some of this expense from your business taxes. You can also expect your employees to share some of the cost. Also, remember that employees do like group health insurance as a workplace benefit. So consider this option, but keep in mind, that costs and extra paperwork can be daunting.

On the other hand, individual health insurers get to underwrite everybody they accept. Younger and/or healthier people will get a cheaper rate. Older people, or especially those with health conditions, will either get charged more, or they may not be able to get a plan to accept them at all! Of course, every state has some sort of high risk plan for people who cannot obtain their own plan, but expect to pay for this.

Employees must pay for the premium themselves, but some companies will let you pay a list bill. You withdraw the amount from each worker's paycheck. Because you will not have the burden of carrying the plan yourself, maybe you can afford to pay your employees a bit more to make up for it. The advantage for the employees is that their policy is portable, and so they can take it with them even if they leave your company. Another advantage for healthy employees, is that the premium should be lower. However, less healthy employees, may have a hard time, and you should probably consult with an experienced agent for options.

Now, if you do not have any employees at all, or if you only employ your spouse, then you must get a family plan. If premiums seem to high, I suggest looking at very high deductible major medical with Health Savings Accounts (HSA). You can offset the deductible with the money in the HSA, and those contributions have tax advantages. Plus, if you retire and join Medicare with any money left in your account, you can add it to your retirement savings without a penalty!

You may have worked with an employee benefits broker when setting up and reviewing your company's employee benefits program. This is the person that markets plans, usually from a number of different insurance companies, and assists the employer in selecting an insurer and plan design that best suits the company's needs.

But what if you're not happy with your broker or your plan? How do you go about finding a new one, or making sure your company's group insurance is in the best hands? Here are a few things to consider when you're choosing a group health and dental insurance broker.

Is the broker focused on the employee benefits marketplace?

If the broker is an insurance agent that discusses your benefits plan, and then wants to talk about your personal life insurance or property and casualty insurance, this might be a bad sign. There are thousands of different kinds of insurance out there, each with its own set of laws and policies. You don't want a jack-of-all-trades here. You want a specialist.

A broker that focuses on employee benefits will be more likely to be familiar with the increasingly complex benefits market. He should also be able to not only help you put a new plan in place, but be there after the initial sale is made to assist in the everyday servicing of the benefits plan.

Can you get referrals?

Don't be shy about asking the broker for names and phone numbers for at least 15 of his current, local business clients that his firm has served for at least five years. Referrals are absolutely your best way to distinguish between a slick talker and the broker that offers good, long-term value to his clients.

When you call these referrals, ask them questions such as "What happens when you have a claims or billing problem? Does your broker's office work with your employees on these issues, or do they have to call the insurance company? How satisfied have you been with the long-term service that your broker's office gives you?"

What kind of customer service does the broker offer?

Customer service really is the most vital factor. As the client, you do not pay directly for the broker's services. All brokers are paid an ongoing commission by the insurance company. So, it really costs you no more to work with a good, service-oriented broker than one that sells you a plan and disappears.

Are you familiar with the insurance companies being marketed?

The group medical insurance industry has greatly consolidated over the last decade or so. A market that once offered endless choices for health insurance has been reduced to less than 10 credible choices in most parts of the country. Most good brokers will show you the same array of leading insurance plans, simply because the choice is limited.

Beware of a broker that tries to market an off-brand plan, one that you are not familiar with, or that has low financial ratings. Often these kinds of programs offer low initial premiums to the buyer and high commissions to the broker, but do not perform well over time.

Because most good brokers will offer the same plan choices, the buying decision comes down to this: Which broker demonstrates the best service capability to your company? Which broker offers a long list of referrals of current, long-term clients without being asked for it?

Most employees and job seekers consider a company's benefit package nearly as important as salary when deciding whether to stay at a job or which job offer to accept. A good benefits broker should be like a human resources director for your company: helping you hire and retain the caliber of employees that makes your business successful.

You've met with three or four insurance brokers, and all have given you spreadsheets presenting proposals from a number of insurance carriers vying for your company's business. Most of these spreadsheets, from all the brokers you met with, show basically the same selection of programs.

You go through each plan to understand it as best you can. You even run it by some other employees to get their input. Finally, you make a decision, call the broker to give him the good news, and away you go. The broker? Well, since all the brokers showed basically the same plans, you call the broker that also sold you the property and casualty insurance to your firm.

What have you forgotten?

It's a problem.

Your new group medical insurance plan has been in force for some time now. Employees come to you at least several times a week with claims problems, benefit questions and complaints.

Your job is NOT to be an insurance expert, so you call the broker that sold you the plan, looking for help. When he calls you back a couple of days after you left him a voice mail, he says he will check into your various questions and get back with you.

The broker calls you back a week later, with some garbled answers that really don't address the issues. You end up having your assistant call the insurance company's toll-free number, where she gets passed around to three different extensions, still not getting answers.

The forgotten factor

Go back to the beginning. You spent a lot of time trying to choose the right group insurance plan. But you really didn't put much consideration into which broker to write the program with. Broker selection was the forgotten factor.

Choosing a good broker is at least as important as which plan of insurance you select.

What should an employee benefits broker provide to you?

The broker will talk to your employees.

Your employees should be able to call your broker's office with claims problems and benefit questions, and talk to someone who is knowledgeable and will not leave them hanging. Your broker's office should be a dependable resource to you and your employees.

The broker will talk to the insurance company.

Your broker should do most or all of the communicating with the insurance company for all claims and billing issues. Again, you and your employees are NOT insurance experts. Your broker's office should be.

The broker will become a trusted advisor.

A good broker will become an extension of the human resources efforts of your company. His office will, by keeping your benefits program efficient and well-serviced, help you hire and keep the best employees. Even more than your accountant and attorney, he and his support staff will become trusted advisors.

How can you choose a good broker?

Make sure that your broker is a specialist in employee benefits. This will not be the broker that handles your property insurance or personal financial planning.

Ask for a list of at least 15 of his local business clients that have used his firm for at least five years, and call these referrals asking what type of job the broker's office has done for them. If the broker balks at this, or only can give you a few referrals, move on.

Make sure the broker has a knowledgeable and experienced staff. The broker is only one person, and he will often be out of the office. You should ask to talk to the person in the broker's office who will be handling the day-to-day servicing of your plan. Talk to that person on the telephone and make sure he or she seems competent and will be comfortable to work with.

The broker is often the forgotten factor. And don't you forget it.

If you've been to a doctor, you know how crazy things can get with the billing even if you have insurance. In this article, we seek to explain how this maze of red tape works.

Simply put, medical billing involves a series of communications between a doctor's office and a medical insurer. What is medical billing used for? As you sit atop that cold steel table awaiting your prognosis, your doctor's office is engaging in a dialogue with your current insurance company. The topic of conversation? You, of course. As your doctor checks for all your vital signs, various medical codes are placed next to your personal medical information contained within your file.

Once your doctor leaves the examination room, your file then goes into the hands of a medical secretary, and it is sent electronically to your insurance provider using the codes mentioned above. Once your insurer has your medical information, they then begin to check your policy in order to make sure that your claim is valid. If you are covered insurance wise, your insurer will then pay the claim. If not, your medical request will be rejected.

As a matter of fact, medical claims are rejected nearly 50% of the time. In most cases, a lack of adequate communication between your doctor's staff and the insurance company is to blame. Most of the time, a medical provider will have to contact an insurance company more than once in order to make a claim. Codes can become crossed, and medical diagnoses may be overly complicated causing a bit of a problem. What is medical billing used for when it comes to government medical programs?

Whether you have a private or governmental insurance provider, the billing remains the same. No matter what sort of coverage you currently have, there must be some form of consultation between an insurance provider and a medical facility. It is interesting to note just how many claims are filed every day within the United States (millions), and how many people actually know what a medical claim consists of (hundreds).

Now that you are able to answer the original question (what is medical billing?), you have a better understanding of how insurance companies work. The next time that you visit your doctor's office, think about all the different types of interactions that are occurring at that very moment. It may not be the most intriguing subject, but it does effect nearly every person that's ever made a doctor's appointment.