www.gallagherbenefits.com

Healthcare Consumerism

Mount Vernon Nazarene University – October 2012

Common Insurance Terms

DeductibleCoinsurance

Maximum Out of PocketProcedure CodeDiagnosis Code

Network DiscountPre-Certification

How a Claim Gets Paid

Services are received by member at provider – members shows their identification card

Provider completes claim form identifying procedure and diagnosis codes and sends it to UMR for processing

UMR electronically matches member identification number, procedure and diagnosis codes and electronically adjudicates the claim applying discount and employee cost sharing

Payment is sent to provider and Explanation of Benefits is sent to the member

Future of Health Plans

Factors Influencing Healthcare Costs

• Technology Advances – MRIs $1890 vs. Chest X-ray $175

• Prescription Drugs – Generic vs. Brand• Increased Patient Demand – 30% of healthcare

treatments viewed as unnecessary• Government Regulations & Coverage Mandates –

HIPAA, PPACA• Increased Financial Pressure on Doctors &

Hospitals – malpractice insurance, consolidation• Lifestyle Choices – 50% of all healthcare costs

stem from preventable lifestyle choices

Factors Influencing Healthcare Costs

• Direct-to-Consumer Marketing– TV Commercials– Magazine Ads– Billboards

• Increased number of chronic conditions• Increased availability and access to care

Consumer Tools

• Discounted Prescription Medications– Wal-Mart - $4/$10 – Kroger - $4/$10– K-Mart - $5/$10 with Pharmacy Prescription Savings Club

Membership– Meijer - Costco – no membership required

• Websites to Compare Prices– www.healthcarebluebook.com– www.fairhealthconsumer.org – www.rxaminer.com

• Online Drug Stores– www.drugsource.com

• Physician & Hospital Quality– www.healthgrades.com– www.hospitalcompare.hhs.gov– www.umr.com

• Consumer Reports Health

Consumer Tips

• Get the Most of Doctor Visits – www.choosingwisely.com

• Ask for prescription samples from your physician for short-term medications

• Ask your physician for copay assistance prescription cards for long-term medications

• Review medical bills• Stay in-network• Utilize generics• Shop around

Additional Tips

• Prescription Drug costs can change daily and vary widely from store to store

• Generic drugs are not cheaper than brand name drugs the first six months on the market

• You can negotiate your provider bills• Antibiotics and Prenatal vitamins are FREE

at Meijer

Questions