Insurance carriers

Medical Programs. Large chemical plants have at least one hill-time physician who is at the plant five days a week and on call at all other times. Smaller plants either have part-time physicians or take injured employees to a nearby hospital or clinic by arrangement with the company compensation-insurance carrier. When part-time physicians or outside medical services are used, there is Httle opportunity for medical personnel to become familiar with plant operations or to assist in improving the health aspects of plant work. Therefore, it is essential that chemical-ha2ards manuals and procedures, which highlight symptoms and methods of treatment, be developed. A hill-time industrial physician should devote a substantial amount of time to becoming familiar with the plant, its processes, and the materials employed. Such education enables the physician to be better prepared to treat injuries and illnesses and to advise on preventive measures. 

Finally, another obstacle is that some clients will not seek help out of fear that others will discover that they have drug problems and use that information against them. One solution is to educate the client about federal confidentiality laws that protect against disclosure while in treatment, or state laws that protect client confidentiality in therapy. Flowever, you also should be very honest that there are ways in which confidentiality can be suspended, or when outside institutions can access personal health information. For example, make sure to explain that state confidentiality laws can and will be suspended if the client expresses thoughts about harming him- or herself or others, and in some states, if he or she damages property. Additionally, if a client is mandated to services, he or she should be told that those officials who mandated the treatment may have access to treatment records and reports. Finally, tell clients that insurance carriers and their representatives also may have the right to access that information. Clients should be made aware that there are a number of protections in place to protect them, but also told frankly that some of the protections have limits. 

In March 2004, Bayer settled with its insurance carriers, eliminating the insurers rights of litigation and settlement and setting the limits of liability at 1.2 billion. In July 2004, the company settled 2771 cases for 1.06 billion. In September 2004, Bayer settled another 2861 product liability cases for 1.09 billion. There are still 7577 such suits pending. ... 

Before beginning the installation of a fire protection system, it may be necessary to secure approval from local, state or federal agencies that govern fire protection installations. The facility insurance carrier may request that they be notified of any new fire protection construction or retrofitting of existing systems so that they may offer assistance in managing the change. 

Acceptance tests should be documented. Local regulations, insurance carriers, and company requirements may require that officials from these groups witness the acceptance testing. Acceptance testing typically includes ... 

Dr. Joachim Breuer, CEO of the association of commercial and industrial statutory accident insurance, stated in a press release on 17.12.2002 We do not expect deaths to reach their peak until between 2005 and 2015 . Breuer estimates that the overall expenditure of the iability insurance carriers could probably rise to well in excess of 10,000 million. By 2020 up to 20,000 deaths in Germany could be due to asbestos. 

Representatives from OSHA, the local fire department, and the property insurance carrier were also invited to participate in the incident investigation. 

Price discrimination refers to the practice of selling identical products to different sets of customers at different prices. Expressed another way, different customers pay different markups over the identical incremental cost of producing an identical product. Price discrimination is widely practiced in the hotel and airline industries, by universities in the United States that can vary their tuition through scholarships, by electric power companies, and in the health care industry. Hospitals in the United States, for example, routinely charge different payers different prices for the same services. In the U.S. pharmaceutical market, different prices are charged to different insurance carriers and to self-paying patients. Worldwide, the same pharmaceutical firms sell the identical product to different countries at different prices. 

Compensation traditionally is provided by a patient (e.g., first-party payer) or by an insurance carrier (third-party payers). With first-party payers, the fee for the service is requested directly from the patient. There are advantages and disadvantages to charging patients directly for a clinical service. Advantages include the fact that the pharmacist can ask directly for and... 

A pharmacist or any other professional does not necessarily have to become an official provider with each insurance carrier. However, an insurance carrier can restrict compensation to only those professionals considered to be providers (e.g., Medicare) or require that the patient be responsible for a larger portion of the bill if an out of network or nonapproved provider is seen. 

To be credentialed, health care professionals usually are required to submit specific information to the insurance carrier, such as license numbers, malpractice insurance information, board certifications, and copies of diplomas. Health insurance plans may have specific requirements, such as requiring physicians and other health care professionals to have specific credentials, carry a specified amount of malpractice insurance, or be board certified. The health care professional typically submits this information along with an application (Snella, 1999). 

When contacting an insurance company to become a provider, it is not unusual for the carrier to be unfamiliar with value-added pharmacist services. Explaining the goals of the service, what is included in the service, the benefits to the client and to the insurance carrier, and the pharmacist s unique capacity to offer such services will help to establish the value... 

When Dr. Brouchard estimated the number of patients with type 2 diabetes, he also took note of their insurance carriers. Since Sun City, Arizona, is a major retirement community with strict age requirements for its residents, it was not surprising that most of the people served by the pharmacy were elderly (Northwest Valley Chamber of Commerce, 2007). Most of the patients with type 2 diabetes had Medicare insurance, followed by a variety of third-party insurance carriers. Because Medicare was the main insurance carrier for his patients, Dr. Brouchard knew he would have to consider compensation strategies for those patients with and without Medicare Part D coverage. 

The type of education or management service offered may also influence compensation. For example, not all third-party payers cover preventive health education services such as weight-loss counseling or smoking cessation. If the service is not covered, the patient is personally responsible for the fees associated with the program. If it is not already known if the insurance carrier will or will not consider these services under the health plan, it would be prudent to contact the carrier before providing the service to a specific patient. In this way, the patient is aware of whether the services will be covered or if the patient will be responsible for the charges. 

In general, the provider determines which CPT code best describes the service that was provided. The specific insurance carriers may have restrictions on which CPT codes can be used. For example, Medicare does not allow pharmacists to use CPT codes 99211 through 99215 but will allow a physician to bill for the nonphysician services (e.g., the pharmacist) using the 99211 code. This can be done if billing using the Incident to Physician Services Regulations described earlier in this chapter (Snella, 1999). 

Following the patient visit, a claim form (CMS 1500 or CMS 1450) is filled out and submitted to the insurance carrier. The insurance carrier may want other items before approving the claim, such as a statement of medical necessity from the referring provider and a copy of the physician s referral. A statement of medical necessity is a statement signed by the provider that states that the referral to the pharmacist (or other provider) is necessary medically (Snella et al., 2004, Poirier et al. 1999). This type of statement can be incorporated into the physician referral form (Snella, 1999). 

While value-added services can enhance existing pharmacy services, to be maintained long term, they also must be financially feasible. Adequate compensation for these services is essential. Numerous compensation strategies are available, but they vary based on the insurance carrier and the physical setting where the service is provided. In addition to payment for direct patient care, compensation can also occur for laboratory tests and procedures. One continuing challenge for the... 

Postponing maintenance when it can be delayed safely. Certain costly steam turbine/gen-erator units outages were scheduled every six years. With the data obtained through vibration surveillance and analysis methods, the intervals between overhauls were extended with the concurrence of the property insurance carrier. 

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