Question

Find out what utilization management practices Tricare prime insurance company follows. This information may be available in your insurance benefits booklet or on your health plan’s website. If you do not have health insurance, go to the website of any major health insurance company and list the practices this company follows to control costs and to ensure the provision of medically necessary services. Provide a summary of your learning.

Answer 1

Below are some of the utilization management practices my insurance company follows:

1. Co-pay : Co-payment is a fixed amount for a covered service that needs to be paid by the patient. For my insurance company it is 20% co-pay, which means if the total claim is of 1000 USD, then I would have to pay 200 USD would have to be paid by me.

2. No claim bonus: My company promises to increase my coverage with with 1000 USD for every zero claimed year of expense upto 5 years. This means that my insurance of 10000 USD would increase every year by 1000 USD if i do not claim any insurance from the provider. The sum can go upto 15000 USD if i dont claim and would stay at this value for upcoming years if i don't claim.

3. Hospitalization: The company mandates hospitalization of at least 3 days to process the claims and does not take into consideration any OTC medications. I can claim post hospitalization medications of upto 2 months.

4. Pre-authorization: In case of non emergency, my service provider has a pre-authorization clause before any service is undertaken.

My understanding from research and analyzing my own insurance plan is that the insurance company formulate the utilization policies with great care so that no needy patient is denied the care while they secure themselves from frivolous claims and frauds.