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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 benefitsthe 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.

About AllMed Healthcare Management

Founded in 1995, AllMed 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 for its independent medical review and hospital peer review services 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. Read the AllMed Medical News Blog and the Independent Review Organization Blog.

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Almost all of us will have taken out some sort of insurance. Whether it be car insurance, home insurance, health insurance or travel insurance to name just a few, we will all have paid over considerable sums of money to an insurance company in exchange for the peace of mind that comes with knowing that should disaster strike, you are insured. However, how many of us have fully understood the details of the agreement we are entering into?

Within all the documentation that comes with any new insurance contract, there is contained some of the most complex legal provisions and contractual terms that you are likely to find anywhere. Insurance companies spend millions on lawyer’s fees and have teams of professionals constantly up dating and amending the terms of their contracts to cover for every possible eventuality. You on the other hand, probably have very little time to spend getting familiar with the contents of your insurance contract and will simply glance over the main points that are highlighted by the insurance company.

However, there are a couple of things that you can do to make sure you have at least a reasonable understanding of the contract you are signing. All insurance contracts basically have the same purpose and methods. They take on the risk of an event, which may or may not occur and pay the cost of it if it does. This may be any event, but the most common are car accidents, house damage, medical treatment and the like. Life assurance is slightly different in that it guarantees to pay out on your death, which unfortunately is still a certainty that is bound to occur. However, the timing of death is uncertain and in this sense there is still a very real risk that you will die at a time when your children or spouse is completely dependent on you.

There must also be some financial cost to the occurrence. The insurer must be able to have a reasonable idea of the cost of the loss if they are to be able to calculate the price of the premium accurately. Therefore, while medical expenses and lost earnings are recoverable under insurance, the pain and suffering, or the sadness of losing a loved one will not be recoverable under an insurance contract.

Therefore, what you will really be looking for in an insurance contract is what exactly is covered. In which circumstances will the policy pay out and which occurrences are not covered. Then there are the exclusions and conditions you must meet to keep the policy valid. This might include keeping your door locked or having health checks. Make sure you understand what you have to do under the contract and do it.

Joseph Kenny is the webmaster of the insurance site http://www.insure121.com/ where you will find information, news and links to the leading providers of insurance in the UK. If you found this article interesting you may find more articles of the same nature in the insurance guide located on site.

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