Health Insurance Industry Explained--Health Insurance from Job (Employer-Sponsored)

Health Insurance Industry Explained... Learn the Fundamentals of Employer-Sponsored Health Plans:
A. The Healthcare System for Employers Has 4 Parts:
1) Employers, 2) Employees, 3) Providers, 4) Insurance Carriers
Understand Their Inter-Relationships
B. Health Insurance Has 2 Forms of Risk-Transfer for Employers:
1) Fully-Insured and 2) Self-Insured
Understand Credibility and Specific/Aggregate Stop-Loss Coverage
C. Network Discounts:
1) Repricing, 2) Contract Methodologies, 3) Medical Coding
D. Administrative Services Only (ASO) and TPA Services:
1) BUCA Carriers, 2) Carrier-Owned TPAs, 3) Independent TPAs
E. Health Insurance Captives:
1) Pooled Risk, 2) Adverse Selection, 3) Death Spiral
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[@lindsaytarvin3514]

As an american 27 year old woman our education system and my parents let us down no one taught us anything about how all these works just told us we have to have it. Thank you for teaching me sir

[@ahealthcarez]

Thank you for watching and for your comment.

[@user-ko1iw1le3h]

thanks again, just added this to our healthcare startups onboarding document for all new employees to watch as part of their self education time. So clear and concise

[@ahealthcarez]

Super! You are not alone. Other companies use these videos for the same purpose. Thank you for watching.

[@martha5082]

Every single video has so much good information!! It doesn’t matter how old or recent it is… THANK YOU, THANK YOU, THANK YOU!!!

[@ahealthcarez]

You are Welcome! Thank you for watching.

[@kendrawyatt1441]

We need transformation and convergence between Banks ISO 20020 and Cures 2.0 standards to enable auto adjudication from HSA accounts for primary care pediatrics and pregnancy. Our very simple claims sit for months with TPAs. Great summary.

[@ahealthcarez]

Thank you for letting us know. Appreciate you watching.

[@ericklou2013]

Great educational content.

[@aangitano]

Ah, thank you for this. Using it as background info for my health law paper.

[@ahealthcarez]

Super. Glad you are using it.

[@user-io3vs7fz5j]

Your videos are very useful and provide lots of information. I have received lots of help after watching this post, please continue to share this kind of information. Thank you.

[@ahealthcarez]

Thank you for watching.

[@dxrulez4]

The man blesses us yet again! 🔥

[@ahealthcarez]

You are too kind. Thank you for watching.

[@jamesimperial7731]

Thanks for the video! Really learned a lot from this!

[@ahealthcarez]

Thank you for your comment.

[@garrywelch4041]

thank you again for the education. Every med student should watch all your videos. Then watch what happens as these young, smart people who are getting into healthcare to make a difference and help patients start to say "this system is insane". They will become change agents who call out the older MD medical school hierarchy as well as the Hospital leadership MDs who are now part of the problem you discuss not due to any personal weaknesses or that they are bad people but due to warped financial incentives in place that are shaping their behavior. Good people, broken system. Financial incentives and performance metrics must be changed to focus on prevention and the common good. If Ochsner Health was a Covid virus?

[@ahealthcarez]

Very well put! Thanks so much for watching and for your comment!

[@Maria-ox6xg]

Wow. Thank you so much for this video. I work in a Doctors office and I find insurances so confusing to understand and you really helped with so much detailed informations.

[@ahealthcarez]

Thank you for watching!

[@tomdiaz4242]

Really good breakdown on payment structures

[@ahealthcarez]

Thanks so much. Appreciate you watching!!

[@MeherScholar]

I work for a major university with a self-funded health plan. This university also has a hospital and clinics which are all in-network. The hospital pricing transparency files show that university employees going to our own university hospital have the highest allowed amounts. For example a flu and strep throat test at the university's Urgent Care gets charged at $824.55, adjusted down to $608, the allowed amount for high-deductible plan holders. If my employer is paying the health bills, what incentive would they have to accept such high allowed amounts for visits to the university's own medical facilities?

[@ahealthcarez]

Revenue for the University Hospital… while they are in the same university, they are different budgets / fiefdoms.

[@evanjohnson9616]

Very informative!

[@ahealthcarez]

Thank you for watching!

[@discodancer22]

You’re the bomb!

[@ahealthcarez]

Thank you for your support.

[@tighthead03]

Excellent video. Have you considered doing a video on ASP Vs. AWP pricing for J codes and the impact on reimbursement? Thanks again

[@ahealthcarez]

Thank you for your feedback. Great suggestion!!

[@tanyatango4197]

Such informative video. If an employer has many claims is there a chance they will discriminate and try to get rid of thay person? (Under the hood of course)

[@ahealthcarez]

Potentially, but it is illegal. Thank you for watching.

[@shametanicole3193]

Thank you

[@ahealthcarez]

Thank YOU for watching.

[@rain7096]

👍

[@ahealthcarez]

Thank you for watching.

[@robvidalbjj]

The only thing missing in all of this great info is the laser!

[@ahealthcarez]

True. Thank you for bringing that up.

[@robertsmith6408]

I have health insurance through the county where i retired at. I get 500 a month from the county to put towards the premium of 1900 a month for me and my wife. So my part is around 1400 a month and it has a 6000 deduction before it pays anything, When I get to Medicare age the 500 will be cut in half and I can use that towards the Medicare part B, so it will be affordable when I reach Medicare age in 5 years. My question is can I just put her on Obamacare right now and I stay on mine because the premium is just to much money. Also if I put her on Obamacare will they use my six figure pension or use her small amount she makes on her part time job. I did a calculation with my income on ACA site and since i am way higher then the average American income, it was more then I am paying now with no subsidiaries. She saids just take her off and since she is a registered Cherokee Indian she can use the clinics but they are way in San Diego. America really sucks for healthcare, we need a one payer system!

[@ahealthcarez]

The Obamacare has a problem called the Family Glitch. I made a video about it here: kzbin.info/www/bejne/rJjbdKZ5qNd-lac Maybe the Native American coverage would be helpful. That is no an area I’m familiar with.

[@TranBaoThien-ip9wj]

What is a TPA role sir?

[@vickyshort5682]

Do one for marketplace health insurance?

[@ahealthcarez]

Great suggestion. Thank you.

[@josepaulloor6449]

So I’m assuming the employer is making the claim to the stop loss insurance company if an employees claims are too high and not the provider in a self funded plan?

[@ahealthcarez]

Facilitated by the Third Party Administrator (TPA) or Insurance Cartier that is providing ASO services.

[@josepaulloor6449]

Wow this is what I tell my employees

[@ahealthcarez]

Thank you for sharing your experience.

[@ramindya]

@ahealthcarez: In case of Fully-Insured employer, how $100 in premium translates to $10,000 per year in premium for 200 employees which costs employers $2 Million per year? Thank you.

[@ramindya]

100 employees * $200 in premium per month (two members per employee) * 12 months = $240,000. How come it is $1 Million?

[@vickyshort5682]

I didn’t realize that the average employee premium is 10k. So many people who have employer based that don’t need that kind of coverage still have that taken out of their pay check… so much for a “benefit”. Healthy people could most likely just pay out-of-pocket and spend maybe 3k a year.

[@ahealthcarez]

Great point. Thank you for weighing in!

[@lordlemond1350]

You've pulled back the curtain to reveal the "wizard of OZ"

[@chrismolloy6885]

😎

[@ahealthcarez]

👍

[@artaxerxes2363]

in other words im screwed

[@ahealthcarez]

There’s alway Hope. 😉

[@artaxerxes2363]

@@ahealthcarez My only hope is that of Jesus Christ return!

[@everythingisfine9988]

Single payer ✨ The current system is ridiculous. Purely designed to funnel money towards pointless tasks & pockets and a way from care.

[@stayswervin554]

not everyone wants a single-payer

[@Coconinga]

Single payer has a lot of issues as well, look at NHS. Also no country has every transitions from a mix of private and public to only public. It isn't going to happen when 20% of this country works in healthcare fields. Less healthcare $ -> less healthcare jobs -> unhappy people

[@telsamorgan5369]

Your videos are very useful and provide lots of information. I have received lots of help after watching this post, please continue to share this kind of information. Thank you.

[@ahealthcarez]

Thank you for watching and for your support.