Navigating the Chasm Between Clinical Work and the Insurance World-Navigating the Chasm Between Clinical Work and the Insurance World

Video Transcription

Video Summary

In this video, Dr. Mary Russell and Dr. Monica Crump-Baldridge discuss the process of navigating the insurance world in healthcare. They explain the different types of health insurance coverage, including private coverage (employer-based, direct purchase, and TRICARE), and public coverage (Medicare, Medicaid, civilian health, VA, and military coverage).<br /><br />Dr. Russell highlights the administrative burden and high costs associated with working with insurance companies. She emphasizes the importance of understanding the rules and guidelines set by insurance companies to improve the odds of success in getting the treatments and services needed for patients. She provides tips for working with insurance companies, including knowing the payer and guidelines for coverage, understanding what the FDA and literature say about treatments, and being prepared for the appeal process if needed.<br /><br />Dr. Crump-Baldridge discusses the history and evolution of utilization management in healthcare. She explains the different types of reviews (prospective, concurrent, and retrospective) and the concept of medical necessity. She also highlights the challenges faced by providers, such as limited clinical autonomy, increased administrative burden, and frustrations with the insurance process. Dr. Crump-Baldridge emphasizes the need for evidence-based practice guidelines, value-based care, and a collaborative relationship between insurers and providers to improve the effectiveness and efficiency of healthcare delivery.<br /><br />Overall, both speakers emphasize the importance of understanding the insurance process and guidelines to navigate the complexities of the insurance world and improve patient outcomes.

Keywords

insurance world

healthcare

health insurance coverage

private coverage

public coverage

administrative burden

insurance companies

treatments

evidence-based practice guidelines