Question

Let's try again, for self-insured employers, meaning that they do not use an insurance company, rather they pay the claims themselves and hire an administrator to process the claims (TPA) ... define and describe how self-insured companies determine risk adjustment? How do they distribute the risk. How is care for treatment reimbursed.

Answer 1

Ans) A third-party administrator is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. It is also a term used to define organizations within the insurance industry which administer other services such as underwriting, customer service.

- The risk adjustment program is intended to reduce the likelihood that an insurer will aim to enroll only low-risk individuals and help ensure that price differences of plans reflect the plan design and benefits available rather than risk.

- Risk-adjustment is a critical tool in the evaluation of health care quality. Its aim is to “level the playing field” so that providers serving different patients can be meaningfully compared.

- Healthcare providers are paid by insurance or government payers through a system of reimbursement. After you receive a medical service, your provider sends a bill to whomever is responsible for covering your medical costs. Private insurance companies negotiate their own reimbursement rates with providers and hospitals.