A new trend is building within American healthcare. Domestic medical tourism- that is the act of seeking out better care or less costly care out of network. By that I mean, way out of network and different time zones. This has occurred internationally for some affluent patients but is now also trendy and more mainstream, domestically as well.
This isn't just about plastic surgery either. Yes, we've all heard those stories. This is different. Some health care providers, within the U.S. actually market themselves as medical destinations. One exceptional, American based provider that does this is Cleveland Clinic. Quoting from that linked Medical Tourism Magazine article: "Known for being one of the preeminent medical institutions in the world, (Cleveland Clinic) has been rated #4 in Overall Best Hospitals and #1 in Heart Care by US World & Report. A major center for Inbound Medical Tourism into the US...welcomes thousands of patients, both national and international, for treatment each year."
So how does this impact health insurance? More specifically, lets consider the impact on large self-funded groups.
Example
Your client, benefit manager Carol at Gadgets, Inc (employing 280 individuals in Memphis, Tenn.) says her top sales staffer, Jim, needs a serious heart procedure and doesn't like local options. He'd like approval to go to Cleveland Clinic in Ohio.
Jim is an essential employee and their top driving force in product development. Jim's patents, to a large extent, are the company. But Carol assumes the cost will be extremely prohibitive, but at the same time need Jim in good health, and happy.
Guess what, because Cleveland is so exceptional they do a lot of these procedures. Don't be surprised when I tell you the cost is probably less than at the best Memphis hospital. Cleveland Clinic employs the lean methodology to get the most efficient and quality care possible.
So Carol decides to strike a deal with Jim and share the extra out-of network costs that go above the normal in-network coverage if the procedure were perform in network. To aide the coverage of those extra costs she also looks into another possibility.... stop loss coverage to protect both the company from potential extra costs from complications.
Here's how: According to Kristen Montez, director of legal and regulatory services at Satori World Medical writing for Agent and Sales Journal "stop loss insurance in the medical travel industry provides significant financial protection for the client".
Agent/ Broker Intervention
If an insured can prove medical necessity is only one part of the equation. To gain benefits out-of-network, often there are pre-certification requirements or a lengthy review process. Its possible that the procedure may even be cheaper with an out-of-nwtwork provider or perhaps the fee can be negotiated to make it palatable to the insurer.
This is an area where a little research and extra effort by an agent can really pay off in retaining renewals with the employer group. Helping the employer contact or a key employee research their coverage options can pay off, literally, down the road. <
