Third Party Payers – Health System Example

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"Third Party Payers" is a perfect example of a paper on the health system. Huge populace prefers acquiring health care from a strategic operated care plan on Health Maintenance Organization, Preferred Provider Organization, and Point of Service Plan. The above bodies endeavor to ensure the well-being of the subscribers and ensure that the costs are consumer-friendly. The organization covers an extra mile in giving information on the advantages and disadvantages of using some subscribers. Since time immemorial consumers, prices have always been monitored to ensure that manufacturers do not harass them.

The Insurance policy providers have both similarities and differences affiliated to them; the benefits accrued to the policyholders; their dependants and the providers cannot pass without mention (Ubokudom, 2012). The Similarities and Differences of different policyholders Currently, almost all individuals covered by wellbeing plans get the attention they need to curb the problem they are ailing. However, it has a limitation in that the health plan can decide that the treatments the doctor and the patient prefer are insufficient medically, in this case, they will not allow such treatment to be carried out in the patient.

The cases likely to harbor such arguments are cases where there are no clear lines between what to undertake and what not to undertake, where the care is new and unfamiliar, and cases where the care has not been medically proven. Centralized and state laws in deciding the health plans a person feels bests suits your recovery process (Beaulieu, Zimmerman & Harvard Business School, 2005) cover the consumers of the services. The Negative Aspects of the Insurance Policy Holders The rights are titled to but not limited to the country of residence and the nature of your health plan.

It is worth noting that some countries have a general assumption on all the three bodies of insurance coverage plans whereas others have specific requirements for a particular kind of managed treatment plans like the HMOs. Internal review procedure applies to both federal plus state policies where the health plans are responsible for the assessment of the denials. Federals always demand that employer-geared health plans follow the processing claims requiring domestic examination of the appeals. Self-sponsored insurance maintains that the state sets the standards of the rules and regulations to adhere to.

Overall, it is wise to say that state’ s requirements apply to both parties whether self-sponsored or employer-sponsored provided it does not interfere with the set federal policies (Health Lawyers Association, 2001). Who Is Affected and How They Are Affected, the Dependents and the Providers The majority of states are trying to contest a health denial benefit by adopting the external review in order to dispute unreasonable health plans with external reviews, due to the changing times. The external or independent review normally gives an unprejudiced way of handling an argument amid patients and the current health plans.

The review, naturally made by a panel associated with the health procedure, made an external assessment plan. It was later noted that 43 states amongst them the District of Columbia had accomplished an independent assessment program. The plan is helpful in steering the internal request process and the parties’ independence review process especially in cases dealing with the employer. However, the guide is forbidden for Medicaid Health procedures since this is a dissimilar entity and set of regulations (Ubokudom, 2012). Conclusion It is paramount for the policyholder to know the contents of his/her coverage before presenting himself or herself in a dispute with the health plan.

Knowing your coverage bills gives one a firm ground to stand on in an argument, and questions are provided to ensure that the holder understands the section at the end of section one. The next section requires the client to know when to use the internal and external appeal plan, normally most state governments require one to exhaust the internal appeal procedure before engaging in the independent appeal plan.

Section 3 entails the benefits accrued from using the independent assessment process. Section four majors inexperienced found in the independence or external assessment series. Finally, section five gives a synopsis of the milestones of the independent review procedures and the person to talk to in case of unclear issues. Reading state’ s program helps the clients have an overview of the crucial points that one should never miss (Beaulieu, Zimmerman, & Harvard Business School, 2005).      


Beaulieu, N. D., Zimmerman, A. M. G., & Harvard Business School. (2005). The New England

Patriots: Making the team. Boston: Harvard Business School. Caldwell, D. H., & American Health Lawyers Association. (2001). U.S. health law and policy, 2001: A guide to the current literature. San Francisco: Jossey-Bass

Ubokudom, S. E. (2012). United States Health Care Policymaking: Ideological, Social and

Cultural Differences and Major Influences. Dordrecht: Springer.

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