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The United States has a multi-payer health care system, with various sources serving as payors for health care services. This includes government agencies at federal, state, and local levels, as well as private companies such as commercial health plans and individuals who pay out-of-pocket for costs. Health care payment and delivery in the U.S. is generally based on two systems: fee-for-service (FFS) and managed care.

In this seminar, attorney Eric Boughman explains how healthcare reimbursement involves the payment that healthcare providers receive for delivering services to patients, often described as reimbursement. The health care payor typically reimburses the provider based on the agreed-upon amount for the health care services provided. Healthcare payors offer health plans with eligibility criteria for beneficiaries or enrollees, which may vary depending on whether they are public or private. Health plans may not cover all costs, and enrollees may need to pay premiums, deductibles, copayments, or coinsurance as out-of-pocket costs. Some health plans have out-of-pocket limits that cap the amount an enrollee has to pay, and after reaching the limit, the health plan will cover all health care costs. Coordination of benefits may be necessary when an individual participates in multiple health plans, and the health plans will work together to determine payment responsibilities. In certain circumstances, the payor may be the individual themselves, as in alternative payment models.

In discussing payment and delivery systems, Eric will go through how historically, healthcare payors, both public and private, used a fee-for-service (FFS) system to reimburse providers for healthcare services. However, as healthcare costs rose, different payment models and systems were developed. The Centers for Medicare and Medicaid Services (CMS) partially shifted from FFS to prospective payment systems, such as the Medicare Inpatient Prospective Payment System (IPPS) and the Medicare Outpatient Prospective Payment System (OPPS), for certain providers. Private payors and some state Medicaid programs also began to create managed care plans.

We will also talk about private or commercial healthcare payors and public payors. Private payors are health insurance companies that offer a wide range of health care plans, including employer-based plans, individual plans, Medicare Advantage (MA) plans, MA-PDPs, PDPs, and Medicaid managed care plans. These commercial health plans can be fee-for-service (FFS) or managed care plans, and they must cover certain essential health benefits while also having the flexibility to choose additional benefits to offer. Public payors in the United States, including federal, state, and local government agencies, administer programs such as Medicare and Medicaid through the Centers for Medicare and Medicaid Services (CMS), TRICARE through the Department of Defense (DoD), Veterans Health Administration through the Department of Veterans Affairs (VA), and the Federal Employees Health Benefits (FEHB) Program through the Office of Personnel Management (OPM). Most health care services covered by public payors are delivered through private systems of health care providers, except for the VA, which primarily uses its own system of providers, and the Indian Health Service (IHS), which combines private and public systems.

Finally, attendees will learn about alternative payment models and options. We will discuss self-pay, direct patient contracting, direct primary care, and concierge medicine. Self-pay refers to individuals paying for health care items and services directly out of pocket, often when the services are not covered by their health plan or if they are uninsured or underinsured. Direct patient contracting involves physicians or physician practices directly contracting with patients for payment, usually through a flat membership or administrative fee, without involving traditional health plan coverage. Direct primary care is a type of direct patient contracting where patients pay a membership fee to a primary care physician practice for defined primary care services. Concierge medicine is a similar model where patients pay a membership fee for a defined set of health care services, often on a monthly, semi-annual, or annual basis, in addition to any deductibles, copayments, or coinsurance required by their health plan.