System for limiting exposure to liability in medical benefit plans

Abstract

Systems and methods are provided to limit exposure of medical Plans to high liabilities for renal dialysis without exposing the insured patient to out-of-pocket liability while still allowing the patient to receive dialysis as they need it. In one embodiment, this goal is achieved by providing an ERISA medical insurance Plan structure that limits Plan responsibility to 125% of the Medicare approved amount for the services provided, and simultaneously supplements coverage of the patient under Medicare Part B. Because Medicare regulations prohibit providers from balance-billing patients subsequent to billing Medicare, the patient cannot be billed for amounts in excess of the Plan limits.

What is claimed is: 
     
         1 . A system for administering medical benefit plans, the system comprising:
 a computer controlled processor to enroll a private medical benefit plan member having a medical condition in a government controlled third-party payer plan according to the rules of the third-party payer plan, the enrollment entitling the private medical benefit plan member to use the third-party payer in a secondary capacity to the private medical benefit plan for the medical condition subject to any coordination of benefits period statutorily imposed by the third-party payer plan;   the computer controlled processor paying to a provider of certain medical services a private medical benefit plan determined amount for a certain number N of certain medical services; and   the computer controlled processor paying to a provider of the certain medical services to the private medical benefit plan member an amount that exceeds by a certain pre-established amount a maximum payment amount, the maximum payment amount is set by Medicare, such that the provider must seek compensation for any underpayment to the third-party payer plan.   
     
     
         2 . The system of  claim 1  wherein the third-party payer plan is Medicare Part B. 
     
     
         3 . The system of  claim 1  wherein the medical condition may require maintenance renal dialysis. 
     
     
         4 . The system of  claim 1  wherein the maximum payment amount comprises a Maximum Allowable Benefit under Medicare Part B. 
     
     
         5 . A non-transitory computer-readable storage medium with an executable program stored thereon to instruct a processor to perform the steps comprising:
 enrolling a private medical benefit plan member having a medical condition in a government controlled third-party payer plan according to the rules of the third-party payer plan, the enrollment entitling the private medical benefit plan member to use the third-party payer in a secondary capacity to the private medical benefit plan for the medical condition subject to any coordination of benefits period statutorily imposed by the third-party payer plan;   paying to a provider of certain medical services a private medical benefit plan determined amount for a certain number N of certain medical services; and   paying to a provider of the certain medical services to the private medical benefit plan member an amount that exceeds by a certain pre-established amount a maximum payment amount, the maximum payment amount is set by Medicare, such that the provider must seek compensation for any underpayment to the third-party payer plan.   
     
     
         6 . The system of  claim 5  wherein the third-party payer plan is Medicare Part B. 
     
     
         7 . The system of  claim 5  wherein the medical condition may require maintenance renal dialysis. 
     
     
         8 . The system of  claim 5  wherein the maximum payment amount comprises a Maximum Allowable Benefit under Medicare Part B. 
     
     
         9 . A system for limiting exposure to liabilities in a private medical benefit plan arising from a need for a specific medical treatment, the system comprising:
 a computer controlled processor executing instructions to modify a criteria of the private medical benefit Plan to limit payment on behalf of a patient to a provider for the specific medical treatment to a patient for an initial number N of treatments to a predetermined percentage Y % of the private medical benefit plan's allowable amount for the specific treatment;   the computer controlled processor executing instructions to modify the criteria of the private medical benefit plan to limit payment on behalf of the patient to a provider for providing the patient with the specific medical treatment in excess of N treatments to an amount which is X % above a Medicare allowable amount for the specific treatment.   
     
     
         10 . The system of  claim 9  wherein the specific medical treatment is renal dialysis maintenance services. 
     
     
         11 . The system of  claim 9  wherein the Medicare allowable amount comprises a Maximum Allowable Benefit under Medicare Part B. 
     
     
         12 . The system of  claim 9  further comprising:
 the computer controlled processor executing instructions to determine if any private medical benefit plan members are diagnosed with ESRD and whether any such diagnosed private medical benefit plan members are already enrolled in Medicare Part B, and if any such members are not so enrolled, enrolling such members.