Method 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 method for limiting exposure to liabilities in a private medical benefit Plan arising from a need for a specific medical treatment, said method comprising:
 modifying a criteria of said private medical benefit Plan using a processor to limit payment on behalf of a patient to a provider for said medical specific 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 said specific treatment; and   modifying the criteria of said private medical benefit Plan using a processor to limit payment on behalf of said patient to a provider for providing said patient with said specific treatment in excess of N treatments to an amount which is X % above a Medicare allowable amount for said specific treatment.   
     
     
         2 . The method of  claim 1 , wherein said private medical benefit Plan provides for obtaining secondary coverage by a government sponsored secondary coverage payer. 
     
     
         3 . The method of  claim 2 , wherein said secondary coverage payer is Medicare Part B. 
     
     
         4 . The method of  claim 1 , wherein said specific medical treatment is renal dialysis maintenance services. 
     
     
         5 . The method of  claim 1 , wherein said Medicare allowable amount comprises a Maximum Allowable Benefit under Medicare Part B. 
     
     
         6 . The method of  claim 1 , further comprising:
 determining if any private medical benefit Plan members are diagnosed with ESRD and whether any such ESRD-diagnosed private medical benefit Plan members are already enrolled in Medicare Part B; and   if any such ESRD-diagnosed private medical Plan members are not enrolled in Medicare Part B, instructing such ESRD-diagnosed private medical Plan members to enroll in Medicare Part B.   
     
     
         7 . A method for limiting exposure to liabilities in a private medical benefit Plan arising from a need for a specific medical treatment, the method comprising:
 modifying a criteria of the private medical benefit Plan using a processor to limit payment on behalf of a patient to a provider for the medical specific treatment to a patient for an initial period of time to a predetermined percentage Y % of the private medical benefit Plan's allowable amount for the specific treatment; and   modifying the criteria of the private medical benefit Plan using a processor to limit payment on behalf of the patient to a provider for providing the patient with the specific treatment in excess of the initial period of time to an amount which is X % above a Medicare allowable amount for the specific treatment.   
     
     
         8 . The method of  claim 7 , wherein the initial period of time, is the period prior to which the patient is eligible to enroll in Medicare. 
     
     
         9 . The method of  claim 7 , wherein said private medical benefit Plan provides for obtaining secondary coverage by a government sponsored secondary coverage payer. 
     
     
         10 . The method of  claim 9 , wherein said secondary coverage payer is Medicare Part B. 
     
     
         11 . The method of  claim 7 , wherein said specific medical treatment is renal dialysis maintenance services. 
     
     
         12 . The method of  claim 7 , wherein said Medicare allowable amount comprises a Maximum Allowable Benefit under Medicare Part B. 
     
     
         13 . The method of  claim 7 , further comprising:
 determining if any private medical benefit Plan members are diagnosed with ESRD and whether any such ESRD-diagnosed private medical benefit Plan members are already enrolled in Medicare Part B; and   if any such ESRD-diagnosed private medical Plan members are not enrolled in Medicare Part B, instructing such ESRD-diagnosed private medical Plan members to enroll in Medicare Part B.