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This is to certify that the
thesis entitled

OUT-OF-NETWORK STUDENT-ATHLETE HEALTH CARE:
A SURVEY OF THE BIG TEN CONFERENCE AND SELECTED
HEALTH MAINTENANCE ORGANIZATIONS

presented by

Kari Ann Langley

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OUT-OF-NETWORK STUDENT-ATHLETE HEALTH CARE:
A SURVEY OF THE BIG TEN CONFERENCE AND SELECTED
HEALTH MAINTENANCE ORGANIZATIONS
By

Kari Ann Langley

A THESIS
Submitted to
Michigan State University

in partial ﬁIlﬁlltnent of the requirements
for the degree of

MASTER OF SCIENCE

Department of Kinesiology

1998

ABSTRACT
Out-of-Network Student-Athlete Health Care:
A Survey of the Big Ten Conference and Selected
Health Maintenance Organizations
By

Kari Ann Langley

Student-athletes across the country are going away to school not knowing how
their medical expenses are going to be covered, especially when their insurance company
is a health maintenance organization (HMO). This particular type of insurance company
may introduce problems when a student-athlete attends school out-of-network according
to their policies. Fortunately for the athletic department, recommendations have been set
forth to guide the primary insurance ﬁler in acquiring coverage by the HMO.

The purpose of this paper is to determine if the Big Ten University insurance
ofﬁcers are utilizing these recommendations and to determine if the medical directors of
HMOs are willing to consider these recommendations. Two separate surveys were
devised. One was sent to all Big Ten athletic insurance ofﬁcers and the second was sent
to medical directors of randomly selected HMOs. It was found that the insurance ofﬁcers
were not utilizing the recommendations to the extent that it is suggested they be used and
that the medical directors were inconsistent with their responses regarding the

recommendations.

Copyright by
Kari Ann Langley
1998

In loving memory of my mom, Pamela Ann.

iv

ACKNOWLEDGMENTS

I would ﬁrst and foremost, like to thank my father, Jim, his wife and my mother
ﬁgure, Linda, and my brother and best friend, Chris, for their continued interest and
dedication to my dreams and me. It is because of their support that my college
experience has proved to be forever meaningful and memorable.

I would also like to thank my committee members Dr. John Haubenstricker, Dr.
Jeff Kevan, and Sally Nogle for their guidance and assistance in completing this project.
Without their wisdom and patience, this thesis would not have been possible. To this
day, Sally remains my mentor and someone I will always look up to as an exemplary role
model for me in this profession.

I would also like to recognize the faculty and staff at Valdosta State University,
both past and present, who prepared me and then encouraged me to pursue graduate
school. Jim Madaleno, especially, has played an instrumental role in my success as an
athletic trainer. He helped to position me with a tremendous athletic training staff and
experience here at Michigan State University, all of which I am humbled by.

In the event that I missed mentioning someone, I would like to thank all of those
who have stuck by me, encouraged me, and endured me, including but not limited to
Brandi V. Kreh, Julie A Neal, S. Anne Campbell, Tory Lindley and LouAnne Jefferson.

Finally, and most importantly, I thank God and pray he will continue to guide me

as I close this chapter of my life and begin yet another chapter of my life.

TABLE OF CONTENTS

LIST OF TABLES .................................................................................. vii
LIST OF ABBREVIATIONS .................................................................... viii
CHAPTER I
INTRODUCTION ..................................................................... 1
Need for the Study ............................................................ 4
Statement of the Problem .................................................... 5
Research Questions ........................................................... 5
Assumptions, Limitations, and Delimitations ............................. 7
CHAPTER II
REVIEW OF LITERATURE ......................................................... 8
CHAPTER III
METHODS ............................................................................ 26
Participants .................................................................... 27
Instrumentation ............................................................... 27
Data Collection ............................................................... 29
Data Analysis ................................................................. 29
CHAPTER IV .
RESULTS .............................................................................. 30
CHAPTER V
DISCUSSION ......................................................................... 38
CHAPTER 6
CONCLUSION AND RECOMMENDATIONS ................................. 46
GLOSSARY ......................................................................................... 49
APPENDICES
A Consent Forms ........................................................................ 51
B. Survey Instrument for University Insurance Ofﬁcers ........................... 53
C. Survey Instrument for Insurance Company's Medical Directors ............... 57
REFERENCES ...................................................................................... 61

LIST OF TABLES

Table 1 - Recommendations from the Literature Regarding Out-of-Network Care ......... 6
Table 2 - Big Ten University Gender and Sport Demographics .............................. 31
Table 3 - Insurance Administration: Job Title and Training .................................. 31
Table 4 - Current Cost-Containment Practices of Big Ten Insurance Ofﬁcers ............. 33
Table 5 - HMOs and their Stand Conerning the Recommendations ......................... 36

LIST OF ABBREVIATIONS

AMCRA .................................... American Managed Care and Review Association
CMP ......................................... Competitive Medical Plans

GHAA ...................................... Group Health Association of America

HMO ........................................ Health Maintenance Organizations

NCAA ....................................... National Collegiate Athletic Association

OOP ......................................... Out-of-Plan

PPO .......................................... Preferred Provider Organizations

USDE ....................................... U. S. Department of Education

Chapter I

INTRODUCTION

Advancements in medical technology have been invaluable considering there has
been a 50% increase in adult life span from 40 to 60 years (Ginzberg, 1995). However,
along with these advancements in medicine come increases in health care costs (Amett,
Cowell, Davidoﬁ‘, & Freeland, 1985). Most informed investigators give credence to the
continuing rise in health care costs to the innovations that ﬂow from the discoveries in
the research laboratories (Ginzberg, 1995). Health insurance coverage is a necessity,
therefore, in order to beneﬁt ﬁ'om and afford these new discoveries and prosper from a
longer life span.

A recent article published in the November issue of the NATA News described
the delivery of health care for college students attending school away from home (Hunt,
1997). A more in-depth evaluation of the literature as a result of this article indicates that
students attending college away from home are sometimes left without medical coverage
(Hunt, 1997; Scitovsky, Benham, & McCall, 1981; Capell, 1997, Bushee, 1996; Clark,
1997; Chambers, Ross, & Kozubowski, 1986). Currently, the literature demonstrates that
the lack of health insurance coverage is often overlooked when going away to school and
10% ofall students will go to college uninsured (Clark, 1993).

As long as the percentage of students enrolled in college continues to increase as
it has from 1985 to 1995 exhibiting a 27.8% to 34.3% shift, the issue of on-campus

l

medical care is signiﬁcant (Census Bureau, 1997). Currently, accOrding to the National
Collegiate Athletic Association (NCAA), representing Division I college campuses
across the nation, 12% of the entire student body are student-athletes, 8.5% at Division H,
and 16% at Division III (Petr, 1998). From these ﬁgures, it is apparent that students are
choosing to participate in sports while they continue their education. As these student-
athletes participate in sports, they are also placing themselves at a higher risk to become
injured than the normal population. Moreover, student-athletes commonly have different
needs than those of the normal population in terms of time to diagnose, treat, and
rehabilitate (Henehan & Jones, 1997).

Recently, the US. Department of Education reported that 79.6% of all college
students are between the ages of 18-24 (U .S. Department of Education [U SDE], 1997).
Most employer health plans cover dependent full-time students up to 23 and sometimes
25 years of age. Therefore, the student-athlete is presumably covered by a health plan
(Clark, 1993). However, it is important to understand how bills are going to be paid if a
student-athlete becomes injured while on-campus (Sallis & Massimino, 1995; Clark,
1993). Student-athletes who are medically covered under a managed care service,
speciﬁcally a health maintenance organization (HMO), are limited to the non-emergent
care rendered to a certain geographical region (Clark, 1993; Chambers, Ross, &
Kozubowski, 1986). Student-athletes do not choose which institution to attend on
whether or not they are medically covered. In addition, athletic departments do not limit
their search for talented athletes to the immediate vicinity of their university. In fact,

recruiting at major universities stretches from coast to coast.

HMOs, begun 52 years ago, are health delivery systems which assume
responsibility for ﬁnancing and providing comprehensive health care services to a
voluntarily enrolled population for whom periodic premiums are paid (American
Managed Care and Review Association [AMCRA], 1994; Rogers, 1993; Anderson, 1995;
Shouldice, 1991). Each emailed member of an HMO is required to choose a primary
care physician (PCP), often referred to as the ”gatekeeper". This term means that the
PCP is the person who sees all patients assigned to him or her and then makes the
necessary referrals (Anderson, 1995). However, a PCP is usually located in the
hometown of the student-athlete where the parents currently live. It is very difﬁcult for
the student-athlete to travel home to see his or her PCP when academies or athletic
competition could be compromised. Moreover, if the student-athlete goes out of the
college community for care, it is laborious for the university's medical staff to maintain
proper records. Timely follow-up medical attention for the student-athlete will also be an
issue because the PCP in control of the medical care for the student-athlete is not as
accessible as the university's team physician.

As the number of HMOs and their enrollees increase, the chances of out-of-
network coverage for non-emergent claims to be denied also increases. At this point, the
out-of-network student-athletes have two choices. First, they may consider putting away
money for possible medical expenses or, secondly, buy into the university's student
insurance policy to cover those cases that are not an emergency. Regardless of the
premiums already being paid by the parents to cover their dependents, this additional

coverage may prove to be cost effective (Shea, 1995; Clark, 1993). However, it would be

important to be sure that the student health plan covers athletic injuries prior to
purchasing.

Fortunately for the student-athletes, a majority of the universities will voluntarily
assume secondary coverage for athletic related injuries and illnesses. For example, once
the student-athlete's primary insurance company is billed; the university pays the balance
(Lehr, 1992; Hart & Cole, 1992). As of 1992, 85% of all institutions provide secondary
insurance coverage, including Divisions 1, II, and III (Lehr, 1992). Therefore, the end
result is generally increased out-of-pocket expenses for the university's athletic
department due to every uninsured and out-of-network student-athlete unless the student-
athlete returns home to acquire a proper referral (W alters, 1994).

W

Effective communication between the insurance oﬂicers of athletic departments
and the medical directors of insurance companies can possibly aid in addressing several
issues. Insurance ofﬁcers of universities are in need of ﬁnding methods for maintaining
control over the medical care provided to student-athletes. These methods could prove to
be effective in controlling out-of-pocket expenses in two separate areas: (1) for the
athletic departments who do provide secondary coverage for athletic injuries and (2) for
student-athletes whose athletic department does not provide secondary coverage for
athletic injuries. This increase in communication can guide insurance ofﬁcers to a better
understanding of patterns of referral, reimbursements for medical services, and access to
specialized testing (Henehan & Jones, 1997; Sallis & Massimino, 1995; Bushee, 1996,

Walters, 1994).

Statement of the Problem
The purpose of this study was twofold. The ﬁrst purpose was to determine if the

college athletic insurance ofﬁcers are currently communicating with HMOs, attempting
to acquire out-of-network medical coverage for student-athletes. The second purpose
was to determine if HMOs are knowledgeable about student—athletes falling out-of-
network, who are not covered as determined by company policies, and if they are
responsive to the requests of university insurance ofﬁcers.

Wight»

This study examined selected questions about the association between athletic
insurance administration and HMOs. The survey, administered to the insurance ofﬁcers
of the Big Ten Conference, was designed to elicit responses to the following questions:
(1) Are university insurance ofﬁcers in the Big Ten Conference trained to perform their
.job?

(2) Are the recommendations set forth in the literature being utilized to maintain
authority over the medical care provided to student-athletes (see Table 1)?
a) What percentage of the insurance oﬁ'lcers are requesting a temporary appointment

of a primary care physician (Ray, 1994)?

b) What percentages of the insurance oﬁcers are requesting information from the

insurance companies (Ray, 1994)?

c) What percentage of the insurance ofﬁcers are pre-authorizing medical services?

Which medical services are they pre-authorizing (Ray, 1994)?

d) What percentage of the insurance oﬁ'lcers are mentioning free rehabilitation and

follow-up visits in their conversations with the HMOs (Bushee, 1996).

e) What percentage of the insurance ofﬁcers are requesting a percentage of the

company's usual, reasonable, and customary rate (UCR) (Bushee, 1996)?

i) What percentage of the insurance officers are requesting the involvement of the

team physician (Bushee, 1996)?

(3) What percentage of the insurance ofﬁcers experience difﬁculty acquiring referrals to

the university's team physicians from local PCPs for in-network student-athletes?

Table 1

 

 

 

R m n l n Author

1. Explain that the rehabilitation and follow-up care is free. Bushee
2. Attempt to ﬁnancially negotiate coverage for student-athlete. Bushee, Walters
3. Request that the team physician contact the medical director. Bushee
4. Request that the HMO pay the deductible for the university's

secondary insurance carrier. Bushee
5. Request a percentage of the UCR Bushee
6. Request literature from the insurance company. Ray, Bushee
7. Request that the HMO allow a temporary PCP appointment. Ray

 

The survey administered to the HMOs elicited responses to the following questions:

(1) Are insurance companies cognizant of the issues surrounding out-of-network students

such that they provide rider options to the subscribers?

(2) Are the medical directors responsive to the requests that the universities' insurance

ofﬁcers propose regarding out-of-network coverage for students?

(a) How frequently will insurance companies appoint a temporary primary care

physician?

(b) How frequently will insurance companies forward literature regarding the policies
and procedures of the company concerning out-of-network usage?

(c) How frequently will insurance companies pay a percentage of the UCR for
medical services rendered out-of-network in exchange for free rehabilitation and
follow-up visits?

(3) How frequently do medical directors of insurance plans place sports medicine
specialists on the decision committee?

(4) How frequently do insurance oﬂicers provide transportability of coverage (allow the
coverage to extend to the subscribers new geographical location) for those attending
school out-of—network?

W

The researcher assumed that the responses elicited through the surveys
administered were representative of both universities and HMOs around the country.

The limitations of this study involved the usage of the after-the-fact survey method. This

particular methodology induced some on-stage affects and attrition that possibly affected

the results of the study. Finally, due to the large number of universities and HMOs in the
country, the researcher limited the administration of the survey to insurance ofﬁcers in
the Big Ten Conference and a random selection of 45 HMOs were surveyed. This

allowed for a manageable research study for the solitary author.

Chapter 11

REVIEW OF LITERATURE

The purpose of this study was twofold. The researcher intended to assess if
insurance ofﬁcers in the collegiate setting are working to maintain costs and to keep
student-athlete health care within the college community by utilizing the
recommendations set forth in the literature. Secondly, the researcha wanted to determine
if medical directors of HMOs are willing to consider the recommendations, presented in
the literature by athletic trainers, concerning out-of-network student-athletes. The intent
was to increase awareness of this issue, increase the continuity of care within the
university community, and decrease out-of-pocket expenses by attaining coverage {Tom
the primary insurance company.

Overview of Key Articles

Athletic trainers and team physicians have recognized that managed care is a
major component of their daily administrative insurance duties (Frankel, 1991). The
need to understand managed care has been prompted by the urgency to address the
challenges insurance policies pose regarding continuity of care, patterns of referral,
reimbursements for medical services, and access to specialized testing (Henehan & Jones,
1997; Sallis & Massimino, 1995; Bushee, 1996). Although there have been many studies

on managed care and its overall performance, there has been little research on the

signiﬁcance of managed care and sports medicine on the health care of student-athletes
(Sallis & Massimino, 1995).

In an article published in the NATA News, Rod Walters of the University of
South Carolina also noted the issues surrounding out-of-network student-athletes and the
limitations of their primary insurance (Hunt, 1997). He made a strong statement about
increasing communication between the insurance companies and the university's health
care team to help promote college community care for student-athletes. At Boston
College, Steve Bushee (1996) has been arranging health care for out-of-network student-
athletes and has proposed ﬁve recommendations to assist other athletic trainers: (I)
explain to the HMO that the student-athlete is a student and going out of the university
area for surgery or rehabilitation will disturb the education process in addition to delaying
the return to competition, (2) make sure the HMO is aware that rehabilitation and follow-
up visits are free if the team physician renders the services (3) contact the I-IMO's
member beneﬁts manager, explain the previous points, then begin to negotiate a payment
agreement, (4) ask the team physician, as well as the parents, to contact the medical
director and make the same points and, (5) request that the student-athlete's primary
insurance company pay the university's deductible for its secondary insurance carrier.
Some of these same guidelines were also brought up in Richard Ray's Management
Strategies for the Athletic Trainer (1994). Ray suggests that the athletic trainer propose
to the insurance company that a temporary primary care physician be appointed for the
student-athlete's collegiate career.

Even though Bushee and Walters assert to having success with the

recommendations aforementioned, Carol Malouf of Continental/NACDA Insurance, who

issues policies for many universities, noticed that many of the insurance companies are
denying referrals. Greene (1997) attributes this to the outside pressures to decrease
premiums, especially with the community-focused HMOs. There is an identiﬁed gap in
the literature investigating out-of-network student-athletes, the administration of their
health care, and the subsequent payment for medical services. However, it is important
to understand how managed care has evolved, its characteristics, its goals and
philosophies; how insurance companies are dealing with out—of-network issues; and then
speciﬁcally how they tackle the issue of student-athletes who seek to further their
education at institutions out of the insurance company's predetermined geographical
service area.
Current Status of Coverage Provided by Athletic Departments

A 1992 article written, by Carolyn Lehr of the University of Georgia, investigated
the extent and type of medical insurance coverage arranged for student-athletes at NCAA
institutions. Lehr developed a questionnaire that demographically deﬁned each
_ institution as public or private, the undergraduate enrollment, NCAA division and sports
oﬂ‘ered. The second portion of her survey solicited information regarding the types and
availability of insurance for the student-athletes. She demonstrated that there are
currently no regulations that mandate coverage or limits for coverage for student-athletes.
She does recognize, however, that the basic medical plan coverage is "limited to injuries
sustained in scheduled games, supervised practices, and team travel" (p. 12). However,
her premise to investigate student-athlete heath care was prompted by the increase in

litigation and insurance costs of medical care.

10

Lehr began by surveying the athletic directors of NCAA Divisions 1, II, and II
institutions. She found that most of the schools relied on other forms of insurance.
policies, such as student heath and/or the parent's policies, to provide primary coverage.
Therefore, Lehr's postulate was upheld and is demonstrated by the following: 81% of
Division I schools, 90% of Division II schools, and 88% of Division III schools offer
insurance coverage secondary to that student-athlete's primary insurance for a combined
average of 85% for all institutions. Only 13% of Division I schools, 7% of Division I]
schools, and 3% of Division 1]] schools provide primary medical coverage for student-
athletes injured in practice, competition, or sport related travel.

Managed Care Deﬁned

Managed care organizations are delivery systems of health care with the goal of
providing quality care at an aﬁ‘ordable cost (Anderson, 1995; Campbell, 1997; Greene,
1997, Iglehart, 1992; Miller & Luft, 1994a; Emanuel & Brett, 1993). The concept behind
the managed care plan is to keep people healthy by emphasizing accessibility and
ﬂexibility through careful selection of diverse physicians while monitoring, assuring, and
improving the quality of care (Carter, 1997). There are currently three types of managed
care: HMOs, the preferred provider organization (PPO), and the competitive medical plan
(CMP). PPOs oﬂ‘er a fee-for-serviee health delivery system usually at a discount of the
UCR charges and a CMP is a plan that is independent of the HMO and PPO, but provides
at-risk Medicare and physician services via contracts with individual physicians
(Shouldice, 1991 ; Miller & Luft, 1994b).

Although there are several health plan structures, HMOs are one of the most

popular and are often considered the ”grandfather" of managed care (Carter, 1997). An

11

HMO is an establishment that provides comprehensive health care to enrolled subscribers
at a predetermined monthly fee (Vadakin & Lipton, 1986; Wagner, 1989). This
organization consists primarily of three parts; the consumer or subscriber, the providers
including the primary and specialty physicians and hospitals, and the health plan which
provides organization and management (Shouldice, 1991).

The term “health maintenance organization” did not come into existence until it
was coined by Paul Elmwood in the early 70's. His efforts were to acquire government
support of prepaid health care by emphasizing the positive connotation versus the
negative connotation often associated with the terms ”medical care" or "sickness care”
(Luﬁ, 1981; Greene, 1997). The ideals of this organization parallel those of managed
care in that it strives to provide quality coverage that is available and affordable (Greene,
1997). Providing quality care while containing costs became an issue back in the early
30's when the Kaiser Plan was founded in the west. It was soon considered to be the
most widely known HMO prototype (Ellwood & Lundberg, 1996; Hunt, 1995; Vadakin
& Lipton, 1986; MacLeod, 1989). However, HMOs did not get their ofﬁcial start until
the 1970's when the federal government realized that the concept of prepaid health plans
might help combat the problems associated with the fee-for-service (FF S) indemnity
plans (Vadakin & Lipton, 1986; Friedman, 1986). FFS is a health plan structure that
traditionally bills for each individual service rendered to the patients (Anderson, 1995;
DelPizzo, 1996). With this knowledge, it is obvious that there exists an incentive to
provide more services to increase revenues. Therefore, a need to help reduce this
stimulus was necessary and obtained through the implementation of HMOs (Kongstvedt,

1989; Luﬁ, 1981).

12

To assist in matters supporting HMOs, Congress passed the Health Maintenance
Organization Act of 1973 which required employers to offer their employees a variety of
health plan options (Iglehart, 1994b). In retrospect, this'Act also generated the demand
for more HMOs due to expanded enrollment and interest (Mach 1989). Since then,
HMOs have built a reputation that some argue to be the exact opposite of FFS, meaning
erring on the conservative side to save money. Yet, HMOs have still managed to become
the model program in health care (Hunt, 1995).

In 1989, approximately 32.2 million people were enrolled in more than 550 HMO
health plans (Shouldice, 1991). According to a news release in 1993 by the Group Health
Association of America (GHAA), the number of people subscribing to HMOs increased
by almost four million from nearly 40 million subscribers amongst the now 725 different
HMOs (Iglehart, 1994a; Evenson, 1997; AMCRA, 1994). Furthermore, the GHAA
predicts that in the year 2000, there will be roughly 112.7 million HMO subscribers
(Evenson, 1997). _ As of 1993, half of all persons whose employers provided health
insurance coverage were enrolled in managed care plans and 22% of managed care
insured persons subscribe to HMOs (Inglehart, 1994).

Classiﬁcations of HMOs

There are currently ﬁve distinct models of HMOs that provide care for enrolled
populations with the major difference between each model being the relationship between
the HMO and the staffed physicians (Wagner, 1989; Vadakin & Linton, 1989). Miller
and Luft (1994a) recognize only two major HMO models. Nonetheless, the ﬁve will be
deﬁned and they are as follows: staff, group, network, individual practice association

(IPA), and direct contract.

13

51mm

Staff model or "closed panel” HMOs directly employ physicians. This means that
the physician is paid by the HMO and that the HMO must employ a variety of physicians
to meet the needs of the enrolled population. With this type of plan, non-plan physicians
are not allowed to participate (Wagner, 1989; Miller & Luft, 1994a; Shouldice, 1991).
The advantage to this type of plan is that the HMO has greater control over the physician
practice patterns, but on the other hand, there are a limited number of physicians ﬁ'om
whom the members can choose (Wagner, 1989; Shouldice, 1991).

1 HM s

Group model HMOs contract with multi-specialty physician groups to provide
their members services. This model also employs the closed panel idea where non-plan
groups cannot participate (Shouldice, 1991; DelPizzo, 1996). The advantage with this
type of plan is that the multiple physician involvement and the shared resources involved
in the decision-making equate to more effective medical services.
Nmk Mtge! HMQs

Network model HMOs contract with more than one group practice to provide
services to the HMO members. These contracts are generally limited to large single or
multi-specialty groups (DelPizzo, 1996). It is possible with this service plan for the
medical groups to contract with more than one HMO (Wagner, 1989; Shouldice, 1991;
Vadakin & Lipton, 1986). The major advantage of this type of model is the potentially

increased geographic service area.

14

ivi Pr i citinIPAM elHM

IPAs are the models displaying the greatest number of plans and enrollments
(Wagner, 1989; Miller & Luﬁ, 1994a). This model type was originally designed to
allow physicians to work out of their own omce versus a central facility. IPA models
contract with both group and individual physicians. Physicians also have the freedom to
see their individual patients as well as their HMO patients allowing them an "open
panel" operation (DelPizzo, 1996; Ellwood & Lundburg, 1996; Wagner, 1989). The
advantages of this model type are the broad-based physician choices that practice out of
their own ofﬁces and thus, a decrease in the necessity to refer patients to
nonparticipating physicians to obtain services (Wagner, 1989; Miller & Luﬁ, 1994b).
W

This model directly contracts with each individual physician. The direct contract
draws upon both primary and specialty physicians to render services. This model utilizes
the "gatekeeper" concept extensively where the primary care physician (PCP) authorizes
any referral to specialty physicians and assists with management. The advantage of this
model is that the HMO can avoid mass physician termination that could turn out to be an
inconvenience to its members. The disadvantage would be any unjustiﬁed referrals to
specialists (Wagner, 1989).

In summary, all the models generally have the same goals and philosophies in
mind such that the ”HMO typically limits the choice of providers to the HMO network of
physicians and hospitals: regardless of the contract” (Albolrn, 1996, p.28). Overall, the
advantage of the HMO is found within the name itself, to maintain health via

preventative health services, diagnostic services, accessibility 24 hours a day, and to be

15

reimbursed for emergency services rendered out of the geographical area if found
medically necessary (Chambers, Ross, & Kozubowski, 1986; Shouldice, 1991). Other
advantages involve the ability to choose a PCP and develop a relationship for the duration
of the plan membership (Gold, Hurley, Lake, Ensor, & Berenson, 1995).
A Cem’ sen of the Diffgent Model Types

A study performed by Miller and Luﬁ (1994a) compared the different models of
HMOs looking at health care utilization; level of premiums; use of preventative tests,
examinations, and procedures; quality of care; and enrollee satisfaction versus the FFS
structured plans. Keying in on the ﬁve areas aforementioned, this comprehensive study
was based entirely on the authors' study of previous individual investigations that they
had distinguished and considered relevant. Miller and Luﬁ (1994a) found through their
review of the literature, that HMOs have lower hospital utilization, lower usage of
expensive and arbitrary testing and procedures, and increased preventative services
versus the FPS health plans. When looking at patient satisfaction, members enrolled in
the HMOs were less satisﬁed, however, they reported that it was offset by the decreased
out-of-pocket expenses. Interestingly, however, no signiﬁcant ﬁndings indicated that one
model HMO performed better than another model HMO. Unfortunately, the overall
quality of care was not assessed due to difﬁculty with interpreting the inconsistencies of
the studies selected for review. Also it is interesting to note that the results of this
literature analysis conﬂicted with a previous literature analysis done by Luﬁ (1981)
concerning the different HMO plans. In 1981, Luft found some nonspeciﬁc performance
differences among the different models. Miller and Luft ( 1994a) attribute the differences

in their results ﬁ'om the results of Luft's 1981 analysis mostly to the lack of observations

16

for each type of HMO and the profound similarities between the models. Gold et al.
(1995) also found in their study that the HMO models were very similar in their plans.
They found that 55% of the models claimed to be a group or staff model when in fact the
health plans were mixed models. Nevertheless, Miller and Luﬁ (1994a) still concluded
from this review of literature that there were no performance differences.
Characteristics of HMOs

In order to grasp the. philosophy and goals of HMOs, it is important to understand
the characteristics of HMOs. There are eight characteristics commonly associated with
HMOs and these are illustrated by Shouldice (1991) and Miller and Luﬁ (1994b): ( 1)
HMOs are organized systems that provide services including primary, specialty,
ambulatory, and inpatient care, (2) comprehensive beneﬁts including drug coverage,
extended care, home health care, and mental health services in addition to the services
mentioned above, (3) enrollment is voluntary where members are given numerous health
plan options, although other researchers indicate that there is an increased number of
employers who offer only a single health plan option (Emanuel and Dubler, 1995;
Iglehart, 1982), (4) services are rendered in a deﬁned geographical area to promote
accessibility and availability to its members, (5) assume risks to produce incentives to
control costs which Campbell (1997) sees as an advantage because it helps retain a
patient base, (6) oﬁ‘er a prepayment plan for premiums, (7) look to contain costs that will

lead to reduced utilization, and ﬁnally, (8) enhance management through the services of a

"gatekeeper" or a primary care physician.

l7

Use efPrimm Cm Physicians (PCP) Ed the Aethorization System

The idea to use a PCP as a ”gatekeeper” to help maintain costs by controlling
access to other physicians, services, and hospitals has resulted in mixed reports (Hillman,
Welch, & Pauly, 1992). Kassirer (1994) informs that HMOs limit access to specialty
care by implementing the PCP as a mediator. This causes the patients to feel as if they
have lost some control over the kind of care they receive. A study was done in 1989 on
the effects of gatekeepers and their management of medical care provided to patients
(Martin, Diehr, Price, & Richardson, 1989). Martin et a1. (1989) studied new enrollees in
a plan with a PCP and those in a plan without a PCP. Both plans offered the same
beneﬁts and subscribers were randomly assigned to one or the other plan. With the PCP
plan, Martin et al. (1989) established that there was no incentive to limit costs of care,
only to monitor referral care. The PCP was deﬁned as the person responsible for the
primary care, referrals to specialists, ancillary services, and hospitalizations. Those in the
PCP plan were required to choose a PCP and then obtain preauthorization from their PCP
prior to seeing anyone else or they would be solely responsible for the bill. The members
enrolled in the non-PCP plan were permitted to seek out any care they desired within the
city limits and would be reimbursed 100%. Results of the study showed that those
enrolled in the PCP plan had more visits to the PCP, saw fewer specialists, and had lower
hospital visits than the non-PCP group enrollees. At the end of the twelve-month study, a
questionnaire was distributed to measure out-of-pocket expenses and satisfaction with the
plan. The results of the questionnaire did not reveal any difference in out-of-pocket
expenditures between the two plans during the study period. As far as satisfaction of the

enrollees was concerned, the researchers found that those enrolled in the non-PCP plan

18

were more satisﬁed that those enrolled in the PCP plan. The authors of this study did,
however, recognize problems with the study. Martin et al. (1989) recognized that some
of those enrolled on the non-PCP plan may have been used to seeing a PCP ﬁrst and vice
versa. The authors also recognize that those enrolled in the non-PCP plan were aware
that the study would only last for a year, thereby taking advantage of the reimbursement
policy and seeking out several physicians.

Regardless of this ﬁnding concerning PCP plan satisfaction, Emanuel and Dubler
(1995) advocate the importance of preserving the physician-patient relationship between
an enrolled member and a PCP. These authors and Gordon, Baker, and Levinson (1995)
point out in their review of literature that the ”physician-patient relationship is the
cornerstone for achieving, maintaining, and improving health” (p.328). Yet, Emanuel
and Dubler (1995) deﬁned the ideal physician-patient relationship by virtue of the six C's
concept: choice, competence, communication, compassion, continuity of care, and (no)
conﬂict of interest.

”Choice" involves practice setting, primary care physician, specialist, and
treatment alternatives. Emanuel and Dubler (1995) state that the enrollees have the
option to decide or choose what is best for them regarding the practice setting, primary
care physician, specialists, and treatment alternatives. Communication, competence, and
compassion are those virtues the authors argue that the PCPs should work to maintain and
uphold. Continuity of care is an element that the authors support; once the relationship is
established, it should endure over time. Emanuel and Dubler (1995) argue that the
stronger the relationship, the better the physician can prescribe the appropriate services.

The concept of no conﬂict of interest includes having the best interest of the patient in

19

mind and putting aside the physician's own personal interests, especially those of a
ﬁnancial nature.
Mileage

As long as HMOs restrict their services to a predetermined geographical region
and have a solid authorization system, it is important for the insurance companies to
evaluate out-of-plan (OOP) usage. Two studies have been performed speciﬁcally looking
at OOP use and prepaid group practices.

The ﬁrst study addresses several issues regarding OOP usage (Scitovsky,
Benham, & McCall, 1981). The authors attempt to address the extent of OOP use in
terms of the number, the services, the characteristics of the OOP users, and the out-of-
pocket expenses for the OOP users. In addition to this, the authors make an effort to
review the problem of deﬁning and measuring OOP use.

niti f ut-of- 1 se. The exact deﬁnition for out-of plan use has been
rather ambiguous and inconsistent (Scitovsky et al., 1981). Some researchers deﬁne it as
a service attained by a plan member from a non—plan physician or some other type of
health professional (Richardson, Boscha, Weaver, Drucker, & Diehr, 1976). In most
studies there are three elements that deﬁne OOP use; ( 1) services not covered by the plan
and therefore not paid by the plan, (2) services covered by the plan, obtained from non-
plan physicians but were covered because the plan member was out of the area, in the
midst of an emergency, or was referred, and (3) services covered by the plan that plan
members received ﬁ'om non-plan providers and were therefore not reimbursed. In a
study performed by Pope, Freeborn, and Greenlick (1972), OOP services are

characterized by the following: (1) services neither covered or provided by the plan; (2)

20

services not covered by the plan but available through the plan; (3) services covered by
the plan but not available at the plan thus utilizing outside physicians on a referral basis;
and, (4) services available through the plan and covered if the services are rendered by
the plan physician. For the purpose of their study, Scitovsky et al. (1981) deﬁned OOP
use as "all medical services other than telephone consultations obtained from non-plan
physicians and paramedical personnel, except those for which the plan paid,” (p. 1170)
due to emergency services rendered when members were out of the area of the plan and
referrals. This means that if a subscriber went out of the system for care without
preauthorization or referral, that service is deﬁned as OOP service.

Scitovsky et al. ’3 study involved retrieving data covering in-plan use from
medical records and OOP use via telephone interviews every three months for a twelve-
month period. At the time of the phone interview, the plan members were asked to report
information on the service, the name of the provider, the reason for going OOP, the place
of service, the out-of-pocket expense, and the type of service obtained. The foremost
question the authors desired to answer was, “How are the beneﬁts packages of a plan
meeting, or failing to meet, the needs of plan members?” Also ﬁ'om this study, the
authors wanted to be able to differentiate the type of people who go OOP.

The authors ﬁrst report the number of OOP usages. They found that in one plan
there was 25.2% OOP usage versus the 31.7% OOP usage in a second plan. Next, the
authors reported the characteristics of OOP users. They found that for a high number of
the plan members “dissatisfaction with the plan” was one of the most important reasons
for OOP use. In regards to the ﬁrst plan, 16.5 % were likely to go OOP when they were

not satisﬁed and 10.8% of the members of the second plan were likely to go OOP for the

21

same reason. Other signiﬁcant characteristics for going OOP included having additional
insurance and the length of time the members were enrolled in the plan. If plan members
were covered by the plan for less than ﬁve years, they were 4.7% more likely to go OOP.
The authors also found that number of family members, age, marital status, and health
status were related to OOP use in one group but not in the other. Incidentally, the greater
the number of people in the family, the less the number of OOP usages. Females were
more likely to be an OOP user than males and the youngest age group (>15 years) was
less likely to go OOP than the oldest age group (45-64 years). There was no statistical
difference between the 15-44 year age group and the oldest age group with respect to the
probability of OOP usage. Finally, the authors cite the top ﬁve reasons for OOP use. Of
the members enrolled in the ﬁrst plan, 50.7% attributed their OOP usage to the fact that
they preferred a non-plan physician. Some members of the second plan also preferred a
non-plan physician (43.5% ). Needing emergency care was the next highest percentage
with 13.8% from both plans. The third reason, being too far away ﬁom plan providers,
was seen more often with the second plan (26.9%) than the ﬁrst plan (13.2%). Next, the
authors found that having to wait too long for an appointment was the fourth reason with
12.1% for the ﬁrst plan and 6.1% with the second plan. The ﬁnal reasons fall under the
"other” category with a plethora of ﬁndings mostly related to conﬁrsion regarding the
policies of the plan. In conclusion, the authors found that their study did not produce
signiﬁcant results of high OOP use and recognize that OOP use will occur from time to
time. The two nrain areas of concern for Scitovsky, et al. (1981) are the dissatisfaction

with the plan associated with OOP use (although the authors never established the root of

22

this dissatisfaction) and, the question regarding duplicate insurance, which the authors
feel, may complicate the evaluation of the rates of usage of each plan.

Two years after the publication of Scitovsky et al.'s (1981) study, Hennelly and
Boxerrnan (1983) resolved to take a closer look at the dissatisfaction of plan members.
They, too, during their review of literature noted that OOP use is strongly correlated with
dissatisfaction of the plan. Therefore, these two researchers reviewed three areas: (1)
factors leading to OOP use, especially the role of satisfaction, (2) factors leading to
disenrollment, and (3) the relationship between OOP use and disenrollment. Data for this
study were collected via a questionnaire sent out to enrolled families. Several
demographic questions were asked in addition to questions that would lead to resolving
the three areas of concern posed earlier. A chi-square analysis was utilized to deduce the
signiﬁcance of OOP usage. The satisfaction variable was determined on a satisfaction
index via the summation of eight scores from eight questions regarding patient
satisfaction. Scores ranged from -2 to +2. The authors found seven factors signiﬁcantly
related to OOP use: (1) age (20.9% OOP use if $29 years), (2) duplicate insurance, (3)
length of membership in the plan, (4) ability to name a regular plan physician, (5) a plan
member‘s perceived health status, (6) days lost from usual activities, and (7) satisfaction
index values. The satisfaction index values revealed members' tendencies to go OOP and
were found to be the most important predictor of OOP use. Due to this, the authors
concluded that dissatisfaction may be due to the ability of family members to identify a
regular physician. Roemer and Shonick (1973) mention that dissatisfaction and OOP use

has been the subject of research on several occasions, however, the term dissatisfaction

23

remains undeﬁned with regards to OOP use. Again, this pattern was observed in the two
studies previously discussed.
Relationship of Managed Care and Sports Medicine

The idea of a PCP as the gatekeeper posed some problems with the sports
medicine department and the out-of-network student-athlete at colleges and universities.
ThePCP actsnotonlyto authorize care, buttoseethatthe service isrendered inan
institution that has contracted with the plan and is medically necessary (Kongstvedt,
1989). The only way a student-athlete can acquire a proper authorization or a referral is
to see his or her own PCP who is typically located in his or her hometown. Otherwise,
the HMO will cover only those procedures that involve emergency care (Bushee, 1996;
Clark, 1997; Hunt, 1997; Chamber, Ross, & Kozubowski, 1986). Henehan and Jones
(1997) have observed that the medical needs of an athlete can be quite different from the
needs of most patients. In fact, the insurance companies typically place limitations on the
PCPs in regards to how quickly, what quantity, and what type of service can be rendered,
which is exactly what the student-athlete requires when suffering from an injury. A
watch-and-wait approach is more or less unacceptable in the world of sports and delays
can often have adverse effects on a sports career. Athletic trainers and team physicians
are not advocating against primary care physicians because it is the primary care
physician who is capable of providing care to at least 75% of all sports related injuries
(Sallis & Massimino, 1995). Moreover, the sports medicine staff proposes appointing a
temporary primary care physician for the student-athlete during the student-athlete's
career for reasons which parallel the goals and philosophies of managed care; namely, to

increase the continuity of care and to maintain a physician-patient relationship (Ray,

24

1994). Ray ﬁrrther explains that if the student-athlete is attending college in the same
town as his or her HMO physician, then the trip to that physician is merely an
inconvenience, however, if the student-athlete is attending college hundreds of miles
from home, the problem becomes more complex From these few points, insurance
companies researching the idea of the physician-patient relationship should be able to
recognize that there would be a disruption in the relationship and continuity of care for
the duration of the student-athlete's career at his or her chosen university. This alone,
based on the research performed by the insurance companies themselves, justiﬁes the
need for a study on managed care and sports medicine particularly with OOP student-

athletes.

25

Chapter III

METHODS

Despite the research done on managed care, there is currently very little published
on out-of-network health insurance policies and procedures and their eﬁ‘ect on student-
athletes. Furthermore, there exists little research on how universities are attempting to
keep college student-athletes in community care. In fact, there have been no studies to
date on managed care and sports medicine (Henehan & Jones, 1997). There have been,
however, several suggestions on what insurance oﬁicers of colleges and universities
should do to maintain costs and medical control over their student-athletes. The focus of
this study was threefold: 1) to determine if insurance officers of the Big Ten Conference
currently put into effect the recommendations set forth by Ray (1994), Walters (1994),
and Bushee (1996), 2) to deternrine if the medical directors of insurance companies are
cognizant of the out-of-network issue surrounding college students and if the insurance
companies will consider the recommendations in the literature at the request of the
university insurance ofﬁcers. The aﬁer-the-fact survey method was utilized to determine
if university insurance ofﬁcers communicate with HMOs regarding out-of-network
student-athletes. This investigation permitted the researcher to understand what the
university's insurance ofﬁcer has done to attain coverage by the student-athlete's primary

insurance company to decrease the out-of-pocket expenses incurred by the university.

26

Also, the insurance Company's medical director was given the opportunity to provide the
company's point-of-view concerning OOP utilization. An open-ended question was
posed at the end of the survey to allow the medical directors of the HMOs an opportunity
to voice any concerns regarding out-of-network usage.

Emitters:

’ 3 The participants in this study were categorized into two groups. The ﬁrst group
included the insurance ofﬁcers responsible for processing claims for student-athletes in
the Big Ten Conference. The survey provided information concerning the position this
individual holds within the athletic department (head athletic trainer, assistant athletic
trainer, athletic director, assistant athletic director, department secretary, or risk
manager), and if he or she has undergone any special insurance training. Participation
was on a voluntary basis and the results of each survey were kept conﬁdential.
Unfortunately, with only 11 universities in the Big Ten Conference, it was important for
all insurance ofﬁcers to respond to add validity to the ﬁndings.

The second survey was administered to HMOs across the country and was
addressed to the ofﬁce manager familiar with the policies of the company. These
companies were chosen randomly from the sample provided by the insurance oﬁicers in
the Big Ten Conference as well as from a list ofHMOs published by the AMCRA
Again, the replies from the HMOs were voluntary and the results were kept conﬁdential.
Inimimcatatien

The assessment of primary insurance coverage concerning out-of-network student
athletes and the HMOs policy was conducted by two separate surveys developed for this

study (see Appendices A and B).

27

The ﬁrst survey was distributed by mail to every Big Ten University insurance ofﬁcer.
The survey consisted of two parts: demographic information and cost containment. The
demographic information section requested information ﬁom the insurance officers of the
universities regarding the number of male and female sports, the approximate number of
student-athletes, facts about the insurance ofﬁcer(s), and facts about their current
insurance administration system. The second section related to the cost containment
procedures of the institution and inquired about possible coverage for the out-of-network
student-athlete. For example, did the insurance officer contact the insurance company:
(1) for an explanation of beneﬁts, (2) to pro-authorize medical procedures, (3) to request
literature, (4) to request a temporary PCP, or (5) to request a percentage of their usual and
customary rate in exchange for ﬁne rehab and follow-up visits. Also did the insurance
oﬁicer request the help of the team physician to acquire coverage (see Appendix A).

The second survey was directed toward the insurance companies themselves.
This survey also had two parts. The ﬁrst part was a demographics section that requested
information regarding policies and procedures of the insurance company, including the
number of physicians employed, type of medical services covered, maximum age
dependents are covered under their parent's policy, and how they deﬁne out-of-network
The second section was designed to investigate policies and procedures related to out-of-
network care including: (1) the temporary appointment of a PCP, (2) paying a certain
percentage of their usual and customary rate for diagnostic testing including x-rays,
MRIs, bone scans, CT scans etc., (3) providing rider options for those students attending
college out-of-network, and (4) placing a sports medicine expert on their review board for

cases pertaining to student-athlete injuries, etc. (see Appendix B).

28

D l 1

Prior to sending the surveys to the prospective participants, a pilot survey was
sent to a local provider's billing office. The oﬁice personnel were requested to make
suggestions. Revised surveys were developed taking into consideration the submitted
comments. All surveys were then mailed with a courtesy letter and a business reply
envelope to ensure no extra costs for the responding participants (see Appendix C). The
surveys were coded to guarantee conﬁdentiality but allowed the researcher the ability to
identify who has not returned a survey. After 3 weeks, a follow-up phone call was made
to all who had not returned their survey and a second survey was either mailed or faxed at
the request of the university insurance oﬁicers and the medical directors of the insurance
companies.
Date Analysis

A descriptive and qualitative analysis was conducted upon receipt of the data
contained in the surveys. Results of the Big Ten Universities' insurance ofﬁcers
responses were compiled to percentages and presented in table format focusing on the
percentage of insurance ofﬁcers instituting the recommendations. Also, a description of
the insurance ofﬁcers was reported. This portion of the results disclosed the professional
title of the insurance ofﬁcer and the amount of training involved in the preparation of this
individual. The insurance company questionnaire was analyzed in actual numerical
format due to the low response rate. The size of the HMO was established by the amount
of physicians it employs or contracts. The responses provided by the medical directors
concerning the recommendations is also given. Results of this portion of the study are

presented in table format.

29

CHAPTER IV

Results

The following are the results of the two surveys administered to both the
insurance ofﬁcers of the Big Ten Universities and the medical directors of HMOs. The
responses ﬁ'om the Big Ten insurance ofﬁcers will be presented ﬁrst reporting the
school’s athletic demographics, information regarding the insurance oﬂicers themselves,
and then their responses to the questions regarding the recommendations from the
literature. The responses from the medical directors of the HMOs will follow the results
of the Big Ten insurance officers. A short demographics section is presented, followed
by medical director’s responses to the questions pertaining to the recommendations found
in the literature.
Bialmlhauanceﬂfﬁm

A 100% return rate was attained ﬁ'om the Big Ten insurance officers. The results
of the average number of male and female athletes at each institution and the average
number of male and female sports per institution are presented in Table 2. From the
demographics section of the survey, it was determined that there are approximately 7,000
student-athletes in the Big Ten Conference with an average of 377.2 male varsity athletes
and 263.5 female varsity athletes at each institution (male range = 250-500; female range

= 164-346). The number of sports per institution was also determined, consisting of an

30

average of 11.4 male varsity sports (mode = 11; range = 8-17) and 10.6 female varsity

sports (mode = 11,12; range = 8-17) at each Big Ten institution.

 

 

 

Table2
EIIZ'V . 51 IS D 1'
Gender
Male ' Female
Varsity Athletes per School 377.20 263.50
Varsity Sports per School 11.40 ' 10.60

 

Note. Values are representative of the mean.

The person responsible for filing insurance is presented in Table 3. Among the insurance
officers, 63.6% are department secretaries/clinicians, 9.1% are risk managers ﬁom the
university’s risk management ofﬁce, 9.1% are assistant athletic trainers, and

 

 

Table 3
fﬁ hi : ' Ti 1 T 'nin
Job Title II = M % Trained

1. Head Athletic Trainer 0 00.0 00.0
2. Assistant Athletic Trainer 1 09.1 00.0
3. Athletic Director 0 00.0 00.0
4. AssistantAthleticDirector 0 00.0 00.0
5. Clerical/Departmental Secretary 7 63.6 14.3
6. Risk Manager 1 09.1 00.0
7. Other 2 18.2 100.0

 

31

18.2% represent the ”other" category consisting of either an administrative assistant or an
insurance coordinator. To date, there are no head athletic trainers, athletic directors, or
assistant athletic directors acting as athletic insurance oﬁ’icers in the Big Ten Conference.
When asked if the acting athletic insurance coordinator has received any special training,
only 27% have received any special training. The rest of the individuals stated they
either received no training or relied on in-house training and experience.

The researcher also determined the method of medical coverage the universities in
the Big Ten Conference are currently utilizing for their student-athletes. A total of 91%
of university athletic departments cover their student-athletes secondarily after other
forms of insurance, including both student and parental plans, are billed. In reference to
policy riders speciﬁc to the university's insurance coverage, 72.8% report that they do
have a speciﬁc rider. When asked what the rider speciﬁed, 7 5% reported that the rider
restricts them to athletic-related injuries and illnesses only.

Finally, the insurance ofﬁcers of the universities were asked to approximate the
cost of their out-of-pocket expenses directly related to student-athlete health care. These
expenses were restricted to that which is not covered by the primary source of insurance
coverage, i.e. student health insurance or parental coverage. Out-of-pocket expenses
remain high for 80% of the universities accounting for $80,000.00 or more annually
(n=10).

Section two of the survey focused on the cost containment procedures

implemented by the institutions. These are presented in Table 4.

32

Table 4
Qment Cog-Centainment Practices of Big Ten Insurance Officers

 

 

 

Responses

Recommendations Yes No Sometimes
1. Requests temporary PCP 3 7 1
2. Requests % of UCR in exchange

for free rehab and follow-up visits 0
3. Requests literature
4. Requests help of team physician 3
5. Requests preauthorization

for medical services 8 3 0
6. Trouble acquiring a referral from

a local PCP to team physician 3 4 4

 

Nine of the insurance ofﬁcers responded that they are currently contacting the
insurance companies. When these oﬁicers contact the insurance companies, 77% are
inquiring about pre-authorizations and explanations of beneﬁts, in addition to explaining
the necessity of the treatment. The two insurance oﬁicers that do not contact the
insurance company stated that they expect the physicians' ofﬁce to call or that the
university pays the bill regardless of the beneﬁts.

The researcher then inquired about the request of a temporary PCP. Three of the
ofﬁcers stated that they request that the insurance company appoint a temporary PCP.

One ofﬁcer reported a 75% success rate while a second ofﬁcer reported a 20% success

33

rate in acquiring a temporary PCP appointment. The third ofﬁcer did not provide any
data regarding success rate of a temporary PCP appointment.

Approximately 82% of the oﬁcerscurrently are not requesting that the HMO pay
a percentage of the UCR for out-of-network student-athletes in exchange for free
rehabilitation and follow up visits. About 45% of the ofﬁcers are requesting beneﬁt
information and/or literature regarding the policies and procedures of the insurance
company, especially if the insurance nﬁcerjsunfamiliar with the insurance company, if
the insurance is international, or if the insurance officer is concerned about optical or
dental coverage. The insurance ofﬁcers that do not call for information state that the
university pays the bill regardless of the beneﬁts or that they do not have the time.
Regarding preauthorization formedicalservices, 72 7% reported they do call forpre-
authorization and are concerned with pre-authorizing mainly major diagnostic testing and
surgeries. One of the 3 insurance ofﬁcers that does not contact the HMO forpre-
authorization of medical services states that the provider's offrce calls for the pre-
authorization. Finally, 27.3%enconntered,problems when localsmdent-athletes neededa
referral, 36.4% said that they did not have trouble, and 36.4% said that they sometimes
had difﬁculty acquiring a referral.

Re onses

Results of the insurance company surveys were also determined using quantitative
analysis. A total of 11 surveys were returned from the original 45 that were administered
yielding a 24.4% return rate. The number of physicians the HMOs employ reﬂected the
size of the insurance company. The average number of physicians employed at each

HMO was 4250 (range = 300-18,500). The speciﬁc medical specialties covered by each

34

HMO were also determined. Insurance coverage for dentistry was not provided by any of
the HMOs, whereas, 3 HMOs covered sports psychiatry, 6 covered exercise physiology,

8 covered manipulative therapy, and 9 covered substance abuse. All other medical
services were covered by all of the HMOs.

The researcher also intended to try and delineate a working deﬁnition of the term
"out-of-network". According to the responses of the surveys, out-of-network was deﬁned
in 5 different ways including: (1) if member is not referred by a PCP, (2) if member did
not see or use a contracting provider, (3) if member received services outside service
area, did not get authorization, and did not see a PCP, (4) if member did not live or work
in the designated service area and, (5) if member received any service "out-of-plan".

The age of dependent coverage is up to 25 years of age as long as the dependent is
a full time student. Rider options for college students are offered by 36.4% of the HMOs.
Two of these HMOs stated that the employer provides this option on the company health
policy as a selection and the remaining two HMOs stated that the rider is part of the basic
plan, thereby not really constituted as a rider. When asked if the HMO would consider
developing a rider for their subscribers, 6 responded ”no" and 1 responded ”possibly”.

The responses of the HMOs to the recommendations set forth in the literature are
presented in Table 5. Nine HMOs stated that they would never appoint a temporary PCP,
although four responded that they have appointed a temporary PCP in the past. Only four
stated that they would never pay apercentage of the company’s UCR for surgical
procedures in exchange for ﬁee rehabilitation and follow—up visits. In fact, three
companies said that they "frequently" or ”very ﬁ'equently" agreed to this ﬁnancial

agreement and 4 indicated that they "occasionally” agreed. With athletic trainers

35

currently looking into pursuing third party reimbursement, 100% of the HMOs stated that
they would not change their mind to the ﬁnancial agreement of partial payment for
surgical cases that require follow-up visits and rehabilitation. This area of concern will
be discussed in more detail in the discussion. When asked if the insurance company
would agree to payment of a percentage of the UCR for diagnostic testing, 3 responded
very frequently, 3 responded occasionally, and 5 responded never. Six of the HMOs
stated that they would not pay the deductible for the university's secondary insurance

policy in exchange for medical control over the student-athlete.

 

 

 

Table 5
HM their n ° the R mmen i
Frequency

Question N R O F VP
1. Allow a temporary PCP 9 1 1 0 0
2. PayaperoentageofUCR(surgieal) 4 4 1
3. Pay a percentage of UCR (diagnostic) 5 3 0
4. Pay university's secondary insurance

policy's deductible 6 1 4 0 0
5. Does distance to home matter when

ruling on a claim 6 1 1 3 1
6. Does attendance to out-of-state school

matter when ruling on a claim 6 1 3 0 l
7. Does athletic scholarship aﬂ’ect ruling

on a claim 9 1 l O 0
8. Istransportabilityofcoverageanoption 7 1 1
9. Issportsmedicinespecialistonpanel 5 1 3 1 l
10. Consider placing a sports medicine

specialist on panel 1 4 3 1 2

 

NA; N= Never, R= Rarely, O= Occasionally, F= Frequently, VF= Very Frequently. Number indicates the
actual numberout ofa possible 11.

36

A mixed response was received when the HMOs were asked whether or not
distance from home was a deciding factor on the ruling of a claim. One insurance
company responded that mileage was ﬁ'equently considered and gave a ﬁgure of 30
miles. Whether or not the patient was attending school out-of-state did not factor into the
ruling of a claim nor did the fact that the patient was on an athletic scholarship. Most of
the HMOs stated that they would never allow the transportability of coverage for young
adults who attend out-of-network universities. However, one company stated that it
performs this option "very frequently", meaning that the beneﬁts of the plan would be the
same as if the subscriber was in-network.

When asked if a sports medicine specialist was ever on their claims panel, 54.5%
responded "rarely” to "never”, while the remainder stated that they do. When asked if
they would consider placing one on the claims panel involving student-athletes, 90.9%

stated that that would consider it. Only one insurance company stated that it would not.

37

CHAPTER V

Discussion

The ﬁndings of this investigation only begin to simplify the issues of athletic
health insurance administration and its association with HMOs. The importance of
understanding the insurance system in the athletic department and how HMOs operate is
rudimentary in nature with regards to the entire health care aspect of student-athletes.

Only one of the Big Ten institutions designates an athletic trainer to run their
insurance program as an insurance coordinator whereas 63 .6% execute their health
insurance program through a departmental secretary. Interestingly enough, the head
athletic trainer was only a small part of the insurance administration. In fact, there was a
lack of participation from the head athletic trainers when some surveys were mailed to
them in addition to the primary insurance ofﬁcer. One head athletic trainer stated that
the survey was beyond his scope and that the department secretary would be the best
person to answer the survey. While having a departmental secretary running the
insurance administration can free time for an athletic trainer to be an athletic trainer, it is
important that he or she and the head athletic trainer be knowledgeable about insurance
matters. The head athletic trainer is typically the ﬁnal reviewer of an insurance claim

before payment by the athletic department is rendered.

38

Understanding the facts and terminology of sports medicine, in addition to the
terminology of the insurance companies, is of utmost importance. Research indicates that
typically there is a multi-head approach to handling the medical insurance of student-
athletes, which could prove to be problematic (Hart & Cole, 1992). In this model, one
person researches the claim, one person prepares the paperwork for the claim, while yet
another person pays the bills. With so many hands on one project, miscommunications
equal errors that can add up to ﬁnancial loss. Hart and Cole (1992) support this view by
stating that the individual who does take responsibility for the student-athlete’s insurance
must have some budgetary training or experience. This training could be valuable when
dealing with the overwhelming costs of medical insurance. Of the insurance oﬁicers
surveyed, only 27% had any special training related to the insurance program The
remaining insurance oﬁicers relied on in-house training. This is consistent with what
Bushee ( 1996) discovered. He reported that the educational backgrounds of the
insurance ofﬁcers did not address the particulars of insurance administration.
Furthermore, if these insurance ofﬁcers leave their position in the athletic department and
the head trainer is not knowledgeable about the process, the next insurance ofﬁcer could
be involved in a long trial and error training process.

The trained insurance ofﬁcers routinely request literature and acquire the help of
the team physician when deemed necessary. Moreover, one of the insurance oﬁicers
stated that calling the insurance companies for information concerning explanation of
beneﬁts and referral information and procedures can be helpﬁrl when advising student-
athletes with non-athletic related injuries and illnesses. Requesting a temporary PCP and

acquiring pro-authorization are other practices used by 67% of the trained insurance

39

ofﬁcers. Those who exercise pro-authorization have at least 50% success in obtaining a
preauthorization for medical procedures. Other insurance ofﬁcers who do not call about
pre-authorizations say that they expect the provider’s ofﬁce to call or that the athletic
department will pay the bill regardless. The problem with having the provider's ofﬁce
call to pre-authorize is that they know that the university will pay secondary regardless of
the coverage provided by the primary insurance company. Therefore, the provider‘s
ofﬁce may not try as hard to convince the HMO that the service needs to be rendered in
the university community and that the insurance company should subsequently provide
coverage. If an injury is not a result of athletics, then the university will not pay
secondary to the student-athlete's primary insurance. Therefore, if the injury is non-
athletic related, then the student-athlete must pay and suffer from the out-of-pocket
expenses. In addition to this, not all universities are ﬁnancially able to pay secondary to
the primary insurance. As stated earlier from the literature, some of the institutions at all
of the division levels fall into this category.

Of the universities surveyed, 7 5% have a rider stating that athletic-related injuries
and illnesses only are covered. This means that for the student-athlete who has a non-
athletic related injury of illness, coverage will be denied if he or she does not return home
for the proper referral back to the university team physicians. But that does not mean that
a referral is assured, because even local student-athletes are being denied referrals to
university team physicians. One of the insurance ofﬁcers expressed that the initial PCP
does not feel it is worth the paperwork

As far as the implementation of the recommendations, university insurance

ofﬁcers are not communicating with the HMOs as Ray (1994), Walters (1994), and

40

Bushee (1996) advocate. In fact, only two of the insurance officers are currently
requesting a percentage of the HMO's UCR in exchange for ﬁ'ee rehabilitation and
follow-up visits, and then on an inconsistent basis only. This may be the primary reason
for the increased out-of-pocket expenses experienced by 80% of the Big Ten Institutions,
accounting for at least $80,000.00 anmrally per school due to lack of insurance coverage.
Most of the insurance ofﬁcers are requesting literature from the HMOs. Those who do
not request literature claim not having enough time or state that the athletic department
will pay the bill regardless. Currently, 95% of the medical procedures that get pre-
authorized include both diagnostic testing and surgery. This is important because this is
where the insurance oﬁicer can introduce the concept of ﬁee rehabilitation and follow-up
visits in exchange for coverage.

When requesting any ﬁrrther comments regarding insurance coverage and its
availability to the out-of-network student-athletes, many of the insurance ofﬁcers made
known their ﬁustrations. One individual stated that HMOs are "virtually worthless”
when it comes to coverage for out-of-network student-athletes. Another insurance ofﬁcer
stated that HMOs ”either cover or they don't, there is no way to change their contract with
the insured". However, as one will see with review of the HMOs surveys, only a few of
the companies do provide some laxity in their policies for college students who attend
school out-of-network

Regardless of the fact that some of the insurance oﬁicers have had good results
with these recommendations either ﬁ'om reports in the literature or from the responses of
this survey, the majority of the HMOs' responses indicate otherwise (Table 5). Prior to

analyzing the results of this survey, it is important to recognize that there was a very low

41

survey return rate from the HMOs (24.4%). One individual explained that a number of
the HMOs were currently going through a merger. Their lawyers advised them not to ﬁll
out the survey in case the results were to “get into the wrong hands and complicate the
merger”. Therefore, perhaps at a different time, the HMOs would be more cooperative in
responding to a survey. On another note, the researcher attempted to contact the
insurance oﬂicers of the universities to request a contact name that might aid in acquiring
HMO participation in the study. Only one university insurance oﬁ'rcer was able to
provide a name. A separate insurance officer stated that when she attempted to request a
prior contact person, the HMO quickly responded that "anyone can help you with that",
and proceeded to transfer her call to anyone but the person she requested. She further
explained that, in her experience, it seemed as if the insurance companies try to avoid
building any relationships with the providers or third party persons involved in the claim.
Another insurance ofﬁcer stated that this is typically the case. Insurance companies
generally do not give policy information to a third party. This can be problematic
because some university insurance policies, in order to pay for a student-athlete's bill,
must follow the proper channels which includes requesting policy information.

There were conﬂicting replies to some of the questions, for example, when asked
if the HMO would consider assigning a temporary PCP, most responded that they would
never do so. However, when asked if they had ever appointed a temporary PCP, four
said that they had. In fact, one of the HMOs that responded "never” to a temporary
appointment said "yes" to having done so in the past further explained that it was

performed with a written ”out-of-network" approval. This leads the researcher to believe

42

that on more than one occasion, these HMOs were willing to consider each case and
make a ruling on it individually.

The arguments for free rehabilitation and follow-up visits appear to be convincing
in that a majority stated that they would at least consider them. Another key reply for the
profession of athletic training pertains to third party reimbursement. Of the seven HMOs
that responded either “ﬁ'equently” or "very ﬁequently” in agreeing to partial payment for
medical services in exchange for free rehabilitation and follow-up visits, 100% stated that
they would still agree to partial payment if athletic trainers pursue billing for
rehabilitation programs and follow-up visits. This is an important concept as the
profession of athletic training becomes more and more recognized as an allied health
profession. Once insurance companies understand the role of the athletic trainer as an
allied health professional, athletic trainers can begin to bill for the services they render in
the training room. However, one of the arguments that has been utilized is the ﬁee
rehabilitation and follow-up visits in the training room in exchange for coverage.
Therefore, if athletic trainers begin billing for these services, are they potentially losing
out on a viable argument for coverage? Walters (1994) states that athletic trainers
pursuing third party reimbursement must proceed with caution for this very reason and
for the philosophy of the profession. In the past, this philosophy has been to provide
care to the athletic population without ﬁnancial compensation, only the gratiﬁcation of a
student-athlete back to competition due to the hands of an athletic trainer. Now, that
philosophy seems to be changing in some employment settings for athletic trainers.

Distance to home, attendance at an out-of-state college, and the possession of an

athletic scholarship did not appear to have an effect on the status of a claim. One of the

43

medical directors stated that the "student-athlete on scholarship should be covered by the
university”. This is more than likely the perspective of most of the medical directors.
This concerned the researcher because one of the areas the HMOs were researching
themselves included OOP usage and the involvement of secondary coverage. Research
on behalf of managed care found that OOP usage was related to having secondary
coverage. Ifit is the insurance company's intent to decrease OOP usage as a result of
secondary coverage, then this perspective is misleading and inconsistent with managed
care goals.

In most cases, there are no sports medicine specialists on the claims panel that
makes those decisions. Only two of the HMOs have sports medicine specialists on their
panels. However, of the remaining HMOs, all but one stated that they would consider
placing a sports medicine specialist on their panel. The researcher believes that if there
were a sports medicine specialist who can attest to the necessity of a procedure,
understands the circumstances surrounding the academics and the urgency of the return to
competition, there would be an increase in the coverage of student-athletes by their
HMOs.

In order for this and other practices to occur, there must be communication
between the athletic trainer and the insurance company. When the HMOs were given the
opportunity to respond to an open-ended question, one actually stated that making a
”quick call to make sure of a member's beneﬁts and options" might begin to help
untangle the issues and increase the full use of the beneﬁts as much as possible. Another
medical director responded that the subscriber might want to consider a Point-of-Service

plan where the subscriber has a list of participating physicians that he or she may choose

from in the event of an out-of-network situation. These suggestions demonstrate to the
researcher that the insurance companies are willing to help answer their subscribers
questions and educate them on their chosen plan if their help is sought, conﬁrming the

necessity forincreased communication.

45

CHAPTER VI

Conclusion and Recommendations

Athletic trainers and insurance companies need to improve methods of
communication for the sake of the student-athletes health, academics, sports
participation, and out-of-pocket expenses. Commonalties have been drawn from the
literature and this survey to help guide insurance administrators in this process.
9mm

Insurance ofﬁcers in the university setting are knowledgeable about the out-of-
network issues and student-athletes, however, they are not completely implementing the
recommendations proposed by fellow colleagues to help maintain medical control over
the student-athletes and to contain department costs. If more insurance oﬂicers agree to
dedicate themselves to obtaining specialized training and implementing more of these
recommendations, precedence could possibly be established to help achieve these goals
and aid others. From this, a detailed record of insurance companies, including a contact
name, beneﬁt explanations, and university/insurance company relationship history, can
be devised to attain a better handle on where the most time needs to be spent when
inquiring about coverage. In the meantime, insurance officers can help educate the

parents to get them prepared for circumstances that may arise due to non-urgent injuries.

Medical directors of HMOs are indifferent regarding the issue of out-of-network
care. They realize that if they deny the claim, 85% of the time the university is going to
cover the expenses. However, the parents of these student-athletes are already paying for
coverage of their dependent. Therefore, if more people alert these medical directors of
out-of-network care, the medical program offered by the insurance company could be
revamped to make amends. Moreover, the ﬁrnds saved by the athletic department could
be reallocated to purchasing more equipment and or supplies for the beneﬁt of the
student-athlete. In addition to these previous points, the medical directors of the HMOs
could help educate both the employers, who provide the different types of plans, and the
parents to help them understand what to expect once their child goes out-of-network for
an education. Finally, there have been recent talks on behalf of the HMOs to move
toward regionalization (Brown & McCool, 1990). This means that they are considering
branching out into other areas of the country as the company becomes bigger and
stronger. For example, the Cleveland Clinic in Cleveland has opened entirely new sites
in Arizona and Florida. These remote sites are offering a ﬁrll range of services in all
geographical areas. This could be extremely beneﬁcial for the student-athlete attending
college out-of-state.

Reeemmendatiens fer Future Studies

This investigation was only a portion of the research needed in the area of health
insurance in the athletic setting. More research needs to be conducted to delineate some
of the ﬁndings of this study and nurture the actions of both the insurance companies and

the insurance oﬁ'rcers.

47

1)

2)

3)

4)

5)

6)

7)

There was a very low return rate of surveys from the HMOs, which later was
found to be a result of supervisors and lawyers in the companies advising
marketing departments not to respond. Perhaps at a different time, this survey
could have elicited more valuable information.

Submit the survey to other conferences outside of the Big Ten Conference and
compare those results to the results of this study.

Another area that should be further investigated is the issue of who is
performing the responsibilities of the insurance oﬁcer and the training he or
she has received.

One might want to further investigate the issue of dissatisfaction and its root
by surveying the parents of students and student-athletes to see if the issue of
out-of-network coverage has any affect on basis of dissatisfaction. By the
statistics given in the review of literature concerning the age group involved,
out-of-state college students could possibly have a bearing on the
dissatisfaction issue.

One might consider investigating the request that a sports medicine specialist
be placed on the claims panel.

Consider the involvement of the parents when contacting the insurance
company to request coverage from the HMO or a temporary PCP
appointment.

Investigate how the remainder of the student population is dealing with this

issue of out-of-network services.

48

Glossary

1) Deductible - An amount that an individual must pay before the insurance coverage
begins.

2) Health Maintenance Organization (HMO) - A health delivery system which assumes
responsibility for ﬁnancing and providing comprehensive health care services to a
voluntarily enrolled population for whom periodic premiums are paid.

3) Managed Care - A growing concept in the insurance industry emphasizing cost
control through the coordination of medical services.

4) Medical Director - A physician responsible for monitoring the medical practice in an
HMO.

5) Out-of-Plan (OOP) - Services rendered out of the service area of the plan or by a non-
plan physician.

6) Out-of-Pocket - Maximum amount an individual is responsible for in a beneﬁt year
after the deductible.

7) Premiums - The invoiced cost of an insurance policy.

8) Primary Care physician (PCP) - A physician selected by the HMO member who acts
as the ﬁrst source of medical service for the patient. Also referred to as the

" gatekeeper".

49

9) Primary Insurance - a type of health, medical, or accidental insurance that begins to
pay for covered expenses immediately after a deductible has been made.

10) Riders - A supplementary clause to an insurance contract that extends the terms of
coverage beyond those associated with the standard coverage.

11) Secondary Insurance - a type of health insurance that that begins to pay for covered
services only after all other sources of insurance coverage have been exhausted.

12) Subscriber - The actual employee who signs the HMO contract.

13) Third-Party Reimbursement - A process by which health care practitioners are
reimbursed by a policyholders insurance company for services they perform.

14) Usual, Customary, and Reasonable Fee (UCR) - The charge consistent with what

other medical vendors would assess.

50

APPENDICES

APPENDIX A

APPENDIX A

Dear ,

I am writing to ask you to participate in a research study that I am conducting in partial
fulﬁllment of my Master of Science degree from Michigan State University. The purpose
of this investigation is to determine how athletic training department insurance ofﬁcers
can work with the health insurance companies on insurance claims of out-of-network
student-athletes.

Medical Technology is growing every day as well as the availability of this technology to
the student-athlete. However, the time and type of services rendered may be linrited by
the policies and procedures mandated by the student-athlete's insurance company. In light
of this, I am investigating how to increase communication between the insurance ofﬁcer
of the institution and the health insurance company to provide the best and most prompt
care for the student-athlete. Therefore, this study will target Midwest Health Maintenance
Organization (HMO) companies, as well as the Big Ten Insurance Ofﬁcers.

Your participation in this study is essential. The samples of companies chosen to respond
to the survey were indicated on the responses of the Big Ten Insurance Ofﬁcers' surveys.
The instrument being used has been devised based on research on the topic of health
insurance and the athletic department. A minimal amount of time is required to complete
the survey.

The design of the survey is in two parts. The ﬁrst is a demographics section and the
second is the actual policies and procedures portion of the survey. Please be as accurate
as possible when responding to the questions and return as soon as you are able.

When the surveys are returned, they will be compiled for data analysis. A coding system
is being used for postcard reminders. When your survey is returned, your code will be
destroyed and all answers will be held conﬁdential. Understand that this is purely
voluntary and you indicate your voluntary agreement to participate in this study by
completing and returning the survey in the provided self-addressed, stamped envelope.

Results of this study will be compiled by June 1, 1998. If you would like to receive results of the
survey to make comparisons to other Midwestern insurance companies, please check the
appropriate box at the end of the questionnaire and results will be forwarded as soon as they are
available. Thank you in advance for your participation.

Sincerely,
Kari A. Langley, ATC

2621 Hopkins Ave.
Lansing, MI 48912

51

Dear Big Ten Insurance Ofﬁcer,

I am writing to ask you to participate in a research study that I am conducting in partial
fulﬁllment of my Master of Science degree from Michigan State University. The purpose
of this investigation is to determine how insurance ofﬁcers are trying to control out-of-
pocket expenses for insurance claims on out-of-network student-athletes.

Medical Technology is growing every day as well as the availability of this technology to
the student-athlete that can sometimes be limited by the policies and procedures
mandated by the student-athlete's insurance company. In light of this, the athletic
department's insurance must pay the bill or delay care until the insurance company can
respond after a series of debates. Therefore, this study will target the Big Ten Insurance
Ofﬁcers as well as surrounding Health Maintenance Organization (HMO) companies in
the Midwest to aid in providing the best and most prompt care for the student-athlete.

Your participation in this study is essential. Only the Big Ten Insurance Ofﬁcers are
being asked to respond to the survey that allows for a very limited sample. The
instrument being used has been devised based on research on the topic of cost
containment and the athletic department. A minimal amount of time is required to
complete the survey.

The design of the survey is in two parts. The ﬁrst is a demographics section and the
second is the actual cost containment portion of the survey. Please be as accurate as
possible when responding to the questions and return it by January 26, 1998.

When the surveys are returned, they will be compiled for data analysis. A coding system
is being used for postcard reminders. When your survey is returned, your code will be
destroyed and all answers will be held conﬁdential. Understand that this is purely
voluntary and you indicate your voluntary agreement to participate in this study by
completing and returning the survey in the provided self-addressed, stamped envelope.

Results of this study will be compiled by May 1, 1998. You may obtain the results of the
study from the investigator under a separate cover to the address below.

Thank you in advance for your participation.
Sincerely,
Kari A. Langley, ATC

2621 Hopkins Ave.
Lansing, MI 48912

52

APPENDIX B

APPENDIX B

Code—
Student-Athlete Health Care - Insurance Ofﬁcer Questionnaire

SI' 1D I. II !I'°||'2
1. The number of intercollegiate sports sponsored by the university:
Men's Women's

2. The approximate number of intercollegiate athletes at the university:
Men Women Total

3. The person directly responsible for the daily operation of athletic insurance (please

circle):

Head Athletic Trainer Assistant Athletic Trainer
Department Secretary/Clerical Athletic Director

Asst. Athletic Director Risk Manager

Other (please specify):

 

4. Has the insurance ofﬁcer had any special training in medical insurance
policies, claims processing, etc. If so, please describe.
Yes _ No __

Comments:

 

 

5. How does your athletic department cover the student-athletes? Please check all that
apply.

_ Primary (pays regardless of athlete's personal insurance)

_ Secondary (pays after students' or parents' insurance policy has been billed)

__ No coverage, balance becomes the responsibility of the student-athlete and/or
parent(s).

_ Other (please explain):

 

6. Does your athletic department have any self-insurance? If so, what is the annual
premium of the insurance company coverage?

 

\l

. Does your university insurance policy have a pre-established deductible?
No _ Yes _ If yes, what is the amount?

53

8.

9.

Does your insurance have speciﬁc riders? If so, please check all that apply:
Athletic Injuries Only

_ Other:

 

 

Your approximate yearly expense for student—athlete health care (expenses not
covered by insurance and are considered out-of-pocket):
$0 - $9,999 $30,000 - $39,999 $60,000 - $69,999
$10,000 - $19,999 $40,000 - $49,999 $70,000 - $79,999
$20,000 - $29,999 $50,000 - $59,999 $80,000 - over

SI' ZCICI' |Bl°"

10. Are you currently contacting those insurance companies that provide coverage to

11.

12.

13.

those student-athletes that fall out of the network?

If yes, please specify by circling all that apply:
For Pre-authorization For an Explanation of Beneﬁts
To Explain Necessity of Treatment Other:

 

If not, please specify why by circling all that apply:
Not Enough Time Will Pay Bill Regardless
Expect Physician's Ofﬁce to Contact Insurance Other:

 

Do you request that the insurance company temporarily appoint a primary care
physician for the duration of the student-athlete's career at your university?
_Yes _No Sometimes

If yes, please record the approximate percentage of times you are successful:

Do you request that the student-athlete's insurance pay a certain percentage of the
their established amount for certain procedures in exchange for free follow-up visits
and rehabilitation after deductible is met?

_Yes _No Sometimes, please explain.

 

If yes, please record the approximate percentage of times you are successful:
Do you request beneﬁt information and/or literature from student-athletes' insurance
providers that could help you to decrease costs from out-of-pocket expenses?

Yes No

If yes, please check all that apply:

_ All Insurance Companies

_ Unfamiliar Insurance Companies Only

__ International Insurance Companies Only

_ Concerning Possible Dental or Optical Coverage
_ Other:

 

54

Please record the approximate percentage of times your are successful acquiring
information:

If not, please indicate why by circling all that apply:
Not Enough Time Will Not Read Literature Will Pay Bill Regardless
Other”.

 

14. For what procedures do you consistently call for pro-authorization? Circle all that
apply:

All Medical Procedures All Surgeries Only Laboratory
Major Diagnostic Testing (MRI, CT, Bone Scan) Dental Coverage Pharmacy
Alternative Medicine (Acupuncture, Chiropractic) Psychiatry Psychiatry
Other.

 

Please record the percentage of time you are successﬁrl:

15. Please list the major HMO's in your area that you deal with on a regular basis.

 

 

16. Does the team physician facilitate payment by the student-athlete's insurance by
contacting the insurance company to help provide additional information concerning
any of the following (please circle all that apply):

All Medical Procedures All Surgeries Only Laboratory
Diagnostic Testing (MRI, CT, Bone Scans) Dental Coverage Pharmacy
Alternative Medicine (Acupuncture, Chiropractic) Psychiatry
Optical Coverage Other.

 

17. When local student-athletes (those within their established network) are injured, are
you ever unable to acquire a referral to your athletic department's team physician
ﬁ'om the student-athletes' chosen primary care physician?

Yes No Sometimes

Comment(s):

 

 

18. Other comments about your experiences dealing with insurance coverage and its
availability to the out-of-network student-athlete(s).

 

 

55

Please indicate whether or not you wish to receive results of the study.

Yes, I would like to receive the results of this study. Please send the results
to the following (please exclude your name to ensure conﬁdentiality, forms
are coded):

 

 

 

No, I would not like to receive the results of this study.

56

APPENDIX C

APPENDIX C

Code—
Insurance Company Questionnaire

S I. l D I . .

1. Approximately how many physicians provide services under your health insurance
plan?

2. What types of medical care are covered under your plan? Circle all that apply.
Allergy Cardiology Dentistry Dermatology
Endocrinology Exercise Physiology Gastroenterology General Surgery
Hand Surgery Hematology Internal Medicine Manipulative Therapy
Neurology Nutrition OB-GYN Oncology
Ophthalmology Optometry Psychiatry Pulmonology
Orthotics Radiology Rheumatology Sports Psychology
Substance Abuse Urology Other:

Specialized Surgery (please specify):

 

 

 

How is a policyholder considered out-of-network?

 

 

Up to what age does your company cover dependents of a policyholder?

 

Do you provide rider options for your policyholders that have children attending
college out-of-network?
NO YES

If you answered yes to question #5, how are your policyholders eligible for such A

rider?

 

If you answered yes to question #5, how are your policyholders made aware of such a

rider?

 

Would you consider developing a rider for those families who anticipate furthering
education

out of state?

NO YES

57

SI“ 22].. 'liIQI-E-Nl l

> Please note: All questions refer to student-athletes, covered by their parent's policy,
who attend a university that is considered out-of-network, established by your
policies and procedures.

1. Would you consider allowing a physician under your plan to temporarily appoint a
primary care physician for a subscriber while he or she attends a college that is
deemed out-of-network established by your policy?

Never Rarely Occasionally Frequently Very Frequently

2. Have you ever allowed a temporary primary care physician appointment?

NO YES

3. After the deductible is met as described in the subscriber's policy, would you consider
agreeing to pay a certain percentage of your established rate for certain surgical
procedures including, but not limited to, ligament reconstruction, fractured bone
setting, arthroscopic surgeries, etc. in exchange for free rehabilitation and follow up
visits? (Assume all procedures are out patient procedures.)

Never Rarely Occasionally Frequently Very Frequently

4. If athletic trainers in the education setting continue to pursue third party
reimbursement, would your answer to question # 3 change? If yes, what would your
new response be?

NO YES (Please comment):

 

5. After the deductible is met as described in the subscriber's policy, would you consider
agreeing to pay a certain percentage of your established rate for certain diagnostic
testing including, but not limited to, Magnetic Resonance Imaging, CT Scans, Bone
Scans, etc.? (Assume all diagnostic testing procedures are outpatient procedures.)

Never Rarely Occasionally Frequently Very Frequently
6. Would you consider paying the deductible for the university's secondary insurance
carrier for a student-athlete who has their claim denied in order for that student-

athlete to remain at school for the ordered procedure?

_Never Rarely Occasionally Frequently Very Frequently

58

7. Does distance to home matter when deciding on whether or not to rule in favor of the
patient on a particular claim when services were rendered out-of-network?

Never Rarely Occasionally Frequently Very Frequently

8. Does the ruling on a claim, in favor of the patient, matter if he or she is out of state
attending a college or university?

Never Rarely Occasionally Frequently Very Frequently

9. Does the ruling on a claim, in favor of the patient, matter if he or she is out of state
attending a college or university on an athletic scholarship?

Never Rarely Occasionally Frequently Very Frequently

10. Does your company provide, or would you consider transportability of coverage for
those young adults that attend college out-of-network?

Never Rarely Occasionally Frequently Very Frequently
11. Are there any sports medicine specialists on the decision making board for a
particular claim at any point in time when deciding on the necessity of a diagnostic
service, procedure, brace, etc. for a sports related incident?

Never Rarely Occasionally Frequently Very Frequently

12. Would you agree to place a sports medicine specialist on the decision making board
for claims involving student-athletes?

Never Rarely Occasionally Frequently Very Frequently
13. Would you be interested in sending out literature that might help insurance ofﬁcers in

the university and collegiate setting to aid in dealing with these sensitive issues
regarding student-athletes? Why or why not?

 

14. Any other suggestions you or your company may have to help decrease the time and
cost investment athletic insurance ofﬁcers, as well as your insurance ofﬁcers, and to
hasten the most efﬁcient care given to the student-athletes within the limitations of
your policies and procedures?

 

 

 

59

 

Thank you again, for taking time out to respond to this survey. In closing, please indicate
whether or not you wish to receive results from this study and where you would like to
have the results sent.

Yes, I would like to receive results of this study. Please send the results to the
following (please exclude your name to ensure conﬁdentiality, forms are

coded):

 

 

 

No, I would not like to receive results of this study.

60

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