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EPISODE 2: How Employer Decisions Impact Coverage & Reimbursement

Updated: Mar 1

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Welcome to the second episode of Only Healthcare! We dive into the complexities of the commercial insurance landscape, particularly focusing on how employer decisions shape health benefits coverage and reimbursement processes. The conversation does not touch on entitlement programs but rather hones in on the intricacies of commercial health insurance and its impact on both employers and employees.


Topics Discussed:


1. Coverage:

  • Definition and Legal Framework: We explore the legal right to receive reimbursement or payment for healthcare costs under a contract with an insurance company, a group health plan, or government programs like Medicare.

  • Difference Between Coverage and Policy: Learn about the nuances between insurance coverage and policy, including how a typical insurance policy is a collection of coverages with distinct limits.

2. Reimbursement:

  • Understanding Healthcare Reimbursement: The episode clarifies how payments are made to healthcare providers, hospitals, or pharmacies after services are rendered. We discuss how the amount billed is based on pre-agreed terms with health insurance companies, PBMs, or Medicare.

  • Types of Insurance and Reimbursement: Discover the concept of Health Reimbursement Arrangements (HRAs), a non-traditional type of insurance allowing employers to provide non-taxed reimbursements for eligible medical expenses.

About the Hosts:


Michael Navin brings 27+ years of experience in the pharmaceutical industry, specializing in commercialization. As the owner of a successful agency, he has launched numerous pharmaceutical products, making advanced treatments accessible to the public. 


Dr. Randy Vogenberg started his career as a pharmacist and has since worked across all areas of healthcare delivery, including policy and employer-sponsored plans. With a doctorate in healthcare administration, Randy spent the last 25 years navigating the self-insured marketplace, providing value for the ongoing changes in healthcare. 


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Disclaimer:© 2024 Only Healthcare Podcast. All rights reserved.


This podcast and its content, including but not limited to audio recordings, images, and text, are the property of the Only Healthcare Podcast and are protected by international copyright laws. We appreciate all distribution and content sharing. Contact us at onlyhealthcarepodcast@gmail.com to access media kits, provide feedback, inquire about guest participation or to learn more. Thank you for listening!


Hosted by: Michael Navin & Randy Vogenberg, PhD


This Podcast is sponsored by:


Peek: Peek is reimagining access through innovation, technology, connectivity, and partnership. Peek offers a comprehensive and unique suite of solutions to help clients improve access and affordability for prescription drugs.


The Peek Meds Marketplace is one of Peek’s differentiated offerings that gives employers a revolutionary new approach to controlling runaway prescription costs for their employees by providing unprecedented transparency, simplicity - and cost savings. The Peek Meds Marketplace aggregates cash discount cards, manufacturer copay offset programs, and an employee’s insurance information to provide a holistic and personalized view of prescription price options. This easy-to-use platform offers a one-stop-shopping experience for prescription drugs.


Peek’s team has decades of experience in the pharmaceutical industry and offers various services to biopharma manufacturers, brokers, benefits consultants, third-party administrators and employers. Visit peekmeds.com to learn more.


Institute for Integrated Health (IIH): Health care benefits, insurance coverage regulations, and doing business in the healthcare industry can be complicated. At IIH, Dr. Randy Vogenberg and his team understand these unique challenges and provides strategic guidance customized to every client. To help overcome your unique challenges, IIH delivers education, planning and advisory on market trends, and U.S. health care market intelligence. The firm’s decades of proven success are due to strategic collaboration with associates from the business, clinical, and scientific communities. https://iih-online.com/.


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