Employer / Employee FAQs

About BowTie Medical

Who is BowTie Medical?

BowTie Medical (BTM) is a healthcare organization that integrates health insurance (payer) with medical care (provider), also known as a “payvider”. This integration allows BowTie to attack the root cause of runaway healthcare inflation by aligning the goals of the doctor, employer and employee in providing the best care at fair prices. 

BTM started in 2014 out of the passion of its physician founder to establish a better healthcare model, where:

Current “Sick care” System 

  • Treats symptoms
  • Fragmented and episodic
  • Expensive & complex
  • Physician centered

BTM Health Care

  • Improves health
  • Continuous & coordinated
  • Simpler and fair priced
  • Member focused

Why did my employer select BowTie?

Healthcare costs increased by double digit %’s this year and are expected to continue to rise at an even faster pace over the next few years. Your employer wants to protect healthcare for you and your family and has experienced the cost of care almost tripling since 2000 due to runaway medical cost inflation. They saw the financial benefit of becoming self-funded (see question on self-funding) coupled with the improvement in delivering a better care experience provided by the BowTie model, moving from reactive care that treats symptoms to proactive care focused on improving your health, delivered at fair prices.

Why did my employer move from fully insured to become self-funded?

Self-funding is one of the smartest strategies companies can use to help control runaway medical costs. When companies are fully insured, the insurance company takes on the risk and charges premiums that include their profit and any additional funding needed to minimize their risk of losing money. Any savings that occur benefit the insurance company. 

In self-funding, the employer takes on the risk and the benefit of any savings, including the insurer’s profit, are realized by the employer and help offset the rising cost of healthcare. It is estimated that the majority of private companies with a health plan are self-insured and that number is only increasing. As a result of this strategic decision by your employer, your medical premium is significantly lower than what it would have been had your employer remained fully insured. 

How Does BowTie Work?

For the employer: BTM has created a self-funded insurance structure for employers. Self-funded insurance has been used by organizations of 50 or more employees for years to give them more control over their healthcare spend while reducing costs for their employees.

For you, the employee: You will be assigned a Care Team of Virtual Primary Care Physicians, Health Guardians™, and Nurses to work with you on your care needs. BTM functions as providers of primary care, navigators of specialty/complex healthcare, and payers of medical bills. 

Unlike traditional “sick” care, BTM provides Virtual Primary Care coverage from 8am – 8pm, Mon. – Fri. and Tele-Urgent care 24×7. This is at NO ADDITIONAL COST to you, improving your access to care and care experience while reducing your costs for needed care.

Our Health Guardians™ are available from 8am – 8pm,
Mon. – Fri. to ensure you receive the best care experience at a fair price. Armed with pricing transparency tools, our Guardians navigate you through the complex healthcare system, providing you with well-researched options, taking into consideration quality ratings, convenience, availability. and pricing.

Why a BowTie Care Team?

Each member that joins BTM is assigned to a virtual care, physician-led team consisting of Primary, Urgent Care & 2nd Opinion Physicians and Health Guardians™. The care team supports you at the level that fits your needs, up to delivering all your primary and acute care, price shopping and referrals to high quality / fair price specialists and testing.

What training & qualifications do BTM Care Teams have?

Our Health Guardians™ come from nursing, behavioral and mental health counseling, medical assistant and other licensed healthcare backgrounds. Our Guardians are given access to powerful transparency tools, giving them the resources necessary to provide you with well researched, high-quality options for your healthcare needs. Most importantly, they are empowered to improve your care experience, acting as problem solvers that play an instrumental role in improving your healthcare.

BTM Physicians are board certified in family practice and internal medicine and are passionate about your health. They collaborate with a number of specialists to safely & effectively deliver the majority of your care needs.

Questions on Care

Why virtual care instead of in-person care?

90% of healthcare is an exchange of information between you and your physician and does not require being face to face. Virtual care allows you to see specialists sooner, avoid travel and waiting rooms, saving valuable time and exposure to other illnesses. Virtual care is more cost effective, saves time and provides access to a larger pool of high-quality specialists across the country in the privacy of your preferred location. 

What happens if I need in person care?

BowTie physicians will work with your Health Guardian™
to find the right care at the right place at the right price
for those health issues that require something more than
a virtual visit.

What do I do in the case of an emergency?

If this is life threatening, call 911. If you don’t believe it is but it still needs immediate attention, call BowTie and connect with one of our physicians.

If I have questions, who should I call?

We always recommend you call the BowTie number first 877.3BOWTIE (877.326.9843) for any questions. Through this phone number you can access your Guardians, schedule time with your BTM physician, as well as get help on billing, pharmacy, and claims questions. You can also send an email to info@bowtiemedical.com. In the case of a life-threatening emergency, always call 911 directly. 

How do I interact with BTM Guardians?

At BTM we take a virtual first, mobile centric approach to delivering our services so you can reach out to us wherever you are. We offer a combination of phone, text, chat and app-based interfaces to simplify and enhance your experience and communicate with you the way you prefer.

What do I do if I already have a procedure scheduled after start my BowTie plan?

We recommend that you keep the schedule and call your Health Guardian™ to notify them. After speaking with your Guardian, they may recommend talking to one of our BTM Physicians to review your health situation. You are under no obligation to do so, though we believe it would be beneficial to either validate the approach or provide you with an alternative that may avoid costly, and unnecessary specialty services. 

What happens if I already have a primary care doctor or specialist (OBGYN, dermatologist, etc.) that I want to continue to see?

You are in control regarding the doctors you choose, and we are there to support those relationships however we can. Our ability to deliver the best care experience while reducing your out-of-pocket cost is fully realized when you use BowTie primary care physicians as your main primary care doctor because they aren’t incentivized to send you to specialists employed by the same hospital. Our physicians work with many specialists and will work with yours as needed if you are already under their care. 

There are many ways we can help when you call BowTie first so please call us and see! 

Do plan participants have the freedom of choice to go anywhere for care and services?

Yes. BTM has access to direct contracts with all leading providers including the Cleveland Clinic, UH and Metro Health therefore you are no longer limited by a traditional network. BowTie augments these direct contracts with Reference-based Pricing (RBP) for those providers that are RBP-friendly, maximizing your savings on the services offered. Our Health Guardians™ will do the research for you and present up to 3 best-rated options for you to choose from. 

Please keep in mind, like your previous plans, certain specialty services require a prior authorization by your physician and BowTie will work to make this as seamless as possible. 

How do I know if my provider is “in network”?

One of the benefits of the BowTie solution is there are no longer in and out of network providers. We may recommend you to any health network and any facility that is convenient for you and recognized for providing high quality services, specific to your needs. 

Please keep in mind, like your previous plans, certain specialty services require a prior authorization by your physician and BowTie will work to make this as seamless as possible.

Questions on Insurance

Will I be receiving a new benefit card?

Yes. Your new insurance card will be sent to the mailing address on record within 7-10 business days of your plan’s start date. In the meantime, you will be provided a PDF version of the card, giving you access to any and all services. 

What happens to the $$ I paid toward my deductible already?

All of the money you have contributed to your deductible rolls over to your new BowTie Medical Health plan and you pick up where you left off.

Are annual wellness visits (including blood work), mammograms, colonoscopies, and other proactive tests covered?

Yes. We take a proactive approach to healthcare and believe in early identification of health related issues so they can be treated with the best outcomes. Blood work and other age/sex appropriate testing is designed into our care plans, following national medical care guidelines. Please refer to your plan for more specifics. 

Who is my insurance provider?

All critical information will be on your benefits card that you will receive in the mail. Because your employer is self-insured, the name on the card will be that of the TPA being used, called The Health Plan or THP for short. THP is well known in Ohio and this should have no impact on your ability to receive the care you need. 

How are my medical bills paid?

Your visits with BTM’s doctors and guardians come at no additional cost to you. 

When you choose to see other physicians (primary or specialist), you give them your new insurance card and they send the bill to BTM’s Third Party Administrator, The Health Plan (THP). THP will determine the appropriate amount to reimburse the provider of services (pre negotiated rates including Reference Based Pricing – RBP) and charge both you and your employer the appropriate split, (based on the plan chosen), of the negotiated charge amount.

What is Reference Based Pricing (RBP)?

At its core, reference-based pricing is a way that health plans can base their claims spending in objective, industry-accepted metrics, using a method of reimbursement tied to a percent over Medicare reimbursement. You may not be aware that healthcare providers mark up their costs by as much as 10,000% with little transparency into pricing, until you receive the final bill. This common practice led to new price transparency laws effective July 1, 2022. 

Who provides Pharmacy Services (PBM)?

BowTie has engaged trueRx to provide pharmacy benefit management services. You have access to 66,000+ pharmacies nationwide and easy resources to find the pharmacy nearest you. Check out the pharmacy locator: truerx.com/pharmacy-locator

Does trueRx have a mail order program?

Yes, they do. You will need to provide a new prescription from your doctor, your insurance card information, your home address, and your payment information to set up your mail order:

Who is responsible for paying claims?

In employer provided health insurance, the employer always has the ultimate responsibility to pay for the cost of healthcare, including claims. In the fully-insured model, all costs are built into the monthly premiums your employer pays to the insurer, which is significantly more than your monthly premium. When self-funded, employers work with a Third-Party Administrator (TPA) to process all claims and the TPA in turn charges the employer directly for the cost of claims and the fees to process them.

Will my healthcare bills be shared with my employer because they are self-funded?

No. HIPAA (Health Insurance Portability and Accountability Act) laws protect your personal health information (PHI) from being disclosed. BowTie Medical and our provider partners are subject to all relevant laws and regulations. Being self-insured means your employer may see deidentified (anonymous) information on claims as they are paying the bills, but they will not see any PHI.

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