ch 7: working with managed care and third party reimbursement agencies Flashcards
fee-for-service system
a payment model that itemizes each service component, which maximizes the quantity of services provided
Health Maintenance Organization Act in 1973
spurred the promotion and development of health maintenance organizations (HMOs) as a mechanism to control the rising costs of health care in the US
Managed care
an umbrella term used to describe a practice or set of practices that provides oversight in the delivery of health care services
cost-effective services while ensuring the appropriateness and quality of those services
Managed care considerations
- reduces health care costs
- creates a network of readily available providers
- expedites information among in-network providers
- provides access to affordable health care services
criticisms of managed care
- restricted access to services and providers of care
- exclusionary practices based on pre-existing conditions
- quality of services provided
patient protection and affordable care act AKA Affordable care act (ACA)
expanded health care coverage for millions of Americans in both
eligibility and expansion of medicaid programs at the state level
four major types of managed care programs
HMOs
PPOs
POS
EPOs
HMO (health maintenance organization)
type of managed care that focuses on preventative care and utilization management
PCPs are first point of contact
utilization management
a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs. by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision
mitigates unnecessary health care costs by ensuring services are medically necessary
HMO advantages
low out of pocket cost
stability in price over time
focus on preventative care
HMO disadvantages
challenges in receiving specialized care
no coverage for out of network services
limited to no freedom of choice
PPOs
contract with doctors, hospitals, clinics, etc. who agree to provide health services at a reduced rate
low co-payments monthly premiums are paid for by sponsors or employers
more flexibility in selecting providers
con: higher cost with out of network providers
POS (point of service)
have characteristics of both HMOS and PPOs
must choose an in network PCP and pay minimum copayments for each visit without a deductible
provide coverage for out-of-network services (pay more for out-of-network if referred by PCP)
advantages of POS
maximum freedom of choice
smaller copayments
nondeductible when in network
omission of gatekeeper function of out of network
disadvantages of POS
high co pays of out of network
deductibles that must be met before insurance pays for out of network
gatekeeper for reduced out of network costs
