Chapter 29 - Blues, PPOs And HMOs Flashcards
Indemnity Plans, Blues, Managed Care ( PPOs,HMOs)
Indemnity Plans - or reimbursement plan. Still used today. Stock or mutual insurance company transacts directly with the insured. The insurance company has no relationship with the provider. The insured chooses a doctor, pays the bills, applies to the insurer for reimbursement and then receives the check from the insurer.
-FEE FOR SERVICE -The doctor gets paid after the service, when the provider gets paid by the insurer its not an indemnity plan.
-usually the insured agrees to have the insurer pay the provider directly (assignment of benefits).
NOT ON THE TEST But…Blue Cross, Blue Shield - in the 1930s, the Blues positioned themselves between the insured and the provider. They assessed the quality and costs of the services and then negotiated lower costs for the services and contracted with the providers, then sending members there. Providers handle the paperwork for claims, are NOT indemnity plans but fee for service, reward members for using a preferred network of doctors and hospitals, emphasize reduced costs through negotiation.
-They are not for profit company. Franchise company to each individual state.
-Blue Cross - originally provided hospital coverage
- Blue Shield - provided coverage for doctor bills.
-today they have merged together.
Managed Care (PPO/HMO)
- the health insurance plan seeks to lower costs by influencing the health behavior of the insured.
-preventive care
-financial incentive to encourage members to use care efficiently.
- second opinion for surgery
- pre auth for major non emergency medical expenses
Utilization review - a managed care concept. Provisions in a policy designed to let the insurer and doctor team up in the treatment process. Includes, Precertification for service, concurrent review (which treatments are best), discharge plan (best follow up care), retrospective review (make sure things were done right).
PPO (Preferred Provider Organization)
Negotiates and contracts with various providers in a community to offer services to members at a reduced rate. Providers are paid fee for service. The patient has deductible, copays, ect. They don’t need a referral to see a specialist.
-covers preventative care
-has the providers handle the paperwork for claims
-is not an indemnity plan
-rewards subscribers for using a preferred list of doctors and hospitals
-pays less if the insured uses a provider outside the preferred list
HMO (Health Maintenance Organization)
Offers a prepaid health plan. The member is subscribed a doctor who serves as the primary care physician ( internist, pediatrician, just NOT a high level specialist). The doctor works for the HMO (typically owned by the insurer). The doctors gets a salary and isn’t paid Fee For Service. Usually there is No deductibles, no coinsurance, no or low copays. You see your PCP and they will refer you to a specialist.
-covers preventative care
-has the providers handle the claims
-reduced costs through negotiation
-is not indemnity plan
-is not Fee for Service
-provides prepaid health care
-owns the hospital and hires the doctors
-operates in a local community
-assigns the member to a PCP (gatekeeper)
-controls access to specialists
-requires the member to use the HMOs hospital and doctors
-WONT pay if the member uses a provider outside the preferred list
HMOs Point of Service Plan (POS)
Members can choose not to coordinate their care through a PCP and still receive some coverage.
-its an indemnity plan under an HMO
-covered referrals at a reduced costs
-covers costs of providers outside of the network, but the coinsurance may be larger, 30%
Self -Funded Plans
Employer is responsible for funding the plan, administering the plan, pays claims and taking the risk.
Most self insured groups hire professional admins called Group Administrators or TPAs (third party administrators) to help with claims and processes.
- to protect against large claims a self funded plan will purchase a STOP LOSS COVERAGE or REINSURANCE from a regular insurance company.
Wellness Programs - workplace programs to help promote better health and living. The would provide flu shots, prizes for walking, ect.
Emergency Care Out of Network - Will the HMO, PPO and POS plans pay? The ACA requires the plan to pay the GREATER OF…
-the amount negotiated with the in network providers for services furnished.
-the amount for emergency services calculated using the same method the plan generally uses to determine payments for out of network services
-the amount that would be paid under Medicare standards.
The out of network provider can balance bill the patient.
