Explain How Managed Care Works Flashcards
What is managed care?
Type of healthcare system that manages utilization, quality, and cost of services.
Resources and services are closely monitored to ensure that the costs of services are within the amount that the insurance company will reimburse.
What are some examples of managed care?
HMOs and PPOs.
What is a managed care health plan?
A collection of interdependent systems that integrate the delivery of healthcare services to a specific population.
-Arrangements with selected providers to furnish a comprehensive set of healthcare services to members
-Credentialing standards for the selection of healthcare providers
-quality assurance and utilization review programs
-financial incentives for members to use providers and procedures associated with the health plan (network).
What is an HMO?
Health Maintenance Organization
Prepaid medical service plan that provides services to plan members.
Fixed payment per patient per month (Capitated payment)
Gatekeeper concept: PCP is go to
What are the advantages of an HMO?
No claim forms
Broader and more routine coverage
Predictable costs.
What are the disadvantages of an HMO?
Possibility of delayed payment for out-of-area services
Pre-approval for care needed
PCP directs patient care.
What are the HMO models?
Group model
Independent (or individual) practice association
Network model
Staff Model
What is the group model?
HMO contracts a multispeciality group for services.
What is the independent (or individual) practice association model?
HMO contracts an organized group of individual physicians.
What is the network model?
HMO contracts a combo of multispecialty groups, IPAs and independent physicians.
What is the staff model?
HMO employees physicians and healthcare workers.
What is a PPO?
Preferred Provider Organizations
Represents a network of hospitals and physicians who provide services to ensured plan members for a set fee.
What are the advantages of a PPO?
Ability to choose between doctors in the network
Choice to go to an out-of-network physician and receive some reimbursement but will be responsible for higher share of the cost.
What are the disadvantages of a PPO?
Higher premiums and out-of-pocket costs for PPO services than an HMO
In-network coverage is usually 80 to 100 percent with a co-payment for each office visit or hospital stay.
What are POS plans?
Insured chooses PCP but has option to receive care from hospitals or physicians that aren’t on the plan with a reduced level of benefits without referrals.
