Exclusive Provider Organization Analysis

As far as insurance plans go, generally there are three plans a patient will have, they are Health Maintenance Organization (HM0), Preferred Provider Organization (PPO) and Point-of-Service (POS).

Most of the plans have a higher deductible, which allows the person holding the policy to have lower premiums. In order to control costs and compete for contract, the plans offer many managed care features (Valerius, Bayes, Newby, Seggern , 2008).

The HMO’s stress wellness and preventive care, therefore its focus is more on health maintenance rather than just the treatment itself. Because of this, HMO’s offer much richer benefits than the traditional plans. HMO’s have little to no upfront costs in an effort to encourage maintenance, while comprehensive and major medical plans have up-front cost sharing so as to discourage over utilization.

The patient is informed about their coverage and the amount of copayment they would have to pay.

EPO vs HMO-- EPO contracts solely with specific specialists, clinics, hospitals and other health care providers to form a network. EPO clients know they don't have many options when it comes to providers, but they do have the comfort of knowing they'll always be reimbursed for any in-network expenses. HMO’s requires a co-payment on each visit while EPO’s have no co-pays. Both EPO’s and HMO’s keep costs low. EPO’s do not require a referral while HMO’s must confirm that specialized care is required before they will issue a referral

This insurance encouraged people that had this basic form of insurance to get a second opinion on their medical issues especially elective surgeries. You had to pay for services that you were receiving right away.

POS plans provide the ability to receive the medical attention they need with a provider they want to administer the care they need. This flexibility can be extremely valuable for certain people, such as members who frequently use outpatient medical services, such as physical therapy or counseling. It is also valuable in being able to choose a desired specialized physician such as a neurologist or cancer specialist.

As a single employee, I want to select a PPO health network as my medical insurance so that I can continue to see my current family doctor.

However, the coverage Medicare provides comes with premium and cost-sharing requirements as well as gaps in covered benefits, especially for long-term services and supports (LTSS). As a result, Medicare coverage often is supplemented by additional coverage from retiree benefits, Medigap policies separately purchased, and, for low-income beneficiaries, Medicaid (Rowland, 2015). Now, the eligible Medicare beneficiaries can choose between managed care and indemnity plans. Medicare managed care program, Medicare advantage plan, promoted new forms of managed care that were more like traditional insurance policies than like HMOs.

Unlike Health Maintenance Organizations, there are managed care programs that offer a deductible, coinsurance feature and earn money by charging a fee to the insurance company for using their network. This service is formally known as Preferred Provider Organizations (PPO). The deductible must be fully paid before any benefits are provided and subsequently, the coinsurance benefits will be applied. For instance, if the PPO plan is an 80% coinsurance plan with a $1,000 deductible, then the patient will pay 100% of the allowed provider fee up to $1,000. After this amount has

Other programs under DM that have shown to be beneficial to both the members and the health plans are, shared decision-making programs and medical informatics. PPOs, HMOs and CDHPs have preventive services programs being implemented. Preventive services include services such as: immunizations, mammograms, physicals, and counseling. An independent study on an indemnity plan that had prenatal preventive services showed that members who enrolled into this program had an average of $3200 less per delivery than those who had not (p.194). Health risk appraisals are a program geared to obtain information from members regarding activities or behaviors that can affect their health status (Kongstvedt, 2007,p.193). When the health plan obtains this information it

The relationship of an HMO and its physician member is to help provide a wider range health care for its patients and a wide area of services available for its physician members. A patient must choose a primary care physician from a list of providers. The relationship with the physician provided from the HMO is in a contract that is to deliver services to their patients for a fee. There can also be a group plan which is a HMOs contract with a group of physicians to deliver services. The HMO organization compared to PPOs, a PPO is a variation of an HMO, and it features traditional insurance and managed care.

As has been denoted by the history of the BCBSIL above, the medical structure of BCBSIL is composed of providers that may, or may not have a contract with the BCBSIL. The contract with the providers or the modality of payment to providers for services rendered to their beneficiaries is dependent on the BCBSIL’s health care plan. Therefore, providers that decide to accept BCBSIL’s PPO patient are reimbursement based on fee-for-service in accordance with the Blue Choice PPO Schedule of Maximum Allowances (SMA). However, the providers that opt to accept the BCBSIL HMO patients do not contract directly with BCBSIL for their HMO products. Instead ,providers that wish to participate in the BCBSIL HMO network must contact a BCBSIL contracting HMO Medical Group or IPA in their area of practice (“Contracting”, 2016).

The United States being referred for specialties depends on the insurance plan (Mossialos, Wenzel, Osborn, Sarnak, 2016, pp. 171-177). Health Maintenance Organization (HMO) plans give access to certain healthcare organizations and physician within their network that have agreed to lower rates for their services. The individual must agree to these services to have services covered. All services will be coordinated by the primary care physician PCP. Medicaid coverage is also based on these principles. Preferred Provider Organization (PPO) plan have higher premiums but give more flexibility. PPO allows the individual to see any physician they choose but cost is less if the individual stays within the network. PPO does not require that the individual have a PCP. No referrals for specialist are needed.

The drawbacks from these insurances (HMO, PPO) are you have a limited to select from a network of physicians, therefore if you changed professions and had to work somewhere else that offered a different insurance which your current doctor did not participate with, you would now need to switch over to someone