Exclusive Provider Organization Analysis

HMO- Is the most popular of the plans and is a group of providers that provides services to subscribers with a very small or even co copay when services are rendered. There actually are various types of HMO's that link providers to create a healthcare delivery system, they are Group Model HMO, Individual Practice Association HMO, Network Model HMO, Staff Model HMO, and Open Access HMO.

The PPO plan is the most 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).

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

An interview should be conducted with the patient prior to giving a patient an initial appointment, this allows the office staff to collect preliminary data to ensure that the patient has called the appropriate office for an appointment and to verify the patient's eligibility. Insurance of the patient and the

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

University of Phoenix Material Health Insurance Matrix As you learn about health care delivery in the United States, it is important to understand the various models of health insurance to develop a working knowledge as you progress through the course. The following matrix is designed to help you develop that knowledge and

The answer to the question about point-of-service (POS) payment asked in the assignment is as follows. The question: What is the amount a patient has to pay to see an out of network physician when the bill is 2000.00 and out of that amount, 1200.00 is approved charges with the POS out of network insurance paying 80% of approved charges?

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

• User stories/requirements for testing 1) 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.

I currently work for a hospital which is part of an academic medical center. It offers 3 health plan options to choose from. The first is the hospitals own medical plan which which is has features of an EPO, and can be categorized as a CDHP (Consumer Driven Health Plan). It has a higher monthly cost, but lower out-of-pocket costs when care is needed. It has a large network of providers including the hospital, and a network of providers who have partnered with the institution. You are not required to have a PCP, but it is recommended, you must use in-network providers, it has a HIA (Health Incentive Account) with wellness incentive funds available for members. The second is a POS plan from one of the larger Insurance companies with 2 tiers of in-network providers, lowest monthly cost, but a higher out-of-pocket cost when care is needed, until you meet the annual deductible amount. This has a Health Savings Account (HSA) attached, and you can have tax deductible contributions go to the fund, and wellness incentives funds can be deposited into the HSA. The third is an HMO plan with the highest monthly cost, but a lower out-of-pocket cost compared to the POS plan when care is needed. It also has an HIA attached as well.

Comparison of HMO’s and PPO’s May 9, 2011 Dr. Rhonda Hatfield MHA 628 Health care cost has risen dramatically in the last decade. Health care plans have been forced to look at the quality of health care given by the providers so they can

I had one option where I would essentially pay nothing, but the coverage was different if I had needed to have a major surgery or something of that magnitude. You will have to weigh your options when it comes to your risks of having a large medical cost, but I opted to pick a coverage that was somewhere in the middle, where I still have costs per month, but the overall charges for a long hospital stay would not be massive. So far I have used the plan to see a regular doctor at least six or seven times, have seen several specialist, and picked up medication and I have to say it is the most professional and efficient health insurance company that I have ever dealt

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 BCBS IL has been able to use its experience to catapult itself to the forefront of many MCO in the health care market, today the organization offers dual health insurance model to their beneficiaries; the PPO model and the open- panel HMO model. The Medical Of Structure: BCBSIL As has