Health Insurance Matrix Essay

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Health Insurance Matrix

Origin: When was the model first used?
What kind of payment system is used, such as prospective, retrospective, or concurrent?
Who pays for care?
What is the access structure, such as gatekeeper, open-access, and so forth?
How does the model affect patients? Include pros and cons.
How does the model affect providers? Include pros and cons.
In 1932 the American Medical Association (AMA) adopted a strong position against prepaid group practices, favoring instead indemnity-type insurance that protects the policyholder from expenses by reimbursement (Jones & Bartlett, 2007). As one of the first health policies in the U.S., indemnity plans are considered
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Potential for higher payment amounts at time of service. Alternatively, there is a potential for greater debt amounts. Larger debts will make it necessary for health care providers to be more aggressive for collections. Providers will also encounter increased staff costs in order to follow-up with patients in advance of treatment, as well as in subsequent collection efforts (Fifth Third Bank, 2008).
HealthPartners of Minneapolis pioneered point-of-service (POS) plans in 1961, but the concept took 25 years to get off the starting blocks (Dimmit, B., 1996). In 1986 CIGNA Healthcare launched Flexcare, the first POS plan. By 1995 forty percent of employers with at least 200 employees offered POS plans.
Providers within a point-of-service network are usually paid a capitated fee. The fee is fixed and does not alter regardless of services rendered. POS plans operate using a prospective payment system. Insurance companies reimburse providers an agreed amount that is decided before a patient receives services.

Patients are responsible for paying a co-payment when visiting a doctor. After the patient is seen, the provider submits claim forms to the insurer for the services rendered. Once the claims are processed the insurer will reimburse the provider (Austin & Wetle, 2012). If a patient goes out-of-network, they are required to pay the provider in full. Afterwards the patient can submit a claim for reimbursement.

Point-of-service insurance plans
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