Health Reimbursement Essay

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 types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

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.

HMOs are usually the least expensive health plans, offer predictable costs for health care, the least administrative paperwork, and cover preventive care (Barsukiewicz, Raffel, & Raffel, 2010). However, HMOs also restrict direct access to specialists by requiring referrals by a PCP, requiring patients to see a provider in the HMO network, and often not covering more costly procedures or care options, because care is managed to control excessive or unnecessary care. Providers gain if they provide less care (Austin & Wetle, 2012). This incentive could affect patient-provider trust.

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

Today, there are several types of managed care plans including Preferred Provider Organizations (PPOs), HMOs, and Point-of-Service (POS) plans. There are many types of HMOs that offer members a variety of health benefits. An HMO plan requires the member to use health care providers and facilities within the HMO network in order receive coverage, unless it is an emergency (Andrews, 2014, p. 1). A PPO is a form of managed care that most resembles a fee-for-service type situation. The plan members can generally refer themselves to doctors, including doctors outside the plan, although they typically will pay a higher percentage of the cost if the doctor is out of the network (Andrews, 2014, p. 1). A POS plan allows members to refer themselves outside the HMO network and still get some coverage (Andrews, 2014, p. 1). While these

HMO has access you can use to certain doctors and hospitals that’s in your network. The network has physicians that agreed to lower rates to plan members that

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.

An HMO delivers all health services through a network of healthcare providers and facilities. A primary care doctor to manage the care and refer to specialists when we need one so the care is covered by the health plan; most HMOs will require a referral before we can see a specialist. The plan may require us to pay the amount of a deductible before it covers care beyond our essential benefits. There are no claim forms to fill out.

Health Maintenance Organization (HMO) – HMOs are indeed the typical type of managed care health insurance plans, and they mainly focus on preventive care and wellness. Members pay a fixed annual premium and they only have limited access to certain physicians and hospitals within its network. Medical care is also limited to a prearranged. Most HMO plans require members to choose a network physician as a primary care provider (PCP). In addition, to consult with a specialists, members must obtain referrals from their PCP or their case manager. (USLegal.com)

The three major types of health insurance available in the US are "Health Maintenance Organizations--HMOs, Point of Service plans--POS, Preferred Provider Organizations --PPOs." (Health Insurance Coverage, 2010) All the three coverage options come under managed care plans wherein the health insurers collaborate with healthcare providers to build networks. HMOs offer the most economical health insurance coverage, however their plans are not always flexible. As they come under HMO purview the insured has to pay monthly premium while the co-payments are relatively low for hospital and subsequent office visits. When an insured belongs to an HMO, there is a restriction to visit doctors within his network only and any failure will entail footing the bill by the insured himself. Prior to visiting Specialist Doctors, HMOs often need the insured to get referrals. Even visiting the Emergency Room needs approval if one belongs to an HMO. (Health Insurance Coverage, 2010)

Physicians who provide care through an HMO can reap lots of benefits for being associated with the plan. One benefit is they paid regardless if they see the patient, consequently, having the ability to be paid without actually doing work is appealing for some doctors. This type of plan requires patients to have a primary care doctor increasing the number of patients assigned to the doctor which will ultimately enhance their salary. The downside is the effects on patient care. Since the aim is to reduce cost doctors may reduce the number of diagnostic testing and lab work that are not deemed essential to stay in line with the premiums.

Since they genuinely care about their patients, they want to offer them quality healthcare at an affordable price. To do so, they offer a variety of financial plans to best suit individualized needs and budgets. After working with an employee to create a prioritized plan, you can pay in a variety of ways, including:

An HMO is an organized health care delivery system, which provides health care to its members through networks of doctors and hospitals. Rather than traditional health plans, HMO’s cost less. Two ways HMO’s control costs are: controlling hospital admission and length of stay, and by providing incentives to physicians. These two cost control methods are further examined by an article published by The National Bureau of Economic Research (2002). The article examines the incentives to physician strategy for reducing utilization cost. The Physician Guide to Managed Care (1994) describes HMOs the case management procedures used to control cost through hospital length of stay and admissions.

In retrospective payment methods, the insurer learns of the costs of health services after providers give patients care, and the third party payer is at risk. To control financial risk, insurers have replaced retrospective and fee-for-service systems with hybrid plans and managed care plans such as HMOs, POSs, and