Managed Care Research Paper

An HMO may have central medical offices or clinics (such as those used by Kaiser Permanente), or it may consist of a network of individual practices. In general, you must see HMO-approved physicians or pay the entire cost of the visit yourself. HMOs have the best reputation for covering preventive care services and health improvement programs (Quickquotes.com, 2012). With a PPO plan it

Just like Medicare and Medicaid are insurances in place to help certain types of patients in a population, Tricare is insurance used by active military, retirees, and their families and is run by the Department of Defense. It is also used as a secondary plan (or, when paired with Medicare a tertiary, insurance plan) behind a private plan, such a BlueCross BlueShield. Since Tricare is a government based plan, it does have limitations, such as all procedures needing to have preauthorization and patients seeing doctors within a specific network. It has many different levels to fit any veteran’s lifestyle and needs.

In recent years, health care has been a huge topic in public debates, legislations, and even in deciding who will become the next president. There have been many acts, legislations, and debates on what the country has to do in regards to health care. According to University of Phoenix Read Me First HCS/235 (n.d.), “How health care is financed influences access to health care, how health care is delivered, the quality of health care provided, and its cost”.

It is composed of its members, plans, payments and providers. The members make up the patients, and every patient has their own "benefits" when it comes to healthcare coverage. Each person's "benefits" varies widely. What it typically means is that the health plan provides coverage for certain types of medical procedures, services and goods. This coverage is provided only under certain circumstances described in the plan. The payments are made by "payers," which manage the "benefits" for healthcare procedures, services, and goods. Basically, what procedures, services, and goods will be paid for, how much they will pay for it, when their "benefits" cover it, and how much the patient will have to pay out of pocket. As for the different types of payers, they range widely from health maintenance organizations (HMOs), preferred provider organizations (PPOs) and managed care organization (MCOs). These types of payers can also be not for profit, for-profit, or member owned. Last is the providers, these are the people and/or manufacturers who perform the services and/or procedures for the patients. The providers then contact the patient’s insurance holders to receive payment for their services. Besides members, plans, payments, and providers, managed care is also composed of manufacturers. They manufacture the pharmaceuticals used, as well as the medical devices. When

TRICARE Health Plans is the replacement for CHAMPUS which was the provider of health care services for military dependents. TRICARE not only replaced CHAMPUS but its purpose was also to facilitate members with access to better health care. Unfortunately, TRICARE has gone through many changes and upheavals since its inception in 1997. First, they began by dividing the company into regions. Each member was placed into a region based on where the military member was stationed. If the member was stationed in Maryland then his family belonged to the East Region. Unfortunately, there were many problems with this plan. First, some military members and their families did not live in the same regions. Therefore, the families either had to travel

|Expanded Coverage for young adults |Employers are required to cover dependents up to|Insured population will increase as well as |

Tricare is a health care policy for those in the military, their families, and retirees. Tricare is managed by the defense department. Tricare covers the uniformed services, including the Army, Navy, Marines, Air Force, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration. Tricare compromises families three choices of health care benefits which consist of Tricare prime this is a health maintenance organization, Tricare extra which is a managed care network or health care providers that families can use on a case-by-case basis without a required enrollment and Tricare standard which is a fee-for-service plan. Tricare also offers a plan for those Medicare eligible military retirees and Medicare eligible family members. This program offers the opportunity to receive health care at a military treatment facility for individuals aged 65 or older who are eligible for both Medicare and Tricare. Tricare billing consists of several elements which are; check in process information that is needed such as benefit verification, pre-authorizations, and forms used, coding from the medical such as what forms are needed for the process of coding, then a scenario with the actual ICD-9 and or CPT codes, the type of claim forms that were used and the claims verification process and finally, the claims payment process such as verification and accuracy of payment. Also the possibility of rejection and how to resolve issues that may become present.

What is TRICARE? A question that many of us really do not know how to answer. TRICARE is a major part of the Military Health System, its purpose is to combine the resources of military hospitals and clinics with civilian health care networks, provides access to high-quality health care, supports military operations and readiness. In order to participate in TRICARE benefits, beneficiaries must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS) before you can reap these benefits.

What is Medicare and Medicaid? Medicare is the federal health insurance program for people who are 65 years or older. Medicare can also be used by Younger people who have disabilities. Medicaid is a jointly funded health insurance program for low-income and needy people. 64 million people are covered by Medicaid.

Tricare, which was formerly known as the Civilian Health and Medical Program of the Uniformed Services, is a health care program of the United States Department of Defense Military Health System. Tricare provides civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. There are three types of medical plans with Tricare: Standard, Extra, and Prime.

This writer does not believe Terri suffered a painful and agonizing death. By Michael removing her feeding tube Terri was allowed to die naturally. According to the American Journal of Managed Care, pain is not an expected part of the dying process. Additionally, federal guidelines regulate hospice and require hospice make every reasonable effort to assure patient's pain is well controlled. With proper management of medication, patients can be pain-free without hastening the dying process. Terri was admitted for hospice care so this writer is confident in stating Terri was kept comfort throughout her dying process. Also, Dr. Cheryl Arenelladoes, a writer for the American Hospice Foundation, states patients suffering from persistent vegetative

In chapter 4, I learned about managed care organizations (MCOs), preferred provider organization (PPOs), and health maintenance organizations (HMOs). In PPO there is a list of in-network providers that patients are allowed to see but pay a lot more if they see a physician that is not on the list. In a HMO patients are only allowed to see physicians that are employed by them and may not see anyone else. There are a variety of methods to pay providers for healthcare services. Two of them are widely known as capitation and per diagnosis. Under capitation, organizations receive a fixed amount of money each month regardless of use. In per diagnosis, organizations are paid based on the diagnosis of the patient. The chapter also explained cost shifting

here are three (3) different types of TRICARE, which are standard, extra and, prime. Which means there is major differences between each of the three, starting with TRICARE Standard this is simply a fee for service plan, cost-sharing option. Under this option the expenses are shared between the beneficiary TRICARE themselves. This plan also covers the medical expenses from the civilian physician if they can not be seen by the MTF, once the patient seeks care from a outside provided the benefits start immediately. TRICARE standard it's normal to pay a deductible but it is different for everyone. Now, for TRICARE Prime it is similar to an HMO it is a managed care plan. For the most part it does have the same benefits are the standard but also

Managed care was started as early as the 1900’s, the cited pioneer of the structured system of care that is known today as “Managed Care” is Dr. Michael Shadid. His goal was to help meet the health care needs of a certain groups of people. Such as: rural residents, workers and families in the lumber, mining and railroad industries; the enrollees paid a set fee to physicians who then delivered care under the terms of their agreement. By 1929 the Los Angeles department of water and power contracted with Drs Ronald Ross and H. Clifford Loos to provide service for almost 2,000

With the vast adjustment in health care which came into Law on March 23, 2012,