National Committee Of Quality Assurance Of Health Insurers Essay

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).

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

Despite the countless advanced in technology and the abundance of health care organization popping up all over the place, whether they are free standing clinics, hospitals, urgent cares or etc, many people still lack the ability to receive quality health care. This has become a concern throughout the world, but especially a more vocal concern for residents of the United States in the past few years. In this paper we will discuss the reasons preventing access to quality health care and how we can overcome the many obstacles that stand in our way to provide quality health care to many who lack it today.

There are several types of private payer plans including preferred provider organizations (PPO’s), health maintenance organizations (HMO’s), and point of service (POS). Indemnity plans would cost the most for employees and they usually choose a PPO plan. A trend that is gaining popularity with employees and employers is the consumer driven health plan (CDHP) that has a high deductable combined with a funding option of some type. All of the plans have unique features for coverage of services and financial responsibility.

What is HEDIS? This abbreviation stands for the Healthcare Effectiveness Data and Information Set. This information set has morphed in its usefulness since 1991, where it was first termed the “HMO Employer Data and Information Set” (AHRQ, 2010). Since its inception, this information has been used by a majority of the country’s health care plans to evaluate performance. Today, the data sets allow for evaluation and more fluid comparison of certain areas of care and service. Furthermore, HEDIS comprises eighty-one measures that spans over five domains of care. Due to this amount of information gathered, stakeholders are given the opportunity to compare different plans in similar terms. In addition, the healthcare plans have the availability to view their own rankings to make necessary adjustments. The data sets are also examined to assess which plan is best for employers and employees based on specific needs. This data is also utilized when seeking accreditation and is now a powerful reimbursement tool. The HEDIS results are accessible for stakeholders via Quality Compass, which is a web-based tool that allows one to view and compare benchmark information (HEDIS, 2015).

AHRQ (The Agency for Healthcare Research and Quality) which is the nation's lead federal agency for research on health care quality, costs, outcomes, and patient safety. In this website I found out best

You have open access to indemnity insurance. You have the right to choose your PCP and it doesn’t matter what your insurance may like. This makes things very convenient considering many people go to the same doctor for the vast majority of their life and solely rely on them for their treatment or care.

NAHQ is dedicated to the advancement of healthcare quality and patient safety and the professionals working in the field. “These professionals drive the delivery of vital data for effective decision making in healthcare systems by combining technology with their unique expertise in quality management” (NAHQ, n.d.). Also, at NAHQ, these healthcare quality professionals are provided with resources and tools that expand knowledge and skills in the competency areas that require advance quality. This helps the strategic leaders in achieving regulatory, accreditation and organizational compliance in quality and safety improvement

*NCQA-focuses on patient safety, confidentiality, consumer protection, access to services, service quality, and continous improvement.

Joining the American Health Information Management Association (AHIMA) benefits individuals and distinguishes them apart from others. AHIMA labels individual’s as competent, knowledgeable and committed to the association through quality healthcare delivery and quality information.

As the CFO of Community Memorial Hospital, I have a major problem on my hands that could lead the hospital in a financial bid. Bill Jacobs, the Human Resource Director of Commercial Intertech (CI) which is the largest employer in the community, has signed a contract MegaPlan Health. MegaPlan is a known insurance company that gives hospitals a very hard time especially when it comes to discounts and fighting claims the hospitals make. Since all of our employees and their families will be using MegaPlan Insurance and Community Memorial is not on their Preferred Provider Network (PPN), I need to figure out if we should work with or without

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.

Humana, Inc. is a health insurance company from Louisville, Kentucky that started in 1961 by Lawyers Wendell Cherry and David A. Jones, Sr. Humana started as a nursing home where it later become the largest nursing home company in the nation. After the nursing homes they soon began to purchase hospitals entirely for expansion. The name of the company changed to Humana, Inc. two years later. Cherry and Jones continued to expand by purchasing other companies. In 1984, the company began focusing on Health Insurance where it remains to focus on even today. Since 2014, Humana has had over 13 million customers and over 52,000, and a revenue of $41.3 billion that was reported in 2013.

Some hospital trusts and health authorities consistently outperform others on different dimensions of performance. Why? There is some evidence that “management matters”, as well as the combined efforts of individual clinicians and teams. However, studies that have been conducted on the link between the organisation

Health care reform has been a big topic since the Clinton administration when First Lady, Hillary Rodham Clinton, took it under her belt to devise a new system. Health care is the provision taken to preserve mental and physical health using prevention and treatment. Compared to other health care systems in the world, the United States is ranked 37th in terms of care, claims Michael Moore (2007). Ironically, our health care system spends more than any other nation on its patients, averaging nearly $8,000 per person (DiNitto, 2012). With soaring costs, it is no surprise that one in every seven Americans are uninsured (Kaiser, 2011). Even with these sorry figures, statistics show that 85% of Americans are satisfied with their health care