Nicoleta Shamah Case Analysis

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.

During our investigation, we reached out to our Grievance & Appeal contact and we spoke with Candice who advised us that Dr. Dozier is not contracted as of June 1, 2015, we currently have your primary care physician as Dr. Nassef Henein, that with an HMO plan, your Primary Care Physician should coordinate our care and refer you when you need to see another provider or specialist, that you should chose providers who are not only contracted with Blue Cross Senior Secure Plan II (HMO). We are also participating with heritage IPA, which you may call Heritage IPA at 1-661-327-441. you can then search each at the www.anthem.com/ca/ “Find a Doctor” tool to make sure each is INN for Blue Cross Senior Secure Plan II (HMO). If you have questions about

This insurance encouraged people that had this basic form of insurance to get a second opinion on their medical issues especially elective surgeries. You had to pay for services that you were receiving right away.

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This will be a cooperative plan with the primary care offices. Patients with chronic illnesses will be referred to care managers if they don’t already have one assigned.

Cooper-Pearson’s focus was on recruiting highly intellectual men and women right out of college and willingly paid great amounts of salary for joining the company, these individuals do not have families and insurance is not so important to them at that time, but after developing a family of their own these individuals seek for coverage and when those needs are not meet they turn to other companies. For these reasons, I believe that the company should turn to a stable managed care plan in order to maintain their staffs; one of the approaches would be an improvement on customer care. The PPO plan happens to carry this message in mind since they give individuals the opportunity to make their own decisions. The plan is not as cheap as HMO, but it gives the participant the rights that they all want, and if Cooper-Pearson Sports Marketing would like to retain their employees, it is discernable that the PPO plan is the best choice for them.

With the ACA, consumers can chose an insurance plan from online marketplaces. Some states have their own marketplace, like New York, and others use the Federal based marketplace. Once a consumer chooses a plan, there are certain healthcare providers in an insurer’s network. A network is a group of health care providers that have contracted with a health plan to provide care to its enrollees at negotiated rates. To access these providers, a consumer can either call the insurers customer service line or use the online provider directory which is located on the insurer’s website. The directories are designed for consumers to input their zip code, and select a specialty, in which a list of providers who are accepting patients nearby will populate. With the newly populated list, consumers can call a provider and set an appointment.

A Preferred Provider Organization plan is one which permits liberate movement equally within and outside of the organization's contributing provider association. The association may incorporate general physicians, experts, laboratories, diagnostic services, outpatient or free-standing accommodations, hospitals, resilient medical equipment, apothecaries, opticians, holistic/alternative contributors, therapists and more. “Free movement” inside the arrangement is generally referred to as referral-free access (or self-referral) to practitioners, specialists and more. Supplementary arrangement models will necessitate the preference of a Primary Care Physician (PCP) who is subsequently responsible for evaluating your care requirements and composing the applicable referrals for additional maintenance. Though, in a referral-free PPO plan various hospital admissions, diagnostic assessment, out-patient surgical treatment and more will necessitate pre- authorization. This is a procedure of informing the insurance provider of your intents to have specific services provided and basically obtaining their consent to do so. (Conference Associates,

This letter is in response to Sara Lipe’s inquiry submitted to your office and received by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, on June 3, 2016.

Jonathan Friedman had coverage under the Blue Choice Silver PPO 004 Individual Health insurance policy effective January 1, 2014. The policy was terminated April 30, 2014.

Instead, customers are encouraged to use providers within the network through offering them reduced rates for service. When a customer uses a provider that participates with the program, they pay less in the form of out of pocket copayments. These discounts are available because the health care providers within the network have contracts with the PPO stating the agreed upon discounted rates the providers will be paid when they provide services for members of that particular PPO (Gapenski, 2013).

With the scenario regarding Emmanuel, he has health insurance from his job, however, his employer offers a low-cost POS health insurance plan that gives him a limited choice of health providers

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 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.

All of Dr. Stanton’s current interactions with the Advocate Medical Group/Illinois Professionals Health Program are documented in their fax to me dated 06/15/15. Relative to monitoring standards, at the present time he was noted to be in full compliance with the directives of the IPHP.