Nt1330 Unit 3

While our understanding has evolved with respect to certain advantages of MCO’s, our understanding of the disadvantages has also grown. This analysis will evaluate the use of MCO’s as a gatekeeper to controlling health care cost and offerings. It will evaluate the advantage MCO’s provide in a rapidly growing market due to the aging of baby boomers. The analysis will evaluate disadvantages that can arise with relying on MCO’s. These disadvantages work against the insurance company forcing a polarizing balance between how much control the MCO should retain over recommendation and provision of services.

There are various differences between managed care plans. With an HMO, the member would receive most or all healthcare from a provider within the network. Also, members are required to choose a PCP and would need a referral to see a specialist or another doctor. PPOs have contracts with a network of providers which they deem “preferred”. Furthermore, PCPs are not required by a PPO and members do not need a referral to see other providers in the network. The POS plan is a combination of both the HMO and PPO plans. With a POS plan, the member must pick a PCP and is allowed to see a provider that is not in the

The purpose of this assignment is to choose a Managed Care Organizations (MCO) that operates within your state or local community, discuss the MCO in detail and determine which MCO model best represents this organization. Outline the historical perspective of the organization, summarize the medical/organizational structure and explain the model of governance.

There are several reasons for choosing the Mayo Clinic. They have locations in Arizona, Florida, Minnesota or the Mayo Clinic Health System. The Mayo Clinic is not for profit, provides doctors in various specialties, recognized as a “Diversity Inc. Top Hospital and Health System” for the last five years in a row. The diversity allows for the team to collaborate with other doctors to obtain viewpoints, which will help provide the patient with the best care option. The Mayo Clinic also has the

Keystone First. Since I have two health insurances Blue Cross and Blue Shield (PPO) the

Hello Carlo, I do agree with every statement you have pointed out regarding the traditional and managed care insurance. Like you have mentioned, traditional insurance is for individuals who are willing to pay high deductibles and co-payments. Even though the freedom of choice is a big advantage for the consumers there is a downside to it as well. Yes, the patient has the freedom to choose a health care provider, doctor or a hospital according to their will. But, this type of insurance mainly focuses on treatment expenses rather than encouraging preventive treatment options and yearly physical check-ups. People more likely prefer to get involved in preventive care measures.

PPO, HMO and POS are all types are all managed care health insurance plans. Virtually all modern health insurance plans are managed care plans, but there is considerable variation in terms of the size of the provider network and the requirements that plans have for member utilization. HMOs, PPOs,and POS plans all have provider networks. This network includes doctors, hospitals, labs and other providers that either have a contract with the health plan or, in some cases, are employed by the health plan. Plans differ as to whether you'll have coverage for health care services from providers who aren’t in their network.If you see an out-of-network doctor or get your blood test done at an out-of-network lab, some health plans won’t pay. You’ll be

Preferred Provider Organizations (PPOs) consist of a network of hospitals, healthcare facilities, physicians and labs that patient may choose from for services and the services will be covered under the insurance policy. Managed care organizations (MCOs) began to proliferate during the 1980s. A Managed Care Organization (MCO) is part of a Family

I find myself liking the point of service plan (POS). This kind of health plan puts together a lower cost option for members selecting to use in the network, but a higher cost for out of network care providers, physicians, and care facilities within their network. These health care providers and services are selected to provide services at a discounted contracted price for the point of the service plan. It is imperative for members to get consent from their primary care physician (PCP) to visit a specialist. Members must remember to receive the best value in the health care plan, they should contact their PCP first or pay extra expenses in the end.

These are all different types of organizations that are different forms of a health maintenance programs.it’s important to know the differences between all these programs and know the benefits so you the patient knows what works for you.

Private insurance companies negotiate prices with hospitals and health care providers to confirm what will be paid by the insurer. These negotiations can be taxing as both entities fight for what is most profitable for them. The providers involved with the negotiations are “in network providers” and all others fall into the out of network realm and run the risk of not being reimbursed or being paid a certain amount leaving it up to the consumer to pick up the remaining balance. Managed care provides a system by which the priority of health care is to reduce costs while ensuring that the delivery of quality health care is provided to consumers. The different types of managed care organizations include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) and both systems follow different payment methods. HMO’s use capitation or fixed annual payments for each person its exclusive list of providers sees no matter what type of care or how much care is provided and PPO’s, like traditional insurance companies, negotiate rates of payment with providers and members enjoy lower out of pocket costs such as deductibles and copays. With PPO’s, members could choose out of network providers and would pay the difference between the reimbursement rate of the plan and the changes of the

It is important to check to see if the insurance you are considering requires an in-network provider, and if your provider is part of their network. If not you may end up paying higher co-pays and overall costs to continue with your current care

While both the PPO and HDHP offer unlimited coverage, the PPO will be less, as our provider is in-network. The HDHP had no discounted pricing. Both plans have unlimited use of provider care, however, a PPO has a co-pay, while the HDHP expenses were out of pocket till the deductible had been met. Our current plan focuses on preventative care and covers vaccines, flu shots, as well as over the counter medications, contraceptive drugs and devices as long as there is a prescription from the provider. The HDHP did not cover preventative care, and so we had to pay every year out of pocket to have our children and ourselves immunized from the flu, and any other preventative courses of action we wished to consider. Our HDHP, like many insurers now, had us submitting our prescriptions to their home delivery prescription service, and they had to be filled in 90 days increments. This meant paying for a three months subscription out of pocket until the $2,500 deductible had been met, and only being able to use the local pharmacy for immediate prescriptions. Any reoccurring subscriptions had to be filled through our plan, and they did not cover any

You will see the greatest value while receiving exceptional care by choosing the Mercy Plus Plan or using Mercy Network providers in the Choice Plan.

The healthcare organization that I chose has many issues. There is a high turnover rate with nurse practitioners, doctors, and office staff. It is difficult to reach someone on the phone to make an appointment, prescriptions are not being called in, and test results are not available when promised. Many patients are