Questions On Types Of Payment

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

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.

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.

An HMO provides comprehensive health-care services to the insured for a fixed periodic payment. There may also be a nominal fee paid for each visit to a health-care provider. Unlike traditional insurance, HMOs actually provide the health care rather than just making payments to health-care providers. HMOs can have a variety of relationships with hospitals and physicians. Plan physicians may be salaried employees, members of an independent multi-specialty group, of a network of independent multi-specialty groups, or part of an individual practice association.

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

As a rise for medical services grew, this caused the cost of healthcare to rise. As a result of the rising healthcare costs, the government created a hospital inpatient perspective payment system called the diagnosis related group system. The diagnosis related group system created a fixed and determined payment structure based on the diagnosis of the patient that enabled them to be reimbursed for products and services that were used to treat the given diagnosis with one payment. The diagnosis related group system created an efficient and less costly care for the patient. Outpatient services are not a part of the diagnosis related group

Managed Care is a complex health care system in which physicians, hospitals, and other healthcare professionals organize in an interrelated system of people and facilities that communicate with one another and work together as a unit, commonly referred to as a network. This network coordinates and arranges health care services and benefits for a specific group of individuals, referred as enrollees, for the purpose of managing costs, quality, and access to health care. The Managed care program may be provided in a variety of settings, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). In Health Maintenance Organization, the insurance company will only pay for care within the network. The member will pick a primary care provider who coordinates most of their care. Preferred Provider Organization (PPO) usually pays more if the member will get care within the network, but they still pay a portion if the member will go outside. And Point of Service (POS) plans let you choose between an HMO and a PPO each time you need care (Merrick, 2013).

HMO Plans requirements are that beneficiaries must see their health-care providers, doctors, and hospitals within the chosen plans network. With the expectations of urgent care and emergency care situations. With an HMO plan the participants are required to have a primary care physician upon enrolling on the plan. With these conditions; only a physicians can refer the plan holder out to see a specialist. But unlike a yearly check up that I have recently had or my mammograms doesn't require me to be referred out. And most all of my medications are covered under the HMO plan.

You can choose between an HMO or a PPO each time you receive medical care. These plans offer more flexibility in choosing doctors and hospitals.

HMOs provide medical treatment on a prepaid basis, which means that HMO members pay a fixed monthly fee, regardless of how much medical care is needed in a given month. In return for this fee, most HMOs provide a wide variety of medical services,

Health maintenance organizations HMOs - Members must have a PCP who is your general doctor, internist, OB/GYN, or pediatrician. PCP also coordinates cares and makes referrals to specialists. Their main concerns preventive care with a goal of containing overall healthcare cost. It only pays for services performed by in-network provider.

With and HMO plan you have one primary care doctor approved by your plan who manages your cares for you through referrals and assistance on getting appointments with specialists. These plans

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.

HMO (Health Management Organization) is a preferred provider organization. Their focus is to reduce the cost of the preventative care as well as implementing utilization management controls as part of their goal. Being part of a HMO, you can choose the primary physician for medical purposes. One of the advantages are the low cost out of pocket costs for the patient’s insurance. Each time you seek medical care you are only obligated to pay a percentage of the bill. Members of HMO are at a fixed cost for the monthly fees. HMO tries to encourage the patients to stay on top of their health, and not let their illnesses get to out of hand by letting it get worse. Another advantage, is that being part of the HMO, your offered education classes and discounted club memberships for your health. The disadvantages of the HMO consist of some strict controls. An example of an advantage would be if you decided you wanted to receive care from another doctor or specialist, it must be consulted. Although by doing the consultation, which helps lower the cost for the HMO and the member, it can also cause problems if your physician doesn’t provide you with the referral. When you receive care from a provider that’s not part of a HMO, the organization will not pay for services that are non-emergency from the physician. (Medical Billing, n.d.)