Preferred Partner Networks (PPN)

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).

Physicians were looking for assistance with HMO and PPO insurance companies and rising healthcare cost and PhyCor, Inc. was there to provide the administrative management. PhyCor, Inc. is considered a physician practice management firm, or PPM, that bought out other management firms to become one of the largest firm due to their ability to negotiate managed care contracts. What attracted physicians to PPMs was their ability to “lower cost and increase revenues” (Burns, L.R., Bradley, E.H., & Weiner, B.J., 2011). PhyCor, Inc. was able to merge large physician groups and specialty clinics creating revenue in the millions, and continued to grow. They grew for several years before the values in stock starting falling, unsatisfied physicians, and

Managed care organizations should have arrangement with both the medical insurers and providers to provide treatment for a contracted rate. Hospital should advertise the services they offer to members of healthcare plans through their healthcare provider by emphasizing on the technology, staff, and other quality of care they provide. Worker compensation plans are similar to commercial plans but treats injured employees. Hospital must contract with all workers compensation plans and must also negotiate coordination of benefits with other insurance carriers of the injured person to full compensate services. For Self pay patients hospital can reach out to them by having pre negotiate rates for treatment when payments are made in advance for certain procedures. Hospital should have system to accept payments when made in any

Since 1984, Medicare patients have been serviced under the prospective payment system of the Medicare program. Under this system, primary care providers are reimbursed for their services using a fixed payment for each patient that is determined by the patient’s diagnosis-related group at the time of the admission. Therefore, under the prospective payment system a hospital’s reimbursement is unaffected by the actual expenditures that are required to care for a patient.

In order to qualify for Federal safe harbors regarding collective bargaining organizations must demonstrate that physicians' who are part of the organization are clinically or financially integrated with-in the practice in order to achieve cost and/or quality improvements to patient care [3]. They must demonstrate that joint contracting is reasonably necessary to achieve these cost and quality savings [3]. While there are no set limitations, the Practice should also consider their organizations market power in the community of their principle place of business. Lastly, they must consider weather they are exclusive in restricting individual physicians' ability to contract with various payors

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

“a) Contracts that explicitly detail the responsibilities of employers as purchasers with insurance, managed care, and hospitals and physician groups as suppliers, b) Information to support the management of purchasing activities, c) Quality management to drive continuous improvement in the process of healthcare purchasing and in the delivery of healthcare services, d) Incentives to encourage and reward consumers, and e) Education to assist employees become better healthcare consumers” (p. 352).

Results indicated a 25% decline growth rate of NP’s was slower in the most restrictive states

The state healthcare marketplaces have increased new insurance companies in their markets and many of these state healthcare marketplaces will increase new health plans as well. These additional physician opportunities will be imperative for them to understand how the contracting process affects their practices.

Preferred provider organizations have also contracted with hospitals and physicians to provide health-care services. Unlike the case with an HMO, you do not have to go to these physicians. However, you will pay more if you go outside the list of preferred providers. PPO plans usually have a deductible, which is the amount that the insured must pay before the PPO begins to pay. When the PPO plan does start to pay, it will usually pay a percentage of the bill and you have to pay the remainder, which is called “coinsurance.” Most plans have an out-of-pocket maximum. This helps protect you from paying more than a certain amount per year. After you exceed the out-of-pocket maximum, the coinsurance percentage paid by the PPO increases to 100%. (www.ajmc.com)

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

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,

The PPO gives discounts, with its doctors and hospitals that participation, and then pays a fee for services given. Patients have a list that they can pick from for a primary physician. The patient pays a set fee per office visit and the insurance provider pays the rest. It’s basically a co-payment which depends on what type of plan they have. However, like an HMO, the PPO has to choose a physician in that network, if they don’t they may be charged a penalty.

Develop payment strategies to reduce unwarranted price variation, such as reference or value pricing (e.g., analysis of price variation among network providers by procedure and service types, pilot value pricing programs,

The year is 1984. A new network, MTV, is premiering a new awards show: The Video Music Awards. Because it is the show 's maiden broadcast, it is having "difficulty booking top talent" (Tannenbaum). Nonetheless, they did secure a "largely unknown singer," who wanted to "sing her new song, 'Like a Virgin, ' to a full-grown, white Bengal tiger" (Tannenbaum). The network would never let that happen. Instead, the burgeoning pop icon, Madonna decided to descend from wedding cake, which she topped with a plastic groom, and writhe on stage in a wedding dress, as she humped the floor and moaned, revealing her undergarments. This became one of the most iconic performances in the awards show 's history and set the standard for other artists preforming on that stage as they tried to "steal the show" (Tannenbaum). This launched MTV 's first "franchise" (Tannenbaum). Needless to say, the network was happy. Others institutions had different reactions: The Canadian government, in particular, was not thrilled. When six years after the infamous performance of the song, they threatened to arrest her if she sang the reinvented version for the Toronto stop of her 1990 Blond Ambition Tour, which found her, once again, simulating masturbation, but this time, it was on a red silk bed in a cone bra. What was it about this song and these interpretations of its female sexuality that made a country 's government threaten legal action? What is about female masturbation that causes a so much panic? The