Third Party Payers In Healthcare

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

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.

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.

There are also two other less common forms of managed care. Point-of-service organizations differ from the previous two forms because they allow their clients to choose a doctor outside of the network for a slightly higher copayment (Chitty & Black, 2007). The last type of managed care involves a hospital corporation teaming with a select group of medical staff. Their teams then negotiate with managed care organizations or self-insured employers to set fees for different services (Chitty & Black, 2007).

It is composed of its members, plans, payments and providers. The members make up the patients, and every patient has their own "benefits" when it comes to healthcare coverage. Each person's "benefits" varies widely. What it typically means is that the health plan provides coverage for certain types of medical procedures, services and goods. This coverage is provided only under certain circumstances described in the plan. The payments are made by "payers," which manage the "benefits" for healthcare procedures, services, and goods. Basically, what procedures, services, and goods will be paid for, how much they will pay for it, when their "benefits" cover it, and how much the patient will have to pay out of pocket. As for the different types of payers, they range widely from health maintenance organizations (HMOs), preferred provider organizations (PPOs) and managed care organization (MCOs). These types of payers can also be not for profit, for-profit, or member owned. Last is the providers, these are the people and/or manufacturers who perform the services and/or procedures for the patients. The providers then contact the patient’s insurance holders to receive payment for their services. Besides members, plans, payments, and providers, managed care is also composed of manufacturers. They manufacture the pharmaceuticals used, as well as the medical devices. When

In healthcare systems there are third party payers. A third party payer is an insurance coverage that pays the healthcare provider for service

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

Insurance is separated into categories called Major Medical Plans, Qualified Health Plans, and Catastrophic Plans. Major medical plans consist of Health Maintenance Organization (HMO) plans: HMOs are one of the most popular types of health insurance you can purchase. With this plan, an entire network of health care providers agrees to offer you its services. You have to select a primary care provider (PCP) who coordinates all of your health services and care (Ehealth, 2014), Preferred Provider Organization (PPO) plans: Under a PPO plan, both you and your family can see any health care provider in their network, including specialists, without a referral. In most cases, you don’t have to

The book discuss about three major types of managed care organization: health maintenance organizations (HMO), preferred provider organizations(PPO), and point of service plans(POS). Managed care has been around for minute. This organization has been around since 1930s. The three managed care organizations are require an agreement between the insurer and a network of health care providers. Policy holders are encouraged to use the providers in the network by the fact a percentage will pay the cost of care if received outside the network.

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).

Depending on the insurer and the type of service provided, third-party payers pay providers by different means

A preferred provider organization (PPO) plan gives patients the flexibility to see providers and specialists within or outside the network of care; it will typically cost less to receive care from an in-network provider (U.S. Centers for Medicare & Medicaid Services, n.d.). In most cases, referrals for specialists and designating one physician as a primary care provider is not required of a PPO plan. (U.S. Centers for Medicare & Medicaid Services, n.d.). Alternatively, a health maintenance organization (HMO) limits patients to receive care from doctors, specialists, and hospitals covered under the health plan (U.S. Centers for Medicare & Medicaid Services, n.d.). With the exception of emergency can and out-of-area urgent care, all care providers

Managed care is described in a couple of different ways. The first way that managed care is described would be for financing insurance, delivery, and payments. The second way that it would be described is as an organization that delivers health care services without an insurance company managing how payments are made (Shi & Singh, 2015). There are three primary payment mechanisms used when dealing with different providers which are; capitation, discounted fees, and salaries.

First of all let us understand the concept of third party payer. Third-party payers are the insurers that reimburse health services organizations and hence are the major source of revenues for most providers. large proportion of provider revenues does not come directly from patients (the users of healthcare services) but from insurers, known collectively as third-party payers. It include private insurers, such as Blue Cross and Blue Shield, and public (government) insurers, such as Medicare and Medicaid. Third-party payers use several reimbursement methods to pay providers, depending on the specific payer (e.g., the Blues versus Medicare) and the type of service rendered (e.g., inpatient versus outpatient).

A third party payer is an organization(s) that reimburses money to physician according to the level of care and treatment that was rendered to the insured member. This payment system represent cost sharing they individuals, about 84.6% of Americans, who elected to pay a set rate in exchange for the access to medical care and service (Buchbinder & Shanks, 2012). Well, the healthcare (HA) system is not longer that simple. The HC system is mandate that legislative and mandates t and most will agree there are that I have HC