How are Physicians reimbursed with a Preferred Provider Organization (PPO)?
On a discounted fee-for-service basis
With this type of Health Maintenance Organization (HMO) Physicians are considered salaried employees instead of independent contractors ?
They work to control the cost of, and access to, healthcare services at the same time they strive to meet high-quality standards.
A generic term for prepaid health plans that integrate the financial and delivery aspects of healthcare services.
Managed Care Plans (Sayles page 703)
A broad term used to describe several types of prepaid health care plans.
This legislation led to the development of investor-owned hospital chains and stimulated the growth of University Medical Centers?
Medicare and Medicaid laws of 1965
Managed Care plans work to control ___?
the cost of, and access to, healthcare services at the same time they strive to meet high-quality standards.
Cost Controlling Methods
Review of utilization of healthcare services (Makes sure services used wisely to control the costs).Using primary care physicians as gatekeepers to control referrals to specialists. Limit the providers from which the enrollee can seek treatment
Types of Managed Care Plans
Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs)
Health Maintenance Organization (HMO) premiums are based on ?
A projection of the costs that are likely to be involved in treating the plan’s average enrollee over a specified time.
GROUP MODEL HMOs
HMO enters into a contract with an independent multi-specialty group to provide services to the members of a plan. Providers agree to a fixed percentage of time to the HMO. HMO may own or directly manage the physician group (employees).Closed panel arrangements: Physicians not allowed to treat patients from other managed care plans. Enrollees are required to seek treatment from the designated physician group.
What is another name for an Independent Practice Associations (IPA)
Individual practice associations
This organization manages and coordinates the delivery of healthcare services performed by a number of healthcare professionals and facilities and its physicians are salaried?
Health Maintenance Organizations vs Fee for Service or other Managed Care
Offered by most employers and insurance companies. Cost savings to enrollees as well as third-party payers. Enrollees enjoy significantly lower out-of-pocket expenses.Employer and enrollees have lower premiums.
Premiums are paid directly to this type of HMO, and services are usually provided within corporate facilities.
Staff Model HMO
Types of Health Maintenance Organization (HMO) Models are ?
Group Model - Independent Practice Association (IPA) - Staff Model - Network Model
Independent Practice Associations (IPAs)
HMO enters into a contract with an organized group of physicians who join together for purposes of fulfilling the HMO contract but retain their individual practices. The physicians are not employees of the HMO
IPA is considered open-panel HMO which means ?
That the physicians are free to treat patients from other plans. Enrollees of the HMO are required to seek services from the designated group.
The Health Maintenance Organization (HMO) will pay the Independent Practice Association (IPA) according to ?
A negotiated list of discounted fees
Similar to a Group Model ?
Network Model HMO
Network Model HMO
Two or more multi-specialty group practices. HMO contracts with two or more multi-specialty group practices instead of one.
Directly employ physicians and other healthcare professionals to provide medical services to members
Staff Model HMO
With this type of plan The subscribers must pay a greater share of the charges for out-of-network services ?
Health care provider made up of a number of associated medical facilities that furnish coordinated healthcare services.
Integrated Delivery Systems (IDS)
This is an arrangement that allows physicians to maintain their own offices, but to share administrative, management, and marketing services, (ie. Transcription, billing) for the purpose of fulfilling contracts with managed care organizations ?
Group Practices with Walls
Medical foundations clinical assests and business assets ?
Medical equipment, Supplies, Treatment facilities,Billing, Administrative support systems.