The hmo contracts with an existing, independent, multi-specialty physician services to its members? Continues to provide services to non-hmo patients while is participates in the hmo common features of Group Models? Both types of group model hmos are also referred to as closed-panel hmos because physicians must be members of the group practice to participate in the hmo? Group practice hmos may have lower capital needs than staff model hmos? Limited choice of participating physicians from which potential hmo members can select? Limited number of office locations for the participating medical groups? Restricts the geographic accessibility of physician for the hmo? Certain group practices may be perceived by some potential hmo members as offering an undesirable clinic setting Network model?
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More costly to develop and implement because of the small membership and the large fixed salary expenses that the hmo must incur for staff physicians and support staff? Provide a limited choice of participating physicians for potential hmo members? Productivity problems with their staff physicians? Raising costs for providing care? Expensive to expand services into new areas Group Model? The hmo contracts with a multi-specialty physician group practice to provide all physician services to the hmo? Physicians in the group practice are employees by the group practice (not by the hmo)? Physicians in a group practice share facilities, equipment, medical record, and support staff Captive group? The physician group practice exists solely to provide services to the hmo? Kaiser foundation health Plan Independent Group?
Staff model hmos are also known as closed panel hmos because most participating physicians are employees of the hmo, and community physicians are unable resumes to participate? Physicians in staff model hmos usually practice in one or more centralized ambulatory care facilities? Staff model hmos usually contract with hospitals or inpatient facilities in the community to provide non-physician services for their members? They have a greater degree of control over their practice patterns of their physicians? Also offer the convenience of one-stop shopping for their members because the hmo? S facilities tend to be full service? Disadvantages of the staff model?
S ions are: 1) Staff 2) business Group 3) Network 4) ipa 5) Direct contact? The major differences among these models pertain to the relationship between the jhmo and its participating physicians? Many hmos cannot easily be classified as a single model type, although such plans are occasionally referred to as mixed models Staff Models? In a staff model hmo, the physicians who serve the hmo? S covered beneficiaries are employed by the hmo? Physicians are usually paid on a salary basis and may also receive bonus or incentive payments that are based on their performance and productivity? Staff model hmos must employ physicians in all the common specialties to provide for the health care needs of their members?
They provide an organized approach for physicians and hospitals to work together on managed care issues, including utilization management and quality improvement? Phos may also offer advantages to some managed care organizations? Phos can provide a means of rapidly establishing a panel of participating physicians and hospitals? Phos can provide a means of reducing operating costs? The lack of success of phos are? Phos offer little or no benefit for enrolling large panels of participating physicians and hospitals? Phos, as of right now, don? T assume financial risk for delivering health services by accepting capitation-based payments hmo models? The five commonly recognized models of hmo?
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Complete menu of utilization management activities selected by individual employer or insurers? Catastrophic or large case management? (regardless of specialty involved)? To address the unique needs of patients covered under workers? Compensation benefits Physician-Hospital Organizations? Physician-hospital organization (PHOs) are organizations that generally are jointly owned and operated by hospitals and their affiliated physicians? A vehicle for hospitals and physicians to contract together with other managed care organizations to provide both physician and hospital service?
Physicians and one or more hospitals are shareholders or members? Phos can offer several advantages for providers who develop them? They may increase the negotiating clout of their individual members with managed care organizations? They provide a vehicle for physicians and hospital to establish reimbursement plan and risk-sharing approaches that align incentives among all providers? They can serve as a clearinghouse for certain administrative activities, including credentialing and utilization management, thereby reducing the administrative burden on their individual physician and hospital members?
Hmo provides the out-of-network benefit using its hmo license 2) via a duel-license approach. The health plan uses an hmp license to provide the in-network care and an indemnity license to provide the out-of-network coverage. Coverage under hmo pos plans recently has been the fastest growing segment of health insurance self-Insured and Experience-rated hmos? The federal hmo act originally mandated community rating for all hmos that decided to pursue federal qualification? Under a typical self-insured benefit option, an hmo receives a fixed monthly payment to cover administrative services (and profit) and variable payment that are based on the actual payments made by the hmo for health services?
Under experience-rated benefit options, an hmo receives monthly premium payments much as it would under traditional premium based plans? The hmo regulations of some states and federal hmo qualification regulations preclude hmos from offering self-insured or experience rated benefit plans Specialty hmos? Specialty hmos serving other health care needs (e.g. Mental health) have also developed in certain stated where they are permitted under the insurance or hmo laws and regulation Managed Care overlays to Indemnity Insurance? Managed care overlays have developed that can be combined with traditional indemnity insurance, service plan insurance, or self-insurance? The term indemnity insurance is used to refer to all three forms of coverage in this context? The following types of managed care overlays currently exist?
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An amount is with held from physician compensation that is paid contingent upon achievement of utilization or cost targets? The primary care statement physician acts as a gatekeeper for referral and institutional medical services? The member retains some coverage for services rendered that either are not authorized by the primary care physician or are delivered by non-participating providers. Open Access or pos hmos? Provides some level of indemnity-type coverage along with the hmo coverage? Hmo members covered under these types of benefit plans may decide whether to use hmo benefits or indemnity-style benefits for each instance of care? The member is allowed to make coverage choice at the point of service when medical care is needed? Most pos plans experience between 65 percent and 85 percent in-network usage, thus retaining considerable cost control compared to indemnity-type plans? There are two primary ways form an hmo to offer pos option 1) via a single hmo license.
Epos, like hmos, require exclusive use of the epo provider network and also use a gatekeeper approach to authorizing non-primary care essay services? The difference between an hmo and an epo is that the former is regulated by hmo laws and regulations, and the latter is regulated under insurance laws and regulations? Employee retirement Income security Act of 1974? Epos usually are implemented by employers (b/c it? Hybrids of hmo and ppo models? Primary care physician are reimbursed through capitation payments (i.e. Fixed payment per member per month)?
use non-ppo providers? Ppos sometimes are described as preferred provider arrangements (PPAs)? Ppa is used to describe a less formal relationship than ppo? The term ppo implies that an organization exists, whereas a ppa may achieve the same goals as a ppo through an informal arrangement among providers and payers? Key common characteristics of a ppo include? Consumer choice, exclusive provider Organizations? Exclusive provider organizations (EPOs) limit their beneficiaries to participating providers for any health care services? The epo generally does not cover services received from other providers, although their may be exceptions?
Types of managed care organizations and common acronyms. Hmos are organized health care systems that are responsible for both the financing are the delivery of a broad range of comprehensive health services to an enrolled population? Hmo health insurer and a health care delivery system? Hmos are responsible for providing health care services to their covered members through affiliated providers, dillard who are reimbursed under various methods? Hmos must ensure that their members have access to covered health care services? Hmos generally are responsible for ensuring the quality and appropriateness of the health services they provide to their members? The five common models of hmos are (1) staff, (2) group practice, (3) network, (4) ipa, and (5) direct contact. Ppos are entities through which employer health benefit plans and health insurance carriers contract to purchase health care services for covered beneficiaries from a selected group of participating providers?
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Managed Care Essay, research Paper, chapter 3: Types of Managed Care Organization? The distinction between health care providers and health care insurers have blurred substantially? 10 years ago managed care organizations were often referred to as alternative delivery systems? Managed care is now the dominant form of health insurance coverage in the United States? Managed care can mean managing the provider delivery system can be equivalent in its outcomes to managing the medical care delivered to the patient? Managed care may not perfectly describe this current generation of financing vehicles, it provides a convenient shorthand description for the range of alternatives to traditional indemnity health insurance? On one end of the continuum is managed indemnity with simple pre-certification of elective admission and large case management of catastrophic cases, superimposed on a traditional indemnity insurance plan? Further along the continuum are ppos, poss, open-panel individual practice association (IPA) type hmos, and closed-panel (group and staff model) with hmos.