Preview

Managed care

Good Essays
Open Document
Open Document
906 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Managed care
MANAGED CARE
Managed health care is a system of health care delivery managed by a company aiming mainly at quality/value cost effective services provided to patients. It has been introduced with an intention to avoid paying for unessential facilities and services directly to physicians. It helps in forming an intermediate between patients and physicians in such a way that health insurance organizations pay the physicians from the premiums paid by patients to insurers for the services provided. This helps in monitoring how cost effectively the services are utilized. It is not to be mistaken as health care delivery at discounted prices. It’s goal is to provide quality care at affordable prices by restricting patient’s choice of physicians and physicians limiting their fees. People who seek care in America are mostly enrolled in health care plans such as health maintenance organizations(HMOs) and preferred provider organizations(PPOs).The less common plan people are enrolled in is point-of-service(POS) which has features of both HMO and PPO.HMO provides integrated and preventive care services to voluntarily enrolled families with low premiums within the network of doctors and hospitals that belong to the organization. It requires to select a primary care physician(PCP) who serves as a personal doctor to provide all basic health care services. PCPs include family physicians and internal medicine physicians. Some HMOs consider pediatricians(for children), gynecologists(for women) as PCPs. Before seeing a specialist or for a diagnostic service, it is required to obtain a referral from PCP(“gatekeeper”). If an outside specialist is chosen or referral is not obtained before seeing a specialist, no coverage for services is rendered by HMO. All or most of the cost for the care must be taken care by the individual. In contrast to HMO, with a PPO it is not necessary to select a single doctor as policy holder’s PCP nor is it necessary to

You May Also Find These Documents Helpful

  • Good Essays

    The Health Maintenance Organization (HMO) Program will coordinate with a specified group of doctors and hospitals to provide care. Employees are limited to only the specified groups or hospitals the HMO provides. The HMO plan offers no deductible, and copayment fees from $0 to $20 for visits depending on services performed. Employee also will be offered the option to seek their own healthcare providers outside the HMO program for an additional cost. A Preferred Provided Organization Program is also available to employees who want to visit their own doctor and hospital providers. There will a yearly family deductible of $500 and $250 for individual before any medical expenses are covered. The plans will pay 80% on care provided or performed within the preferred provider list. The plan will pay only $70 on care rendered outside the preferred provider…

    • 667 Words
    • 3 Pages
    Good Essays
  • Good Essays

    Hcr 230 Week 1 Assignment

    • 473 Words
    • 2 Pages

    PPO plans are the most popular plan that doctors, clinics, hospitals, and pharmacies contract with. One of the reasons that the PPO plans are so popular is because they pay the doctors a discounted fee for service based on their fee schedule. PPO plans offer a low premium that has a higher deductible or the other option is a high premium with a lower deductible. The patients are responsible to pay a copayment, and there is also a yearly deductible that the patient has to pay out of pocket. If a patient sees a doctor outside of the network without a referral, the plan will pay less and the patient is responsible for the remainder of the fee. Patients have their choice of providers, but if the patient goes to a out-of-network provider it will cost more. One thing to remember though is that all non-emergency services require pre-authorization.…

    • 473 Words
    • 2 Pages
    Good Essays
  • Good Essays

    Preferred provider organizations (PPOs) are a private plan which is the most popular, followed by health maintenance organizations (HMOs). PPOs sometimes pay participating providers based on a discount from their physician fee schedules which is called a discounted fee-for-service. With a PPO the patient pays annual premiums and often a deductible. The patient has two choices with the first being offered a low deductible with a higher premium and the second being a high deductible with a low premium and they always pay a copayment at the time medical services are rendered. Consumer-driven health plans (CDHPs) combine two components with the first being a high-deductible…

    • 738 Words
    • 3 Pages
    Good Essays
  • Better Essays

    The purpose of a managed care organization is to coordinate the costs and delivery of health care. A managed care organization oversees money spent on labor, technology, and facilities such as physician offices and hospitals. A type of managed care organization is a Health Maintenance Organization (HMO). A HMO “provides medical care for all its enrollees in return for a fixed annual fee per enrollee” (University of Phoenix, 2010, Key Terms and Concepts Section). An HMO tightly oversees the use of health care services thereby reducing costs and controlling utilization. For example, HMO’s…

    • 1187 Words
    • 5 Pages
    Better Essays
  • Best Essays

    In the United States, the term managed health care or managed care is applied to express an array of different concepts and techniques aimed at decreasing the cost of providing health services, as well as improving the service quality. Various health organizations and service providers use these techniques. Sometimes they even offer the techniques to other organizations, which are often called Managed Care Organization (MCO). The United States National Library of Medicine defined managed health care program as an initiative or program of reducing unnecessary costs in the health care system by using assortment of mechanisms, which include economic inducements and motivations for the patients and physicians to choose less expensive forms of health care, different programs and techniques for reviewing and improving the medical requirements in specific services, sharing amplified beneficiary rates, controls and monitoring the admissions of the patients and lengths of their staying in the hospitals, the issues of cost sharing as well as reasons for outpatient surgery. The health care programs and strategies may be provided in different settings within different systems, like Preferred Provider Organizations and Health Maintenance Organizations.…

    • 1477 Words
    • 5 Pages
    Best Essays
  • Satisfactory Essays

    There are several ways the managed care model is expressed one particular way is the Health Maintenance Organization or better known as HMO. HMOs have their own network of doctors, hospitals and other health care providers who have agreed to accept a payment plan at a certain level of services they provide. With HMO, you would have to pick a Primary Care Physician within the local approved network where that doctor can coordinate any additional care you might need. If you need a specialist, a referral would be needed within the HMO network. HMOs usually have lower monthly premiums, but out of network health care professionals are not typically covered by the insurance.…

    • 394 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Based on my income, age and the frequency of doctor visits I am currently enrolled in a preferred provider organization also known as an (PPO) as stated in Siegel, R., & Yacht, C. on the subject of personal finance (p. 246). Additionally, this is covered through blue Cross/Blue Shield. Therefore, I am under a network of health care providers that provide preventive care. The advantages of carrying this type of health insurance allows me to track my health year to year and detect early sings of health issues. Moreover, covered in my insurance is by a prescription drug plan that I pay ten dollars for generic prescriptions. The disadvantage of carrying a (PPO) health insurance is that it will cost more to go out of network.…

    • 302 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    From these chapter I have gain the knowledge of know, the delivery of health traditionally evolved around the individual relationship between the provider and patient/consumer. The payment was either provided by a health insurance company or paid out of pocket by the consumer. This fee-for-service system or indemnity plan increased the cost of healthcare because there were no controls on how much to charge for the providers service. As healthcare costs continued to spiral out of control throughout the decades, more experiments with contract practice and prepaid service occurred randomly across the U.S. healthcare system (Shi & Singh, 2008)…

    • 290 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Health Insurance Matrix

    • 3146 Words
    • 9 Pages

    Health maintenance organizations use a prospective payment system in which providers within a specific network are paid a flat rate per member on a predetermined scale regardless of if services are not utilized or over utilized. According to (“Patient Advocate Foundation” 2012), “care can be provided in a larger geographic service area than would be possible with only one physician group. This network model offers the patient choice of physicians and managed…

    • 3146 Words
    • 9 Pages
    Powerful Essays
  • Good Essays

    Managed Care Case Study

    • 792 Words
    • 4 Pages

    For the past several years, the health care and insurance industries in America have been undergoing significant reform in order to rein in the high cost of delivering health care services. Managed care has become a cornerstone of this process (Strickland, 1995). The case management industry (with its focus on cost containment, managed competition, and quality care) is playing an increasingly important role in the managed care environment (Owens, 1996). According to Mullahy (1995a), the number of case managers has risen astronomically in recent years. These individuals come from diverse professional backgrounds and practice settings that include nursing, rehabilitation counseling, and social work.…

    • 792 Words
    • 4 Pages
    Good Essays
  • Good Essays

    Managed care has been formed since the 1930 and evolved over the last ten years. Since the evolving of managed care there are three types of managed care plans. People that are enrolled in private health insurance are subscribed to a type of managed care plan. There are many differences between the three types of managed care plans and they also have similarities. The involvement of managed care plans are between the insurer and the selected network of health care providers, and the policyholder’s financial incentive that are used by the providers in the network. There are precise measures for choosing a managed care plan and conventional procedures to acquire quality care (Types of Insurance, 2010).…

    • 686 Words
    • 3 Pages
    Good Essays
  • Good Essays

    References: Academic Medicine: April 2000 - Volume 75 - Issue 4 - p 323-330, Institutional Issues: Articles…

    • 760 Words
    • 4 Pages
    Good Essays
  • Better Essays

    Evolution of Managed Care

    • 1519 Words
    • 7 Pages

    Managed care is a type of system that was formed to help control the costs and quality to health care services; this will give access to services to specific groups of covered patients. The system was created to help the patients (customers) to receive services without having the full financial burden (University of Washington, 1998). The managed care services’ goal is to be able to help individuals and their families by providing health care services that is affordable. This type of managed care will help employees or individuals by requiring a set fee to be paid to the physician for visits, a co-pay and monthly premium to be paid to the insurance company. This will lower the amount that the patient has to pay. There have been many demands that have been needed in the managed care system; changes have had to be made to keep improving the health care services to help it to continue to grow. This paper will cover how the managed care began, in addition to how the system has grown and the changes of the system.…

    • 1519 Words
    • 7 Pages
    Better Essays
  • Good Essays

    US Health Care System

    • 683 Words
    • 5 Pages

    PPO- Preferred Provider Organization allow visits to innetwork doctors or healthcare provider with out a referral…

    • 683 Words
    • 5 Pages
    Good Essays
  • Good Essays

    Coder Interview

    • 1008 Words
    • 5 Pages

    HMO (Health Maintenance Organization): Is a health management plan that requires patients to have a PCP (primary care physician). A PCP is where patients seek out most of their initial treatment at. If the PCP feels like it is necessary to seek treatment from specialist they will send a patient to within that network.…

    • 1008 Words
    • 5 Pages
    Good Essays