Preview

Quiz Review

Better Essays
Open Document
Open Document
1165 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Quiz Review
1. Who are the first, second, and third parties in healthcare situations?
The first party is the patient himself or herself or the person, such as a parent, responsible for the patient’s health bill. The second party, often called providers is the physician, clinic, hospital, nursing home, or the healthcare entity rendering the care. The third party is the payer, and uninvolved insurance company or health agency that pays the physician, clinic, or other secondary party provider for the care or services rendered to the first party. 2. Compare the UCR and the CPR payment systems.
The usual, customary, and reasonable (UCR) is one version of discounted fee-for-service payment method. The UCR is a type of fee-for-service payment method in which the third party payer pays for fees that are usual for the individual providers practice, customary for the community, and reasonable for the situation. Customary, prevailing, and reasonable (CPR) is another version of discounted fee-for-service payment method in which the third-party payer pays for fees that are customary, prevailing, and reasonable. They are both based on data from past claims, and are becoming rare. 3. Describe the two purposes of managed care.
Reducing the cost that third-party payer must reimburse the providers for healthcare is one of them, for example, having patients obtain prior approval for surgery. Ensuring continuing quality of care is the second by providing one primary care provider to coordinate all aspects of healthcare. 4. Why have many insurers replaced retrospective health insurance plans, with group plans such as HMOs and PPOs?
To help control the cost, with HMOs you have a fixed rate for the coverage you received for medical care and with PPOs you have a primary care provider that manages your healthcare and quality of the healthcare you receive. Both HMOs and PPOs have a prepaid health plan and physicians that are under contract with an organization. 5. What are

You May Also Find These Documents Helpful

  • Good Essays

    Hcr 230 Week 1 Assignment

    • 473 Words
    • 2 Pages

    There are nine private payer plans which include preferred provider organizations (PPO), health maintenance organizations (HMO), point of service (POS). Indemnity plans cost the most for employees and they usually have to choose a PPO plan. The new consumer driven health plan (CDHP) which a lot of people are picking, it has a high deductible combined with a funding option of some type. All of the plans have unique features for coverage of services and financial responsibility.…

    • 473 Words
    • 2 Pages
    Good Essays
  • Good Essays

    Hsm 546 You Decide 1

    • 699 Words
    • 3 Pages

    I have been asked by Cooper-Pearson to research different medical insurance plans that they could consider as one of their selected insurance programs for their marketing company. My goal is to provide them with enough details in order for the company to make an informed decision as to which program they would like to consider. This information will allow them to provide their employees with an effective compensation package that is both affordable and desirable and I believe that once an attractive compensation plan is in place; we should expect the retention rate of the company to improve and the recruitment of quality employees to increase as well. First I will start by demonstrating the comparison and contrast between an HMO plan and a PPO plan. The HMO plan requires participants to have a primary care physician with the network and the participant does not have the option of visiting a physician outside of the network. They must be referred by the primary care physician to see a medical specialist and the specialist must be within the approved network, the plan normally costs less than the PPO plans, however the co-pay is significantly high.…

    • 699 Words
    • 3 Pages
    Good Essays
  • Better Essays

    Valerius J Bayes N L Newby C Seggern J I B 2008 Medical Insurance: An Integrated Claims Process ApproachValerius, J., Bayes, N. L., Newby, C., & Seggern, J. I. B. (2008). Medical Insurance: An Integrated Claims Process Approach (3rd Ed.). : McGraw/Hill Higher Education.…

    • 958 Words
    • 4 Pages
    Better Essays
  • Better Essays

    HMO’s are usually on a prospective payment system. This is where providers are paid a set amount no matter how often their services are used. This means that you may have a set amount that you are allotted to use and if you don’t then the provider keeps the difference that has been paid out…

    • 1163 Words
    • 4 Pages
    Better Essays
  • Satisfactory Essays

    HThere are five different health plan options that are available for people that want health coverage. Indemnity Plans let a patient see whoever they would like to see with no limit and there are pre-agreements required for few procedures. Preventative care is usually not covered with the plan and there is higher costs deductibles and can be a co-insurance.…

    • 373 Words
    • 1 Page
    Satisfactory Essays
  • Satisfactory Essays

    Some of the similarities between the major health care options between the HMO organization and the POS organization are that both of these organizations require that a primary care physician manages the care. They also have lower copayments and cover preventive care. The HMO, Indemnity Plan and the PPO require preauthorization on procedures while all five…

    • 269 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    The differences to HMO is limited on coverage of what the employee signed up for and PPO would be privately through which provider would be. For example, the HMO would be what coverage plan are you going to pick. For example PPO would be what provider accepts the plan i chose. I would remember them by the different lettering and what is means. For example, you can remember the H is for health and the P is for preferred. The O's stand for the same thing.…

    • 86 Words
    • 1 Page
    Satisfactory Essays
  • Satisfactory Essays

    quiz review

    • 2124 Words
    • 9 Pages

    Although most slaves came to the colonies before 1776, the majority of other types of labor came to North America voluntarily.…

    • 2124 Words
    • 9 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Difference and Plan

    • 345 Words
    • 2 Pages

    These health plans have a lot of similarities and differences. Some of the similarities are the majority of these plans have low copayments, and very close coverage. The HMO and POS plans have lower copayments than some of the other plans and these plans cover the total cost of preventative care. Some of the plans allow you to go out of network and the other plans will not pay or cover unless it is in the network.…

    • 345 Words
    • 2 Pages
    Satisfactory 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
  • Satisfactory Essays

    Quiz

    • 836 Words
    • 9 Pages

    Which of the following were cited by college students in a national survey as major impediments to performing well academically?…

    • 836 Words
    • 9 Pages
    Satisfactory Essays
  • Good Essays

    Describe the effects of managed care on physician’s practices. Do you see these effects as positive or negative? Why?…

    • 440 Words
    • 2 Pages
    Good 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

    Managed care

    • 906 Words
    • 4 Pages

    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…

    • 906 Words
    • 4 Pages
    Good Essays
  • Better Essays

    Managed Care

    • 1382 Words
    • 6 Pages

    Millions of individuals live in the United States of America, and they all need effective, affordable and accessible health care coverage and services. Within decades, the scope and cost of health care has changed dramatically with increased complexity and significance to the healthcare market. The purpose of this paper is to analyze the managed care industry and examine how organizations try to control costs.…

    • 1382 Words
    • 6 Pages
    Better Essays