Chapter 11 power point HIT 212

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Chapter 11 power point HIT 212

  1. 1. The Blue Plans, Private Insurance and Managed Care Plans<br />Chapter 11<br />
  2. 2. Healthcare Reform <br />Cost of healthcare <br />High tech equipment<br />Expensive medications<br />Uninsured Americans<br />Fraud<br />Inefficency<br />
  3. 3. Managed Care Systems<br />EPO<br />“Exclusive”<br />Regulated by insurance statutes<br />FMC<br />Member physicians bill foundation directly<br />Reimbursement is proportional to number of medical services delivered<br />
  4. 4. Managed Care Systems<br />IPA<br />Contractual arrangement to treat HMO patients<br />Discount of up to 30%<br />PPO<br />Coinsurance requires patient to pay 20-25% of allowed amount<br />“network discount applied”<br />Pre-certify<br />
  5. 5. Managed care Systems<br />PPG<br />Flexible <br />Portion of physician income covers joint expenses<br />Physician owned<br />POS<br />Primary care Physician<br />Use network Providers<br />
  6. 6. Quality Improvement Organization<br />Medically necessary, appropriate and meet standards of care<br />AKA Professional or Peer Review Organizations<br />Review and recommend action<br />
  7. 7. Utilization Review/Management<br />Appropriate and efficient use of resources<br />Cost effective manner<br />
  8. 8. Preauthorization/prior approval<br />VERY IMPORTANT!<br />Unknown to patients<br />Must be medically necessary service<br />ALWAYS CALL!<br />

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