Chapter 11 power point HIT 212
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Chapter 11 power point HIT 212

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Chapter 11 power point HIT 212 Chapter 11 power point HIT 212 Presentation Transcript

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