Chapter 23Managed Care               2
Models of Managed Care             Organizations - I•   Health Maintenance Organizations•   Preferred Provider Organizatio...
Models of Managed Care            Organizations - II•   Specialty HMOs•   Independent Practice Associations•   Group Pract...
Models of Managed Care            Organizations - III•   Physician Hospital Organizations•   Medical Foundations•   Manage...
Managed Care – I•   Federally Qualified HMOs•   State Laws•   Case Management Firms•   Third-Party Administrators         ...
Managed Care – II• Utilization Review  Prospective review  Concurrent review  Retrospective review• Utilization Managem...
Managed Care – III•   Liability for Nonparticipating Physicians•   Employee Retirement Insurance Security Act•   Reducing ...
Managed Care & Legal Actions• Financial incentives disclosed• Insurer and tort-feasor• Benefit denials• False and misleadi...
Market Power•   Product Market•   Geographic Market•   Provider exclusion•   Antitrust & Market Share                     ...
REVIEW QUESTIONS1. Describe the more common models of MCOs.2. What are the advantages & disadvantages of  HMOs?3. What is ...
5530: Chapter 23
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5530: Chapter 23

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5530: Chapter 23

  1. 1. Chapter 23Managed Care 2
  2. 2. Models of Managed Care Organizations - I• Health Maintenance Organizations• Preferred Provider Organizations• Exclusive Provider Organizations• Point of Service Plans• Experience-Rated HMOs 3
  3. 3. Models of Managed Care Organizations - II• Specialty HMOs• Independent Practice Associations• Group Practice• Group Practice without Walls 4
  4. 4. Models of Managed Care Organizations - III• Physician Hospital Organizations• Medical Foundations• Management Services Organizations• Vertically Integrated Delivery System• Horizontal Consolidations 5
  5. 5. Managed Care – I• Federally Qualified HMOs• State Laws• Case Management Firms• Third-Party Administrators 6
  6. 6. Managed Care – II• Utilization Review Prospective review Concurrent review Retrospective review• Utilization Management Firms Negligent UR Decisions 7
  7. 7. Managed Care – III• Liability for Nonparticipating Physicians• Employee Retirement Insurance Security Act• Reducing Exposure to Liability• Health Care Quality Improv. Act – 1986• Open Enrollment• Emergency Care• Ethics in Patient Referral Act (1989) 8
  8. 8. Managed Care & Legal Actions• Financial incentives disclosed• Insurer and tort-feasor• Benefit denials• False and misleading statements 9
  9. 9. Market Power• Product Market• Geographic Market• Provider exclusion• Antitrust & Market Share 10
  10. 10. REVIEW QUESTIONS1. Describe the more common models of MCOs.2. What are the advantages & disadvantages of HMOs?3. What is the purpose of utilization review?4. Why did Congress pass the health care quality improvement act of 1986?5. What is price-fixing? 11

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