Network Development In The Managed Care Organization

Network Development in the Managed Care Organization
Network Development in the Managed Care Organization To guarantee that its members receive
appropriate, high level quality care in a cost–effective manner, each managed care organization
(MCO) tailors its networks according to the characteristics of the providers, consumers, and
competitors in a specific market. Other considerations for creating the network are the managed care
organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic
planning for networks is a continuing process. In addition to an initial evaluation of its markets and
goals, the managed care organization must periodically reevaluate its target markets and objectives.
After reviewing the markets, then the organization must ... Show more content on Helpwriting.net ...
When evaluating a provider's location for accessibility, managed care organizations consider the
distance between the provider's location and members, as well as geographical barriers. It is not the
intent of a managed care organizations to expend long trips to physicians or hospitals for medical
care. For each provider type, the organization also examines typical patterns of utilization and
average costs for selected services. Baker comments, "Defining a panel offers managed care plans
the advantage of selecting providers with whom they are interested in working as well as the
potential to obtain some contracting advantages through which they can sometimes obtain discounts
from physicians who would like to be included in the panel" (Baker, 2000, p.3). Because each type
of managed care organization has certain unique characteristics, network strategies must be chosen
to fit these characteristics. An organization that offers more than one type of health plan may choose
to coordinate provider networks through a network–within–a–network approach. This is done by
including the providers from one product's panel in the network of another panel. Provider network
strategies are also found to vary with the geographic scope and market focus of the plan. A growing
number of managed care organizations are attempting to build national provider
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Healthcare And The United States
Healthcare in the United States is a constant struggle. For generations the country has been in heated
debate over the best approach to this unsettling issue. While many changes have been made, none
seem to be effective enough to please and serve the country effectively. No matter what course is
taken there is always a group, or groups of individuals who are left out and underserved. As a
country we need to provide for all of our citizens to ensure healthy living and overall quality of life.
Unfortunately, our society is based off of socioeconomic class. This becomes an issue in regards to
healthcare requirements due to the fact that many poverty stricken families go throughout their lives
with little or no coverage at all. For those in good financial standing healthcare is easily accessible,
while the poor struggle and deal with illness in inhumane ways. Millions of American citizens are
uninsured; this number includes all walks of life from children through the elderly. In order to
overcome this devastating issue the American people have to come to a decision on how to care for
all of our citizens so that no one is left out. In today's society this has become an even more difficult
task as we face an ongoing struggle within our economy, leaving many families in financial
hardship. Why is it that as a society we cannot overcome this obstacle? The United States of
America, while not flawless, has reached great success and achievements yet cannot provide proper
healthcare

History of Medical Coding and Billing
History and Future Of Medical Coding and Billing John F. McMahon BU480, Central Methodist
University Abstract Medical coding and billing affects everyone during their lifetime and yet the
regulations of medical coding and billing are extremely complex. Examining the history, evaluation,
and effect of new regulations and their cost shed light on an already complex industry. We will
review government regulations, technological advancements, and requirements that providers will
face in the near future. We will examine our current systems and how they evolved through time and
what they may be in the future. We have reviewed articles from the Medical Billing and Coding
Association, the ... Show more content on Helpwriting.net ...
The ninth edition of the ICD codes were developed and pushed in a direction so that the codes could
be used for billing instead of just disease classification. (Department Health and Human Services,
1998) Medical coding after 1976 became the standard for health care providers to set cost and bill
for procedures based on the ICD codes. The ICD codes are taken from the different sources within
patients' health care record, physician notes, lab results, x–rays. Procedures performed on body parts
are all taken into consideration when assessing a value for services rendered. The fees associated
with each procedure are regulated by the U.S. Department of Health and Human Services and by
state governments. Before this system of billing, physicians charged whatever they thought was
appropriate and in many instances bartered for their services. (Department Health and Human
Services, 1998) Government and insurance standards also regulate the cost of procedures that have
been identified by the coding system. The responsibility of making sure that accurate billing takes
place falls to the coder that use the ICD–9 and ICD–10 codes. These codes then tell the biller what
to bill. Reimbursement rates for procedures are controlled the US Department of Health and Human
Services and state governments. (Department Health and Human Services, 1998) Commercial
payers such as Aetna, Blue Cross and Blue Shield, and United Health Care attempt to control pricing
by

Evolution Of Managed Care And The Forces That Have Driven...
Describe the evolution of managed care and the forces that have driven its evolution.
Managed care and its competition is being viewed to solve their issue on the struggle to control
rising health care costs. Managed care can be defined a system of delivering health services in
which care is delivered by a specified network of providers who agree to comply with the care
approaches established through a case management process. Managed care has a one hundred years
of history in the United States, and it gained national recognition around mid–1970s. The health
maintenance organizations (HMOs) are managed care organizations. There are two categories of
MCOs are, preferred provider organizations (PPOs) and point of service plans
(POS). There are over half of Americans with health insurance are enrolled in managed care plans.
Currently the debate in the United States is in regard to the quality of care provided by MCOs and
traditional fee–for–service plans. Another major issue with managed care is the use of gag clauses in
contracts amongst the MCOs and their providers. These clauses limit providers from being more
informative to patients about the alternative treatments or the details of reimbursements for
providers. The U.S. health care reform failed in 1994, and it caused a more focused turn to the
marketplace to provide the stimulus for reducing costs.
A few new trends are rising as managed care enters its second generation: dual– and triple–option
plans with

Health Maintenance Organization Act Of 1973
I was astounded by the beginning stages of the Health Maintenance Organization Act of 1973 which
were presented using a talk between John Ehrlichman and President Richard Nixon; Ehrlichman is
heard uncovering to Nixon that "...the less care they give them, the more money they make," a
course of action that Nixon remarked "fine" and "not horrendous."
An extensive number of us, believe the United States is an extraordinary country. America
encapsulates various morals worth celebrating. Clearly, expressing profound gratitude to God for the
enrichments he has endeavored on this country is more than fitting. It seems, by all accounts, to be,
in any case, that some on the religious right go advance when they talk about American
Exceptionalism. The

What Is Managed Care?
What is managed care? According to the Oxford English Dictionary, managed care is "a system of
health care in which patients agree to visit only certain doctors and hospitals, and in which the cost
of treatment is monitored by a managing company." Managed care is a variety of techniques
designed to essentially reduce the cost of providing health benefits and advance the quality of care.
In the United States alone, there are various managed care programs, that span from less restrictive
to more restrictive. As recently stated in the National Institutes of Health, the future of managed care
is uncertain. It is enthralling to note that in spite of the advances in the health care systems, such as
our hospital's ability to provide patients ... Show more content on Helpwriting.net ...
Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially
accountable for the long–term care of the members that she/he has been assigned and any specialists
that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser
Permanente and Humana. HMOs have been licensed at the state level, under a license that is known
as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their
insurance being authorized; A member may benefit from this because there would be little to no
treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow
provider networks; A member may not benefit if in an emergency because their "in–network"
emergency room might be far or there are "quick–care" in their area. Unlike Health Maintenance
Organizations, there are managed care programs that offer a deductible, coinsurance feature and
earn money by charging a fee to the insurance company for using their network. This service is
formally known as Preferred Provider Organizations (PPO). The deductible must be fully paid
before any benefits are provided and subsequently, the coinsurance benefits will be applied. For
instance, if the PPO plan is an 80% coinsurance plan with a $1,000 deductible, then the patient will
pay 100% of the allowed provider fee up to $1,000. After this amount has

Managed Care Essay
Managed care dominates health care in the United States. It is any health care delivery system that
combines the functions of health insurance and the actual delivery of care, where costs and
utilization of services are controlled by methods such as gatekeeping, case management, and
utilization review. Different types of managed care plans came into development by three major
factors. These factors include choice of providers, different ways of arranging the delivery of
services, and payment and risk sharing. Types of managed care organizations include Health
Maintenance Organizations (HMOs) which consist of five common models that differ according to
how the HMO is related to the participating physicians, Preferred Provider Organizations ... Show
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Case managers also provide support and information to patients and their families. Next, is
utilization review. `Its main objective is to review each case and determine the most appropriate
level of services, the most appropriate settings in which the services be delivered, the most cost
efficient methods for care delivery and the need for planning of subsequent care. Other methods
used for utilization and control are choice restriction and practice profiling' (Douglas, 2003, p.328).
The types of managed care are differentiated by definition, operation, structure, and information
needs. `HMOs were the most common type of MCO until commercial insurance companies
developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that
either arrange for or provide health services to an enrolled population after prepayment of a fixed
sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO
must have. The first is a health care financing and delivery system that provides services for
members in a particular geographic area. Second, is ensured access to a complete range of health
care services, health maintenance, treatment, and routine checkups. Last, health care must be
obtained from voluntary personnel that participate in the HMO. The five HMO models related to the
participating physicians are the Staff

Provider Reimbursement Essay
The concept of provider reimbursement is to make sure payments are being made for the services
rendered that are process by the insurance companies or by the third party to a beneficiary,
Reimbursement happens when an approved healthcare physician or facility offers medical care to an
insured party, this can help the patient because they won't have to pay up front for the services
instead a claim will be submitted to the patients insurance plan. The healthcare provider is going to
verify the insurance to make sure the patient is cover for the procedures that way the insurance
company can reimbursed directly, but in some cases if the patient insurance don't cover the
procedure the patient can make payment arrangements. The reason why reimbursement is necessary
is because the provider of facility must recoup all or some parts of the medical charges. The
different methods of financing for healthcare are for For Profit, Not–For–Profit and Public health.
For Profit is an organization that is made to make money and they are expected to bring more
revenue than needed. Not–For– Profit is an organization made to reinvest excess revenue into the
organization not like For Profit they have to reinvest the money back to the facility when For Profit
may pay out profits to investors, and the other financial method is public health care facilities this
organization is established by the government operated by a local, state, or federal government, they
are supported by tax dollars, and

Why Were Managed Care Organizations?
1. Why were Managed Care Organizations (MCO 's) established? Explain in detail. In 1973,
Congress passed the Health Maintenance Organization Act, which empowered fast development of
Health Maintenance Organizations (HMOs), the principal type of managed care. Managed care
arrangements are broadly credited with repressing medicinal cost swelling in 1980s by decreasing
pointless hospitalizations, driving providers to down their rates, and creating the health care industry
to wind up more effective and focused. The primary elements of the HMO Act were these: ● It made
credits accessible for the arranging and start–up periods of new HMOs and additionally for
administration territory developments for existing HMOs. ● It superseded state laws that limited the
advancement of HMOs if the HMOs met government prerequisites for confirmation. ● Most
essential of all, it required businesses with 25 or more workers that offered reimbursement scope
additionally to present to two unique sorts of governmentally qualified HMO choices if the
arrangements made a formal solicitation. For laborers under aggregate dealing assertions, the union
needed to consent to the advertising. Numerous HMOs were hesitant to practice the order, expecting
that making such a solicitation would irritate businesses and cause them to debilitate representatives
from selecting. In any case, numerous different HMOs utilized the double decision procurement to
in any event publicize themselves to business bunches.

Hmo Influence On Health Care
Running head: INFLUENCE OF HMO 'S
HMO's
University of Phoenix
Abstract
The term Health Maintenance Organization (HMO) was developed in 1970 as part of the Nixon
Administration to promote the growth of prepaid plans as a way to improve the nation's health
system. The Health Maintenance Organization has an appearance on the outside of being very
appealing to those with little money to spend on insurance because it has a very low premium cost,
but the truth be known that sometimes cheaper is not always better. In this paper I will discuss how
HMO's have influenced current healthcare systems.
Influence of HMO's
HMO stands for Health Maintenance Organization and was designed by Congress to eliminate
individual health insurance. ... Show more content on Helpwriting.net ...
This was a great thing and to be honest the fees were only 25 more dollars than what I am paying for
a HMO now. I became ill and was rushed to one of the best hospitals in the U.S. Tests were run and
because I had a PPO there were no questions as to who my primary care doctor was. There were no
questions as to what my insurance would pay for on the expensive tests. Now back home in the
North I currently have an HMO which as I stated is only a few dollars cheaper than my PPO. I
recently broke my back and was rushed to the local hospital because of the emergency situation.
While in the E.R. the doctors had to notify my primary doctor and get permission from the insurance
company to run tests and for me to even be allowed to stay in that hospitals E.R. My primary care
doctor was over an hour away in another state. I was cleared to go to another bigger hospital for
emergency surgery but it took a lot of time to get the clearance. I currently am suffering through
bills because through an HMO it is a courtesy for any hospital to call any insurance. If I still had
PPO I would not have been questioned as to cost and the hospital would have been paid because I
could through a PPO go to any hospital without permission. In summary, the time has come for
Congress to make decisions regarding appropriate health care and to understand that at times
cheaper is not always better.
Bibliography
Safran, D. W.

What Competencies Are Needed For Entry Level Employment In...
1. What competencies are needed for entry level employment in healthcare/HIS?
Healthcare skills: (anatomy and physiology, medical terminology, pathophysiology, clerical and
administrative procedures, laws and ethics, communications),
Computer skills :(MS office, EHR, Internet, billing–related/PM, data mining, records management,
coding/cac,
And knowledge of healthcare reform: (privacy and security, HIPPA, HITECH, PPACA, ICD–10) for
the greatest career opportunities for advancement.
2. Describe various professions (clinical and administrative) and their roles and responsibilities in
the medical office.
Physicians, primary clinicians in the practice
Physician Assistants, formally trained to provide diagnostic, therapeutic, ... Show more content on
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Health Maintenance Organization (HMO): A type of health insurance plan that usually limits
coverage to care from doctors who work for or contract with the HMO. It generally won't cover out–
of–network care except in an emergency. An HMO may require you to live or work in its service
area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and
wellness.
Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other
health care providers that belong to the plan's network. POS plans require you to get a referral from
your primary care doctor in order to see a specialist.
Preferred Provider Organization (PPO): A type of health plan where you pay less if you use
providers in the plan's network. You can use doctors, hospitals, and providers outside of the network
without a referral for an additional cost.
Health Savings Account (HSA): A Health Savings Account allows individuals to pay for current
health expenses and save for future qualified medical expenses on a pretax basis.

7. List and briefly describe the four major government–sponsored insurance programs.
Medicare: is the federal health insurance program for people who are 65 or older, certain younger
people with disabilities, and people with End–Stage Renal Disease (permanent

Three Health Maintenance Organizations
Health Maintenance Organizations
Name
Institution
Health Maintenance Organizations
In the United States, there are different Health Maintenance Organizations that work towards
promoting the health of the American citizens. Each health maintenance organization works
independently since they belong to different categories. Also, the organizations belonging to the
same category have some activities and measures that are common. The Health Maintenance
Organizations can be categorized into four different groups. The different categories include
Commercial, Marketplace, Medicaid and Medicare (Kongstvedt, 2016). In the due process of
undertaking this assignment, the health maintenance organizations that will be accessed include
AmeriHealth, Aetna and Horizon. All these three organizations belong to the same category of
Medicare.
The organization that scores highest on most measures
According to reports collected from the three health maintenance organizations, Aetna emerges to be
the one that has scored the highest in taking most measures. For breast cancer ... Show more content
on Helpwriting.net ...
The first thing that surprised me is how the organizations have taken serious the issue of children
immunization. As noticed, all the organizations have done a lot of immunizations to children in the
United States. Since there are many children who are born in the country, a majority of them have to
go for various important immunizations. If children fail to be immunized, parents understand that
they could run into health problems in future. Therefore, the high percentage of immunization that
cuts across all the three selected organizations shows how parents in the United States as well as the
health care organizations take serious the issue of protecting the new born children against
vulnerable

Bridges To Excellence In Health Care Essay
processed by Medicare part A
ACA– Affordable Care Act
Also called as OBAMA care act enacted in 2010 with main aim of reducing uninsured population by
means of employers mandate, minimal health insurance mandate to all based on economic status,
extending insurance coverage to preexisting conditions etc. (35)
Predictive Analytics– A form of predicting near future events based on available data, statistical
analysis, and artificial intelligence.
Leapfrog–
Health care experts are volunteered to collect health performance indicators and publish annually
with aim of improving quality and safety of health care (36).
Bridges to Excellence
Bridges to Excellence is an incentive program which recognizes and rewards physician or nurse
practitioners ... Show more content on Helpwriting.net ...
NP: Nurse practitioner
Nurse practitioners are registered practitioners who are certified, licensed and are trained to provide
healthcare services to the patients with illness under clinical settings.
EBM: Evidence based medicine
Evidence based medicine is a type of medical practice which involves decision making based on the
evidence from the research, patient values, clinical experience to provide better quality healthcare
services without any errors.
FAH – Federation of American Hospitals
The Federation of American Hospitals (FAH), is the national wide representation of more than
thousand hospitals and health systems which are investor owned. FAH used to negotiate for
unemployment and Medicare cuts.
QHP – Qualified Health Plan
A qualified health plan (QHP) it is a type of health insurance plan which covers all provisions or
benefits of Obama care which are mandatory. These benefits are categorized into 10types which
includes mental health. Emergency, maternity, substance abuse, ambulatory, rehabilitation, pediatric,
hospitalization, drugs and laboratory

Essay on Health Musuem
Health Care Museum Latosha Harris HCS/235 04/08/2013 Ronald Barredo
Health Care Museum Health care is growing and as the curator of The Health care Hall of Fame
Museum, we would like to pay tribute to the five most significant developments in the evolution of
healthcare in the United States. In 1973 the Health Maintenance Organization Act supported the
development of health maintenance organizations ... Show more content on Helpwriting.net ...
From 1998 to 2007, colorectal cancer death rates decreased from 25.6 per 100,000 population to
20.0 (2.8% per year) for men and from 18.0 per 100,000 to 14.2 (2.7% per year) for women (cdc,
2011). After the international and domestic terrorist actions of 2001 highlighted gaps in the nation's
public health preparedness, great improvements have been made. During the 2009 H1N1 influenza
pandemic, these improvements in the ability to develop and implement a coordinated public health
response in an emergency facilitated the rapid detection and characterization of the outbreak,
deployment of laboratory tests, distribution of personal protective equipment from the Strategic
National Stockpile, development of a candidate vaccine virus, and widespread administration of the
resulting vaccine. These public health interventions prevented an estimated 5––10 million cases,
30,000 hospitalizations, and 1,500 deaths (CDC, unpublished data, 2011).
The Patient Protection and Affordable Care Act (PPACA), commonly called Obamacare, is a United
States federal statute signed into law by President Barack Obama on March 23, 2010. It represents
the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare
and Medicaid in 1965. PPACA focuses on decreasing the number of uninsured Americans and
reducing

Essay on Emergency Room Overutilization
Emergency room over utilization is one of the leading causes of today's ever increasing healthcare
costs. The majority of the patients seen in emergency rooms across the nation are Medicaid
recipients, for non–emergent reasons. The federal government initiated Medicaid Managed Care
programs to offer better healthcare delivery, adequately compensate providers and reduce healthcare
costs. Has Medicaid Managed Care addressed the issues and solved the problem? The answer is
'Yes' and 'No'.
Throughout the early 1980's and 1990's the Federal Medicaid program was challenged by rapidly
rising Medicaid program costs and an increasing number of uninsured population. One of the
primary reasons for the overall increase in healthcare costs is the ... Show more content on
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It was also hoped that the number of uninsured people would dramatically decrease by offering
Medicaid managed care coverage to low–income families and individuals that were not Medicaid
eligible. These services and coverage could be delivered through the Medicaid managed care
carriers and be covered by the cost savings.
States have chosen to two forms of Medicaid managed care to better deliver healthcare services
besides the traditional fee–for–service Medicaid programs; primary case management and
traditional health maintenance organizations. "In primary care case management, the state Medicaid
agency contracts with a primary gatekeeper entity (e.g., physician, clinic) that coordinates primary
and specialty care for Medicaid beneficiaries. For healthcare maintenance type programs, a State
Medicaid agency contracts with an existing healthcare maintenance organization, prepaid health
plan, or other institutional health care provider who, in addition to proving primary care services,
assumes insurance risk of providing covered services. Typically primary case management are paid
on a fee–for–service basis plus a monthly case management fee per enrollee, while health
maintenance organization plans are paid a capitation rate and are at full financial risk." (1)
Once implementation of the program began, enrolling and educating the Medicaid population was
one of the

UHG Performance Management
Mission, Goals, and Performance Management Today, organizations need to have a clear
understanding of where their organization is and where it needs to be in the future to secure
longevity and financial success (Moore, Ellsworth, & Kaufman, 2011). Organizations need to have a
performance management system in place to stay competitive. Therefore, having a well–developed
performance management process in place allows the employer and employee to communicate
goals, share information, and establish career growth. Performance management needs to contribute
to the success of the organization while providing a positive impact on the employees. Therefore,
the mission, goals and performance management should coincide with one another. UnitedHealth
Group (UHG) was founded in 1977, and based their organization on health maintenance
organizations (HMOs). UHG is considered the most diversified health care organization in the
United States. They have the largest network s of physicians, and health facilities and caregivers in
the United States. They operate in all 50 states and more than 125 other countries around the world
(UHG, 2015a). Their operating revenue is over $130 billion in 2014 and Fortune magazine ranked
them No. 14 of the 500 largest U.S. corporations (UHG, 2015a). UnitedHealth Group's mission "is
to help people live healthier lives and to help make the health system work better for everyone"
(UHG, 2015b). They enhance the performance of the health care system

Health Maintenance Organization : South University
Assignment 3: Health Maintenance Organization
South University
Nikki Washington
Dr. Perkins
April 8, 2017
Health Maintenance Organization When breaking down various HMO models that is being
evaluated for the region, the
HMO that would be best suited for the hospital in the small rural community that would have
critical care access would be the staff group model. The staff group would be ideal however in some
cases patients would need referrals to gain access to the specialty providers that they may need after
being released from the hospital, but during a hospital visit the providers should already be available
to patients. A potential down side to getting a referral is patients could have a longer wait time for
appointments and ... Show more content on Helpwriting.net ...
This will allow patients' access to providers within the network and could possibly penalize any
patient that goes outside the network. Contracting the network groups also continues to keep money
within the communities and also provide incentives for groups to join the network.
The American Trauma Society has (five) levels of trauma care. The importance and applicability of
the various levels of emergency department trauma care are imperative to helping the community
and providing affordable health care to people with little to no income. Each level of trauma care is
vital in various communities to ensure the appropriate trauma level is made available based on the
communities' population.
According to American Trauma Society (2017), Level I trauma center is a comprehensive regional
resource that is a tertiary care facility central to the trauma system. It is capable of providing total
care for every aspect of injury from prevention through rehabilitation. Level I include 24 hour
coverage by general surgeons and specialty care physicians. Level II also includes 24 hour coverage
but limited on specialty physicians but does include tertiary that are referred in Level I. Level III
also offer some of the same levels of care that I and II offers but Level III through V are limited and
basically stabilize patients before transferring them to a higher level trauma center. It is vital and
very important that the hospital's trauma level matches the community's needs. It

Health Maintenance Organization: Managed Healthcare System
A Health maintenance organization (HMO) is a type of managed healthcare system. HOM's and
their close cousins, preferred provider organization PPO's, share the goal of reducing healthcare cost
by focusing on preventative care and implementing utilization management controls. HMO plans
offer a wide range of healthcare services through a network of providers who agree to supply
services to members.
Preferred Provider Organizations (PPOs) consist of a network of hospitals, healthcare facilities,
physicians and labs that patient may choose from for services and the services will be covered under
the insurance policy. Managed care organizations (MCOs) began to proliferate during the 1980s. A
Managed Care Organization (MCO) is part of a Family

Controlling Health Care Benefits Costs
Controlling Health–Care Benefits Costs The topic that I will be discussing is Health Care Benefits
Costs. There are several different trends in the health care field that are used in business. Major
issues and obstacles are also very big regarding Health Care Benefits Costs. Controlling Health Care
Benefits Costs is a very important topic that is trending today throughout the world. Health Care
benefits costs are a "systematic approach to estimating the strengths and weaknesses of alternatives
that satisfy transactions, activities or functional requirements for a business. It is a techniques that is
used to determine options that provide the best approach for the adoption and practice in terms of
benefits in labor, time and cost savings" (Cost Benefit Analysis). Some companies compromise help
with medical costs. This depends on the company's policy. Either the employees can compensate a
fee to disregard the health care plan, while the company may choose to pay for the whole bulk of the
best. Also, the company may pay for everything. "Employers often provide employees with sort of
group medical insurance, with the level of coverage depending on the status of the employee" (Cost
Benefit Analysis). Part–time employers have less of a privilege to receive benefits than full–time
employers. "Most companies offer managed–care health coverage through HMOs and preferred
provider organizations, PPOs. HMO stands for Health Maintenance and PPO stands for Preferred
Provider

Care Setting Analysis Nursing
Care Setting Analysis
Nursing leaders must apply critical thinking and analysis skills in order to find opportunities to
improve gaps in care. Consequently, nurses with the ability to identify, understand, and influence
opportunities for improvements while consistently achieving quality and safety goals have unlimited
opportunities to exercise leadership (Grossman & Valiga, 2012). Lastly, nurses whom have the
understanding of the complexity of leadership and the awareness that the leadership role is
something every nurse can fulfill will lead nurses towards change and advancing health as the
Robert Wood Johnson Foundation (RWJF) and Institute of Medicine (IOM) has campaigned for
action while enhancing nurses' contributions to delivering quality ... Show more content on
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One useful assessment to analyze performance readiness while using the triple aim concept can be
found on the website, healthcatalyst.com (HealthCatalyst website, 2016). This performance
readiness assessment was used as the feedback from the five keys to an organization being ready to
drive and sustain outcome improvements: leadership, culture, and governance; analytics; best
practice; adoption; financial alignment. These outcome improvements are consistent with Optum's
mission and values: help the health system work better for everyone requiring the employee's fullest
potential and values of integrity, compassion, relationships, innovation, and performance
(UnitedHealth Group,

Case Study: HMO Standss For Health Maintenance Organization
HMO stands for health maintenance organization , with this health plan you can select your primary
care physician who will be responsible for your basic healthcare needs. If you need a referral to see
a specialist your PCP has to send a referral over. Note the referral of the specialist must be within
the HMO network. If you would like to see a doctor that is considered outside of the network or
without a referral, you will brunt the cost, you will be responsible for all out of pocket cost, unless it
a medical emergency and you have no other choice.
PPO stands for preferred provider organization. With this health plan can go to any primary care
physician (PCP) and you do not have to have a referral in order to see a specialist. If you

Healthcare Organization
Healthcare Organization 's – HMO vs. PPO Angela MacLeod, Ifeoma Jonathan HCS–413 April 17,
2011 Jeffery Dodd Healthcare Organization 's – HMO vs PPO Introduction A health care system is
the organization of people, institutions, and resources to deliver health care services to meet the
health needs of target populations. There are two widely known and used healthcare organizations
that deliver insurance to the vast majority of the population, Health Maintenance Organizations
(HMO) and Preferred Provider Organizations (PPO). This document will further compare these
organizations in how they communicate, management style, motivation, culture, conflict resolution
and ongoing management development. Communication ... Show more content on Helpwriting.net
...
PPOs allow consumers to seek care outside the network coverage but this allowance attracts extra
fee. PPOs provide prescription services at a reduced cost; have a larger network covering larger
geophysical areas. PPOs management style has advantages over HMOs as they less restrictive and
affords the consumers opportunity to use out of network facilities with prior approval at a cost.
PPOs are located in more geographical areas and makes access easier. Subscribers are not stuck with
a PCP nor require referrals to see providers outside the network. Consumers file for claims for
reimbursement when visit is made to out of network health provider Motivational Methods There
are as many different methods of motivating employees today as there are companies operating in
the global business environment. Still, some strategies are prevalent across all organizations striving
to improve employee motivation. The best employee motivation efforts will focus on what the
employees deem to be important. It may be that employees within the same department of the same
organization will have different motivators. Many organizations today find that flexibility in job
design and reward systems has resulted in employees ' increased longevity with the company,
improved productivity, and better morale. Conflict Resolution With the need for constant change
comes conflict. There are several strategies for handling conflict, avoidance,

Healthcare Costs Increase Creating A Barrier For Health...
Healthcare costs continued to rise creating a barrier for people to receive medical care in a fee–for–
service world. Advances in technology and an aging population requiring more care has driven up
the costs. In an effort to control this, managed care organizations were created to focus on
efficiency, cost control, and overall quality of care. MCOs channeled their insurances consumers
towards physicians that are within the contracted network and the over utilization of care began to
ebb back, making physicians the gatekeepers. Prescription management and preauthorization before
care from an insured's health plan also aided in the decrease. In the beginning of the twentieth
century, healthcare was available to the ones that could afford it. If you could buy it, it was yours but
much of the population lacked the funds to do so, as well as the knowledge to choose. Prepaid
hospital plans and clinics slowly started to appear. During the 1930s a person could attempt to
negotiate their healthcare prices with a physician since physicians could not advertise at that time.
Not everyone received the same service for the same price. Up until the 1960s, the United States had
a physician shortage that narrowed down choices that individuals had for their healthcare needs.
Physicians that worked alone were considered entrepreneurs and navigated the risks of profit or
financial loss. Others that had fee–for–service practices started to broaden their medical services,
which in turn

Essay about Managed Care
Managed Care
There are so many problems with our society's health care. Everyone wants to find a
solution, but no one has been able to come up with one yet. Many different things have been
tried, but none have put a cease to the exorbitant costs, which most believe to be the main
problem. Out of everything tried, the most recent and popular system is known as managed care.
Managed care is the most common form of health insurance in the United States, and provides
more a cost efficient coverage than paying a fee–for–service charge. However, it is also a very
complicated system. Over the next few pages I am going to try and go over the main parts of the
managed care structure. In the end, I am going to ... Show more content on Helpwriting.net ...
Although the goals have not yet been met, managed care has
continued to grow throughout the past four decades. At the end of 1996, there were over 600
HMO's in operation, enrolling around 65 million members, which is about 1/4 of the population
(Tufts 1998).
Before I get into the different types of managed care organizations, I am going to go over
some cost control methods in managed care. Managed care organizations are different methods
used to control utilization of services. Utilization management requires three things. First, you
have to have an expert evaluation of which services are medically necessary in a given case. This
ensures that unnecessary services are kept to a minimum. Secondly it requires a determination of

how those services can be provided most inexpensively, while maintaining a high level of
quality of care. It also requires a review of the process of care and changes in the patients
condition to revise the course of medical treatment if necessary. The methods that are most
commonly used for utilization monitoring and control are choice restriction, gatekeeping, case
management, utilization reviews, and practice profiling.
The first method I am going to talk about is choice restriction. Traditional health
insurance gave the insured open access to any provider. This led to an over use of services. Most
of the managed care plans have some sort of

Health Insurance Matrix
University of Phoenix Material
Health Insurance Matrix
As you learn about health care delivery in the United States, it is important to understand the various
models of health insurance to develop a working knowledge as you progress through the course. The
following matrix is designed to help you develop that knowledge and assist you in understanding
how health care is financed and how health insurance influences patients and providers as important
foundational information for your role as a future health care worker. Fill in the following matrix.
Each box must contain responses between 50 and 100 words using complete sentences.
Include APA citations for the content you provide.
Origin: When was the model first used?
What kind of ... Show more content on Helpwriting.net ...
Indemnity health plans run on a retrospective payment system. A member has a monthly premium.
Co–pays and a deductible. Upon visits the provider submits claims for services rendered to the
insurance company, upon which the insurance company pays their part and the member is billed for
the remaining balance to be paid out–of–pocket.
With indemnity plans employers deduct the monthly premium from payroll of each employee on the
plan. Both the member and the insurance company pay for services rendered. Upon receipt of the
services the insurer pays the provider their portion if the deductible has been met. The member is
then responsible for the remaining balance and the co–pay at the time of service.
The structure of an indemnity plan is completely "open access". The member may choose any
provider or specialist they would like. In an indemnity plan there are no restrictions on providers or
provider type. It is the member's responsibility to seek and sign on with their preferred provider or
specialist.
Positive aspects of indemnity plans include the liberty of the member to choose their preferred
provider or specialist and their preference of type of care they wish to receive. A negative aspect of
indemnity plans from a members stand point is the cost of these plans. Premiums and deductibles
then to be higher with indemnity plans over other insurance plans due to the freedom

Managed Care Term Paper
U.S. Health Care Delivery System
Term Paper
Margarita Blanco
March.29th, 2010
Managed care was started as early as the 1900's, the cited pioneer of the structured system of care
that is known today as "Managed Care" is Dr. Michael Shadid. His goal was to help meet the health
care needs of a certain groups of people. Such as: rural residents, workers and families in the
lumber, mining and railroad industries; the enrollees paid a set fee to physicians who then delivered
care under the terms of their agreement. By 1929 the Los Angeles department of water and power
contracted with Drs Ronald Ross and H. Clifford Loos to provide service for almost 2,000 ... Show
If you choose to go outside of your network for health care you will get charge a deductible like a
PPO plan, charges will be about 300 dollars for and individual or 600 dollars for a family. For some
reason when I was researching managed care majority of the websites I came across never
mentioned Exclusive Provider Organization [EPO] then I finally came across it. Exclusive Provider
Organization [EPO] is the type of managed care that if you get healthcare outside of your network
you will have to pay for it out of pocket, so its not like a Point of Service where you'll get charged a
deductible or a percentage in this case your on your own. Being that EPO member are restricted to
in network doctors they are able to negotiate prices. EPO does charge co payments each visit that
ranges from 20–30$ and charge a monthly premiums and deductibles. I chose to save the best for
last; I will be talking briefly about Health Maintenance Organization [HMO] as well as its
advantages and disadvantages. I chose HMO because it was the first form of Managed Care. The
earliest from of HMOs can be seen in a number of prepaid health plans tracing back to 1910 the
western clinic in Tahoma, Washington offered lumber mills owners and their employees certain
medical services from is providers for a premium of 50 cents. However; the first HMO considered
in the United States was the Ross–Loss Medical Group in 1929 as I said earlier.

Healthcare Paper
1a. What model of healthcare does the US and your chosen country have (Japan)? Be very specific.
The United States has a healthcare system that is different from almost every country in the world. I
would call the United States health care system a hybrid type system. I would call our system a
hybrid because we fall into almost every type of category possible when it comes to health care; for
instance, people who are uninsured have to pay out–of–pocket when they want to see a doctor
versus someone who is insured and only has to pay a deductable. Many companies in the United
States offer free medical care for employers, or they make health care insurance fairly cheap to
afford. Unlike many countries our healthcare system is a little ... Show more content on
Helpwriting.net ...
The person who utilizes this plan generally has to pay co–pay, which the cost varies depending on
the type of plan you have. Many people like this type of plan because when you go to the doctor you
don't need to fill out claim forms. Members show a card when they go to the doctor or hospital. The
downfall to this plan is that you might have to wait longer in the waiting room. Another plan the
United States has is called point–of–service plan. This plan allows the members of the plan to refer
themselves to an outside plan and still be able to obtain some coverage. A doctor can also make a
referral out of the network and in–turn the health care plan will pay for most if not the entire bill. A
preferred provider organization is another type of plan offered by the United States. Just like the
health maintenance organization, the preferred provider organization limits you to the number of
doctors you can see, but when you do find the right doctor most of your medical bills are covered.
The preferred provider organization requires you to choose a primary care physician in order to
monitor your health care. If you elect to go to a doctor who is not part of this plan, some of the
medical expenses are covered. I deem some people like this plan because if their primary care
doctor is not part of the plan, they don't have to change doctors. According to Health Insurance. Info
"An Exclusive Provider

The Role Of Finances For Health Care Systems
The role of finances for health care systems Inc. will be for managing the business's finances. This
ensures having cash available for expenses to ensure the business stays afloat and to ensures there is
cash to provide a cushion for any costs that come up unexpectedly. Ensuring that the finances are
managed means the company can make plans to ensure the future of the company (Brumley, 2015)
and utilize the resources of the company to ensure its running at peak proficiency. The primary users
for the financial information will be the finance department which consists of the chief financial
officer, comptroller, treasurer and the personnel in charge of specific financial information within
the company departments. This whole department reports to the chief executive officer who is
responsible for all financial transactions for the company (Gapenski, 2013). There are many legal
and regulatory issues that this business has to follow due to being in the health care industry. Some
of these issues are that the health care industry is highly regulated for people entering the industry
for the well–being of the public. The personnel working in the health care industry have to be
licensed or state certified. The facilities themselves have to be licensed and inspected by state
personnel that ensure the quality of the facility and the personnel. The legal concerns for this health
care business are varied for the health care industry but the primary concern is professional

How Managed Care Is A System
Managed care is a system that puts together the financing and delivery of apposite health care by
means of an all–inclusive set of services (Docteur, E., & Oxley, H. 2003).
Although, managed care can be considered an expansive term that covers many form of
organizations and insurance alternative that includes
Health Maintenance Organizations (HMOs), that provides a wide–ranging option of services, over a
period f time and at a fixed rate.
Preferred Provider Organizations (PPOs), that consist of a group of hospitals, physicians and
providers who are in agreement with an insurer, third party administrator, employer, or other group
so as to provide health care services to covered individuals;
Point–of–Service Plans (POSs), that combines the features of the HMO's and PPO's. with this plan
members can select which preference they want to use at the time of service;
Indemnity or Fee–for–Service Plans that integrates the characteristics of managed care, while
providing the benefits in a prearranged amount for covered services;
Self–Insurance Plans that allows employers and businesses assume financial liability and the
responsibilities of an insurer for their own employees.
In the last four decade, the cost of healthcare services has been on the rise, thereby leading to the
promulgation of the Health Maintenance Organization Act of 1973 (Salmon, J. W. 1995). This act
provided the opportunity to control healthcare cost, through membership of a provider network that

Healthcare Organization Emergency Room over Utilization
Emergency room over utilization is one of the leading causes of today's ever increasing healthcare
costs. The majority of the patients seen in emergency rooms across the nation are Medicaid
recipients, for non–emergent reasons. The federal government initiated Medicaid Managed Care
programs to offer better healthcare delivery, adequately compensate providers and reduce healthcare
costs. Has Medicaid Managed Care addressed the issues and solved the problem? The answer is
'Yes' and 'No'.
Throughout the early 1980's and 1990's the Federal Medicaid program was challenged by rapidly
rising Medicaid program costs and an increasing number of uninsured population. One of the
primary reasons for the overall increase in healthcare costs is the over ... Show more content on
Helpwriting.net ...
As enrollment increased emergency room over–utilization for non–emergent reasons decreased. The
new Medicaid Managed Care population was being educated on the 'Gate Keeper' concept; the idea
of having a primary care physician. A large primary care pediatric practice launched an Emergency
Room diversion pilot program and conducted a study of Medicaid recipients, 18 years and younger .
(2) 17,382 children were enrolled in an enhanced access group (intervention group) and 26,066
received services from other local primary care providers (control group). (2) The twelve month
study results showed that the average per member per month cost of emergency room utilization of
the intervention group was $1.36 less than the controlled group. There was no significant difference
in terms of per–visit cost related to emergency room usage. Although the overall cost of healthcare
delivery has not increased the enrollment in traditional Medicaid fee–for–service product has
increased and surpassed Medicaid managed care enrollment in the past six years. This recent change
in the market place is of particular concern. The idea of losing what has been gained such as,
guaranteed access to providers, improved care management attributed to primary care provider
healthcare delivery and the ability to monitor insurance carrier performance motivated State
Medicaid agencies to devise a response on how to handle this current issue. Because managed care
has delivered a value to Medicaid

Health Care Utilization Essay
University of Phoenix Material
Week 5 Health Care Terms Worksheet
Understanding health care terms is a prerequisite for both academic and professional success. This
assignment is intended to ensure you understand some of the basic terms used in this course.
Complete the worksheet according to the following guidelines:
In the space provided, write each term's definition. You must define the term in your own words.
In the space provided after each term's definition, use the term in a sentence as it applies to the
health care industry. You may wish to consider the following: *
How has it influenced heath care?
What role has the term played as health care developed over the years? * * Save the completed
worksheet ... Show more content on Helpwriting.net ...
| Preexisting Medical Condition | A medical condition or health care problem that existed before
enrolling in a health care plan. | My aunt had a preexisting medical condition before she applied for
blue cross insurance. | HMO | Health maintenance organizations. An organization that provides
comprehensive health care to voluntarily enrolled individuals and families in a geographic area by
member physicians with limited referral to outside specialists and that is financed by fixed periodic
payments determined by advanced. | Health maintenance organizations help provides health care for
persons who are referred by physicians. | Affordable Care Act | Is an act that provides Americans
with better health security by putting in place comprehensive health insurance reform that will
expand coverage, holds insurance companies accountable, lower health care cost, guarantee more
choice and enhance the quality care for all Americans. | The new affordable care act helps low
income families to be able to access high quality health care. | Center for Disease Control and
Prevention | A national public health institute of the United States whose main goal is to protect
public health and safety through the control and prevention of disease, injury and disability. | The
center for disease control and prevention helps to protect the environment by promoting health and
safety. | U.S. Food and Drug Administration | A US federal Agency responsible for the enforcement

Types Of Health Maintenance Organization Plans
Two types of health maintenance organization plans that are readily available are the Staff Model
HMO and Group Model HMO, and these plans are often called closed–panel plans (Kongstvedt,
2016, p. 63). These HMO plans are considered closed because either the HMO employs the
physician, or the physician belongs to the HMO group, thus creating a smaller network for the
patient to be seen (Farnham, n.d., Chapter 3). Each HMO plan has its benefits and disadvantages for
the physician and patient. Consequently, depending on what the patient needs to meet their medical
needs the Staff Model HMO plan or Group Model HMO plan would benefit them. Furthermore,
depending on the particular type of freedom the physician is looking for is what would influence the
type of plan they would join.
During a Staff Model HMO the physician is employed by HMO network, thus they are salaried
employees. Therefore, the physician is paid whether he sees an HMO patient or not. On the other
hand, the physician could be very busy and still get the same salary. Sometimes the HMO offers
incentives for quality control, so that the physician does not use expensive medical testing
(Kongstvedt, 2016, p. 65). Besides the HMO paying the salary of the physicians, the HMO actually
owns the medical facilities, equipment, and supplies used by the HMO physician and in some cases
the hospital. Hence, the physician employed by the HMO could be financially beneficial to them.
Additionally, because of the size of the

Health Maintenance Organization Case Study
Health Maintenance Organization (HMO) was enacted in 1973 it is a prepaid group practice that is
operated by the government. The Government helps HMO meet federal standards and provides
loans and grants to organizations. Employers having more than twenty five employees offer HMO
as an alternative health treatment plan for employees. The federal government reimburses the HMOs
on a per capita basis, this means HMOs are paid on a fixed per capita amount. In order for an
employer to qualify for HMO they must provide proof they can provide comprehensive health care
and show performance reports such as medical records to the offices of department of Health and
Human Services (DHHS). HMO plans have a primary care physician also known as (PCP) ... Show
HSA accounts are tax free saving accounts in which an employee deposits money from their
paycheck into a savings account that can roll over year after year. An HRA account is only given to
employees with high deductible. The employer owns the account, limits covered expenses and
determines if money can be rolled over. HFSA accounts allows certain amount of wages to be put
aside for medical and child care. HFSA accounts cannot be rolled over from year to year, only cost
of drugs is deducted from this

Significant Event/Impact on Health Care Organizations:...
Running Header: SIGNIFICANT EVENT/IMPACT ON HEALTH CARE ORGANIZATIONS:
MANAGED CARE
Significant Historical Event/Impact on Health Care Organizations: Managed Care
Erich Hayman
Monday, May 19, 2008
University of Phoenix
HCS/530, Health Care Organizations
Professor David A. Olsen, MHA Significant Historical Event/Impact on Health Care Organizations
"By 1995, managed care plans had become the dominant form of health insurance and enrolled 73
percent of all Americans who were covered by employer–based health benefits (Jenson, Morrisey,
Gaffney, and Liston, 1997)" (Mick & Wyttenbach, 2003, p.6). "In comparing the development of the
U.S., British, and Canadian health systems, Carolyn Tuohy (1999: 7) argues that "key ... Show more
content on Helpwriting.net ...
President Nixon legislative answer came as the health maintenance strategy in 1970 and 1971.
Legislation set in motion the manage care health system and the inevitable commercialization of
modern medicine. "...Paul Ellwood (along with the Nixon administration), a physician specializing
in rehabilitation medicine, who through his Minnesota think tank InterStudy promoted the term
HMO and saw it as the building block for an entirely different approach to health care reform"
(Oliver, 2004). According to the National Library of Medicine, "managed care plans are health
insurance plans that contract with health care providers and medical facilities to provide care for
members at reduced costs" (www.nlm.nih.org). The categories of plans include Health Maintenance
Organization (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS).
According to the American Heart Association the goals of managed health care ensure that
"providers deliver high–quality care in an environment that manages or controls costs, the care
delivered is medically necessary and appropriate for the patient's condition, care is rendered by the
most appropriate provider, and care is rendered in the most appropriate , least restrictive setting"
(www.americanheart.org). Due to the customization ability of managed care plans individuals
control their respective health coverage and allow cost reduction cooperation between health
organizations and

The Healthcare Industry of America; An investigative look...
The Healthcare Industry of America: An investigative look at HMO's
It's no secret that Health Maintenance Organizations, known as HMO's, have made healthcare
affordable for many Americans, but at what risks? Most employers offer some type of health care
plan that is an HMO. Let's face it, given the choice among insurance coverage through your
employer, in which he pays half the costs, or acquiring private insurance coverage outside your
employer, most Americans choose to go with employer–provided HMO's. Why then, has there been
so much controversy with HMO's?
An HMO is an organization whereby the subscriber, or patient, is allowed to choose a medical
provider from a list of doctors within a certain medical group. Each physician ... Show more content
on Helpwriting.net ...
This process could take weeks due to cumbersome paperwork and the limited number of specialist
per each group or health plan. Again, many doctors only accept these plans to supplement their
practices. It is common for them to stop accepting your HMO after only a few years which leaves
the patient a choice of either paying cash, or changing doctors or insurance companies. One can see
why this might be a frustrating process.
Managed care reduces cost by keeping a pool of doctors and specialist to a minimum, and at the
same time keeping the volume of patients high. This often means that a patient may not receive the
same amount of attention and care as they should, or were accustomed to. Consumers have long
grumbled that HMO's have done too much too keep health costs down by stinting on patient care.
(1).
Healthcare expenditures have more than doubled since 1965. Americans spend over a trillion dollars
a year on health care. (2). As of 1996, 110 million Americans were enrolled in HMO's. More than
three–fourths of all individuals in HMO's are covered by job–based insurance. More than 13 million
Medicaid recipients have been put into managed care plans. Managed care and HMO's have been
the subject of many negative stories in the press and are constantly being charged with endangering
the health and lives of their enrollees. As a result, congressional hearing, state, and federal
regulation, and action by the

Cost Control in Health Maintenance Organizations Essay
An HMO is an organized health care delivery system, which provides health care to its members
through networks of doctors and hospitals. Rather than traditional health plans, HMO's cost less.
Two ways HMO's control costs are: controlling hospital admission and length of stay, and by
providing incentives to physicians. These two cost control methods are further examined by an
article published by The National Bureau of Economic Research (2002). The article examines the
incentives to physician strategy for reducing utilization cost. The Physician Guide to Managed Care
(1994) describes HMOs the case management procedures used to control cost through hospital
length of stay and admissions.
Much of the focus regarding HMO controlling cost is ... Show more content on Helpwriting.net ...
Bonus levels are determined on the basis of performance, as performance improves the bonuses
gradually become higher. HMO's rely on rates and member satisfaction survey results to measure
provider performance. By keeping a certain level of member satisfaction, more revenue can be
brought in through new enrollees.
Financial incentives are generally more influential when it comes to physicians improving quality of
care. According to the National Research Council (2001), research regarding payment and quality
improvement efforts of health care administrators was presented at an Institute of Medicine
Workshop in April of 2004. The research showed ,with the use of physician incentives the total
direct savings in health care cost which include reduce visits and hospital episodes was an estimated
net savings of about 2,000 per patient. For more than 13,000 diabetic patients managed by a
physician group it was projected that the savings had the potential to generate over $10 million in
net saving per year. Aligning financial incentives with physician's networks provides the
achievement of better patient outcomes, but generally provides the HMO cost control over their
equity.
HMO's utilize the process of controlling hospital admission and length of stay as another form of
cost control. According to Nash (1994), in order to minimize hospital length of stay, the HMO
arranges in advance for care to

Independent Healht Insurance Company: BlueCross and...
Introduction
BlueCross BlueShield Association (BCBSA) is an independent health insurance association which is
founded in 1929. It is made up by 37 different health insurance organizations and companies in the
United States. They directly or indirectly provide health insurance to over 100 million Americans.
Under the Association, it has two famous products. One is Health Maintenance Organizations
(HMOs), and the other is Preferred Provider Organization (PPOs). Most American who has health
insurance from their employer are enrolled either an HMO or PPO. All of these managed care plans
go through the health plan's network, which contract with doctors, health care providers, clinics, and
hospital.
Body part
Health Maintenance Organizations (HMOs)
HMO is an organization that provides or arranges managed care for health insurance, individual and
other entities in the United States. It existed prior to the 1970s, which required employer who has 25
or more employee to offer HMO healthcare. In most of HMO plans, it required the insurers to select
a primary care physician (PCP) who is responsible for all their healthcare services. If they need care
from a physician specialist in the network, their primary care physician will have to provide them
with a referral. If they don't get the referral or they select to go to see a doctor outside of your
HMO's network, they will most likely have to pay all or most of the cost.
Preferred Provider Organizations (PPOs)
In health insurance, a

History Of Managed Care And Health Maintenance Organizations
Those of us who have served in the Military a very familiar with managed care, we may not totally
understand the concept of managed cared but are recipients of it daily. Unless there is a heated
political debate about health care reform we usually don't worry about health care reform. Health
care cost is not something that we worry about; after all the government takes care of all our medical
needs, even when we are seen out on the economy. The only time we might the troubles of health
cost might visit our door steps occur when family members decided to see an out of network
provider, we are them held accountable for paying medical bills. What I failed to realize during my
time on active duty, Tricare is just another form of a managed care program. In this essay we will
explore the history of managed care and Health Maintenance Organizations (HMOs). Additional,
we'll take a look at how managed came about, and the future of managed care and health care
reform in the U.S.
What is managed care and where did it come from? According to Medicaid. Gov, "managed care is a
health care delivery system organized to managed cost, utilization, and quality" (Medicaid.gov,
2014). The begins of managed care can be dated back to 1910, consumers paid $.50 a month for
medical care. During this time there weren't checks and balances nor were there governing agency to
ensure equal care to control health care cost. 20 years later Dr. Michael Shadid led farmers in the
establishment of a

Questions On Risk Sharing Arrangements
CONTENTS
Introduction 2
Basic Risk Arrangement Structures 3
Common Problems in Risk Sharing Contracts 4
Some Additional Mistakes to Avoid in Risk Sharing 5
Best Practices in Risk Transfer 7
When Hospitals Share Risk With HMOs 7
Approach for Risk Sharing Arrangements 8
Examples of Risk Sharing Arrangements 9
Provider Risk Sharing In Medicaid Managed Care Plans 12
Device Makers Risk Sharing Contracts with Hospitals 13
Walgreens – Going at Risk for Re Admissions 14
Managed Care Risk Sharing Arrangements 15
Factors Influencing the Target Claims 17
Timings of Risk Sharing Arrangements 17
References 18
Introduction
Risk sharing occurs when both the parties finds the risk and agrees to share the loss that may occurs
due to that risk. The co investors and joint ventures get into the risk sharing arrangements by
defining their true contribution and limiting their commitments related to their future and financial
commitments. The risk sharing arrangements or contracts are usually prevented into the
"Outsourcing Transactions" where one has physical control over the process and the other party has
been prevented from such control and therefore these kind of arrangements prefer to go on with the
"Fee for Service" Model. (1)
When we talk about the risk sharing arrangement in managed care so these arrangements between a
managed care organization and the employer are used by the employer to either make sure about the
success of the managed care plan for a short interval of time

Network Development In The Managed Care Organization

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