Hmo ( Health Management Organization ) Is A Preferred...

Hmo ( Health Management Organization ) Is A Preferred...
Chasity Garrison
9/12/2014
Insurance Project
MA 215
HMO (Health Management Organization) is a preferred provider organization. Their focus is to reduce the cost of the preventative care as well as
implementing utilization management controls as part of their goal. Being part of a HMO, you can choose the primary physician for medical
purposes. One of the advantages are the low cost out of pocket costs for the patient's insurance. Each time you seek medical care you are only
obligated to pay a percentage of the bill. Members of HMO are at a fixed cost for the monthly fees. HMO tries to encourage the patients to stay on
top of their health, and not let their illnesses get to out of hand by letting it get worse. Another advantage, is that being part of the HMO, your
offered education classes and discounted club memberships for your health. The disadvantages of the HMO consist of some strict controls. An
example of an advantage would be if you decided you wanted to receive care from another doctor or specialist, it must be consulted. Although by
doing the consultation, which helps lower the cost for the HMO and the member, it can also cause problems if your physician doesn't provide you
with the referral. When you receive care from a provider that's not part of a HMO, the organization will not pay for services that are non–emergency
from the physician. (Medical Billing, n.d.) PPO (Preferred Provider Organization) is considered the group of physicians and hospitals that
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Essay on Hmos: Making A Killing
FACT: Currently 46 million Americans live without any health care insurance whatsoever.
FACT: The United States is the only industrialized nation in the world that does not provide health care insurance for all of its citizens.
FACT: The United States spends more money per person on health care than any other nation in the world.
FACT: The World Health Care Organization has ranked the United States 37th in the world regarding the health care a country provides for its people.
FACT: No country in the history of the earth has provided universal health care coverage for all its citizens under a private health careinsurance system.
The facts stated above are not only embarrassing and frightening; they are simply unacceptable. How our ... Show more content on Helpwriting.net ...
One example of a single–payer health care proposal that is already out is entitled "Physician's Proposal" and was first published in New England
Journal of Medicine in 1989 and then later in the Journal of the American Medical Association in 1991. Under this plan every citizen would be covered
for all necessary medical procedures including rehabilitative, long–term care, mental health care, dental care, prescription drugs, and medical supplies.
Under the plan, every person would have access to local personalized care from the doctor of his or her choice. Physicians would still operate in the
private sector; the whole scheme would provide for different payment structures for health care providers, this would be to minimize the disruption of
the existing system. The scheme would be designed to prevent profit motives from affecting doctor's decisions. Gone would be the incentives that
HMOs give their doctors for NOT recommending treatment for patients.
The largest obstacle between you and me, the American citizen, and universal health care insurance is corporate greed. Jamie Court and Francis Smith
have authored an intelligent and well–researched study entitled "Making A Killing: HMOs and the Threat to Your Health". In it they state that
American medicine is currently in

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 more content on Helpwriting.net ...
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

Statistical Thinking in Health Care-Hmo. Essay
Statistical Thinking in Health Care
Case Study 1 Week 4 Mat 510– Business Statistics
November 1, 2015
With information from the case we will attempt to address some explanations to the issue of medication errors being dispensed at HMO pharmacy. A
dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the
basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality shows the categories of
dispensing errors. If dispensing errors are considered from the perspective that the quality of all pharmacy care activities should be assured by the
pharmacist, this list can be extended by ... Show more content on Helpwriting.net ...
(Gara, Steven, 2013) SIPOC
–––––––––––––––––––––––––––––––––––––––––––––––––
SupplierInputsProcessOutputsCustomers
PatientPrescriptionMedication Patient
DoctorTelephoneDosageComputerAdvicePrinterBill Drug DirectoryCauses of dispensing errors can be traced by root–cause analysis or by inquiring
with practicing pharmacists by means of a survey. Root–cause analysis comes closer to reality, because a survey measures on the perceptions and
opinions of pharmacists. An example of the former type was a study in a UK hospital in which the researchers used semi structured interviews of
pharmacy staff about self–reported dispensing errors (Anacleto, T.A., Perini, Rosa, Cesar, 2007) The complex interactions of variations in materials,
tools, machines, operators, and the environment are not easily understood. Variation due to any of these individual sources appears at random;
individual sources cannot be identified or explained. However, their combined effect is stable and can usually be predicted statistically. These
common causes of variation are factors that are present as a natural part of a process. The remaining variation in a process is the result of special
causes which arise from external sources that are not inherent in the process. (Hisson, Amy) Although rates of dispensing errors are generally low,

Hmo 103 Individual Health Insurance Case
I am writing in response to an inquiry received in our office on June 22, 2016. In your inquiry to the Texas Department of Insurance you expressed
concerns over the termination of your health insurance applications. Our records show you applied for coverage under the Blue Advantage Silver
HMO 103 Individual Health insurance policy with a requested effective date of February 1, 2016. The policy was never effectuated due to
non–payment of full premiums. After a review of the concerns presented in your inquiry to the Texas Department of Insurance, we have determined
that Blue Cross and Blue Shield of Texas (BCBSTX) properly terminated your Blue Advantage Silver HMO 103 Individual Health insurance policy
based on non–payment of full premiums. BCBSTX... Show more content on Helpwriting.net ...
Box 660044 Dallas, TX 75266–0044 Enclosed for your review is a copy of Texas HMO Complaint Appeal Process. Please note that after we receive
your written request for a complaint appeal, a final decision will be made within 30 calendar days of the receipt of your written appeal. Also, your
decision whether or not to submit an appeal of the complaint resolution will have no effect on your rights to any other benefits under the plan. Page
Three Hollis If you decide to pursue filing a claim in court, Texas HMO agrees not to assert a defense of "failure to exhaust available administrative
remedies" against a Claimant who chooses not to make use of the Texas HMO complaint appeal process first. In addition, Texas HMO agrees if you
pursue the complaint appeal process, the time involved for this process will be excluded from any statute of limitations timing requirements. In
addition, we are providing you with the address and phone number of the Texas Department of Insurance: Texas Department of Insurance Consumer
Protection (111–1A) P.O. Box 149091 Austin, Texas 78714
–9091 (800) 252–3439 Fax # (512) 475–1771 Should you have any further questions, we
encourage you to contact our office directly at (888)

Case Study : The Ppo Model And The Open- Panel Hmo Model
The BCBS IL has been able to use its experience to catapult itself to the forefront of many MCO in the health care market, today the organization offers
dual health insurance model to their beneficiaries; the PPO model and the open– panel HMO model. The Medical Of Structure: BCBSIL As has been
denoted by the history of the BCBSIL above, the medical structure of BCBSIL is composed of providers that may, or may not have a contract with
the BCBSIL. The contract with the providers or the modality of payment to providers for services rendered to their beneficiaries is dependent on the
BCBSIL's health care plan. Therefore, providers that decide to accept BCBSIL's PPO patient are reimbursement based on fee–for–service in
accordance with the Blue Choice PPO Schedule of Maximum Allowances (SMA). However, the providers that opt to accept the BCBSIL HMO
patients do not contract directly with BCBSIL for their HMO products. Instead ,providers that wish to participate in the BCBSIL HMO network must
contact a BCBSIL contracting HMO Medical Group or IPA in their area of practice ("Contracting", 2016). Worth noting is that the activities of
providers, meaning the type of health care they deliver to BCBSIL beneficiaries and the providers confidentiality process are constantly being
monitored by various committees within the organization ("Contracting", 2016). According to the BCBSIL's webpage (2009), BCBSIL's Managed
Care Quality Improvement Committee (MCQIC), for example, has the

Preferred Provider Organization Case Study
There are currently have two main insurance options available for consumers, Health Maintenance Organization (HMO) and Preferred Provider
Organization (PPO). Both health insurance plans are great, but we will be focusing on the plan with lower costs in general which is Health
Maintenance Insurance, or HMO. HMO is an organized system of health care that offers medical services to its members on a prepaid foundation. It
combines health insurance and delivery functions in an effort to keep low costs and maximize the quality care provided. There are several types of
HMOs that are available: staff model, group model, network model and individual practice association, or IPA. For the staff model, physicians are
salaried and have offices in HMO

HMO Model Paper
Evaluate the various HMO models (staff, group, and network) and identify the model that would probably be best suited for the region. Justify your
answer. There are four models of HMOs: Staff Model–The Health Maintenance Organization employs the physician, and care is usually provided in a
facility owned by the HMO. Group Model is structured around a multi–specialty medical group that may include internists, obstetricians, gynecologists,
cardiac and oncology specialists and surgeons contracting exclusively with the HMO to provide services. Network Model is an HMO that contracts
with many IPAs and other provider groups to form a "physician network." Mixed Model is a combination of delivery systems. (Patient Advocate,
2015) The mixed model would be the best model for my region. It offers the widest variety of choices and the broadest geographic coverage to its
members. Patients will often have choices of clinics, labs, pharmacies, and hospitals as their providers of care. Research and comment on the
importance and applicability of the various levels of emergency department trauma care. Investigate the exemptions afforded to a critical care rural
hospital with respect to Medicare reimbursement and accreditation. The different levels of the trauma center include... Show more content on
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Generally the installment is determined on a per member/per month (PMPM) basis. The rates are generally calculated form projections of the services
and costs of the provider's patient population, based on historic costs. The payments fluctuate to mirror the total number of patient for a supplier and
the demographic and acuity factors of the patient population. In some cases, co–payments may also be collected from embers for certain services.
Under global capitation all care is covered under the fee including primary care, hospitalizations, specialist care and ancillary

HMO Vs. NHS, Directed By Michael Moore
HMO vs. NHS HMO (Health Maintenance Organization) and NHS (National Healthcare Service) have been a controversial topic for many years. I
watched a movie entitled, "Sicko." It is a documentary that was written and directed by Michael Moore. The Documentary investigates the American
health system and compares it to the National Healthcare Service in many other parts of the world. One of the countries that have socialized medical
care sits directly above the United States. It is Canada. The horror stories I heard about the HMO has made me think twice about our health care
system. Can we honestly say that we are doing everything we can to ensure all Americans (from the bottom of the totem pole to the very top) get the
quality medical... Show more content on Helpwriting.net ...
When and if she did deny 10% or more to save the medical insurance company money. She would be promoted and quickly moved up the corrupted
corporal ladder. When she began to have a conscience and feel that what she was doing is wrong; the HMO came back with this statement, "We
are not denying care, we are simply denying payment." What a crock of horse manure. Hillary Clinton was the only one who believed Americans
should have the right to socialized medical care. Or least she was the only individual in office who had the "balls" to stand up to the oligopoly of the
HMO cartel. Of course the HMO spent over 100 million dollars defeating Hillary Clinton's health care plan. For the next 7 years Hillary Clinton was
forbidden to bring up the idea of Americans having socialized medical care. For Hillary's silence she quickly went from the HMO's worst enemy to a
devil's advocate. HMO paid Hillary Clinton $854,462 in the 2005–2006 year as an obvious reward or incentive to remain quiet. There is four times
more health care lobbyist than there is congress. That is an interesting fact. Drug companies quickly followed behind the HMO cartel. Drug
companies were buying off the congress including the President of the United States, George W. Bush; he was making an astonishing 891,208 a year
from the drug companies. In 2003 George W. Bush set what he referred to as "historic piece of legislation" into

Health Care Plan Summary
Payers impact California Pacific Medical Center marketing for health plans, which is located at the St. Luke's Hospital. Not all Sutter Health network
of providers participate in all of the health plans networks or products. A patient should contact his or her health plan if they have questions about
benefits, a particular product, or a provider network. Sutter Health, on behalf of St. Luke's network of providers, is currently in agreements with several
health plans to renew their contracts for 2017 (California Pacific Medical Center, 2015). Renewed health plans include Blue Shield, Care1st, Chinese
Community Health Plan, Cigna and Health Net. The organizations plan to successfully complete these renewals by the end of 2016, so that any
interruptions ... Show more content on Helpwriting.net ...
Chinese Community Health Plan: Amber Plan, Bronze 60 HMO (including Covered CA for Individual & Families), Bronze 60 HMO (including
Covered CA for Small Group), Gold 80 HMO (including Covered CA for Individual & Families), Gold 80 HMO (including Covered CA for Small
Group), Jade Plan, with minimum Coverage HMO (including Covered CA for Individual & Families) and other approved by physician HMO's
(California Pacific Medical Center,

Hmo Vs Hmco
The HMOs' claims and benefits administration department, on the other hand, is responsible for ensuring that all providers are paid for their services
and that health care benefits that members are entitled to are honored by the organization (Kongstvedt, 2009; Anderson & Gray, 2013).
Finance and budget
In terms of finance and budget administration, the MSO manages inventory; prepare budgets and financial statements; manage overhead and revenue;
manage accounting and auditing; payroll and benefits; inventory management for their providers. Likewise,the HMOs' finance department manages and
trace their organizations' money throughout their operational systems and the budgeting department is responsible for their medical expense and
operating expense budget. However, the health insurance companies are not involved in either the operational finances or budgeting of their contracted
physicians ("Welcome to HealthSmart MSO," 2015).
Marketing and Sales
The MSOs is responsible for business development and marketing, sales for their providers while the HMO's are responsible for the development of
their organizational marketing strategies and sales of their own products.
Credentialing and relations In addition to assisting providers with accreditation; negotiating, monitoring, managing ... Show more content on
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Conversely,the managed care, HMOs and PPOs' fundamentals principles are rooted in their ability to reduce the costs of hospitals and physicians by
providing a set of incentives and disincentives for physicians to limit their use of unnecessary medical

Why Did Hmo Come From Case Study
Where Did HMO's Come From?
In 1973 Congressional Republicans and Democrats agreed that American patients should gently but firmly be forced into managed care. That patients
do not know this fact is evidenced by public outrage directed at health maintenance organizations (HMOs) instead of Congress. But when the House of
Representatives refused to concur, it was left to the 93rd Congress to pass the HMO Act in 1973.
Just before a voice vote passed the bill in the House, U.S. Representative Harley O. Staggers, Sr., of West Virginia said,"I rise in support of the
conference report which will stimulate development of health maintenance organizations. . .
I think that this new system will be successful and give us exciting and

Chesapeake Health Plans : Hmo Financial Performance
Background Chesapeake Health Plans is one of Virginia's largest managed care organizations
(MCOs) operating. The hospital group is the state's largest not–for–profit organization and boasts an impressive performance plan, serving the
healthcare needs of approximately 8 million citizens in Virginia. Moreover, Chesapeake Health Plans was the first organization to successfully
attempt to request and obtain the highest level of accreditation from the National Committee of Quality Assurance (NCQA). Furthermore,
Chesapeake health plans are structured to provide medical plans that cover services under the HMO's, PPO's, POS, and Medicare HMO's.
Chesapeake health plans attributes a considerable portion of their net service revenue generated to their effective HMO health plans, which realized
a 46% of total revenue, while their Medicare HMO produced an impressive 39% of total revenue. Furthermore, their Preferred Provider Plan (PPO)
generated 10%, and the Point of Service Plan (POS) saw a 5% figure. This case study financial analysis will effectively assess Chesapeake Health
Plans: HMO financial performance, focusing on a competitive analysis, a cash flow analysis, clear profitability ratios, liquidity ratios, debt management
ratios, asset management ratios, operating indicator analysis, a comprehensive financial assessment of Chesapeake's financial state, as well as effective
fiscal recommendations for their organization.
Competitive Analysis Presently,

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
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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.

Hereditary Multiple Osteochondromas (HMO)
"Hereditary Multiple Osteochondromas (HMO) is a genetic condition in which people develop multiple benign (noncancerous) bone tumors that are
covered by cartilage (called osteochondromas)" (2). HMO is estimated to affect 1 in 50,000 individuals (1). The tumors "typically form at the end of
long bones and on flat bones" (1). The number, size, and location of the tumors vary between individuals (1). The tumors are not present at birth and
about 96% of individuals with HMO develop multiple by the time they are 12 years old (1). Once an individual has reached skeletal maturity, the
growth of tumors and the development of new tumors tends to stop (2). "These tumors can cause pain, limit joint movement, and exert pressure on
nerves, blood vessels, and surround tissues" (2). Multiple tumors can also "disrupt bone growth and can cause disturbances of the arms, hands, and legs,
leading to ... Show more content on Helpwriting.net ...
These genes are responsible for coding for the proteins exostosin–1 and exostosin–2. These two proteins bind together and form a complex in the Golgi
apparatus, which is a structure in cells (1). "The exostosin–1 and exostosin–2 complex modifies a protein called heparan sulfate so it can be used by
the cell" (1). When there is a mutation in the EXT1 or EXT2 gene, the heparan sulfate can not be processed correctly and becomes nonfunctional (1).
"Although heparan sulfate is involved in many bodily processes, it is unclear how the lack of this protein contributes to the development of
osteochondromas" (1). Individuals who have a mutation in the EXT1 gene have HMO type 1 and those who have a mutation in the EXT2 gene
have HMO type 2. It is estimated that a mutation in the EXT1 gene is likely to cause about "55 to 75 percent of all cases of HMO" (1). It is also
estimated that about 15% of individuals with HMO do not have a mutation in the EXT1 or EXT2 gene and it is unknown why these individuals
develop osteochondromas

Differences Between PPO And HMO
The relationship of an HMO and its physician member is to help provide a wider range health care for its patients and a wide area of services
available for its physician members. A patient must choose a primary care physician from a list of providers. The relationship with the physician
provided from the HMO is in a contract that is to deliver services to their patients for a fee. There can also be a group plan which is a HMOs contract
with a group of physicians to deliver services. The HMO organization compared to PPOs, a PPO is a variation of an HMO, and it features traditional
insurance and managed care.
The PPO gives discounts, with its doctors and hospitals that participation, and then pays a fee for services given. Patients have a list that they can
pick from for a primary physician. The patient pays a set fee per office visit and the insurance provider pays the rest. It's basically a co–payment which
depends on what type of plan they have. However, like an HMO, the PPO has to choose a physician in that network, if they don't they may be charged
a penalty. ... Show more content on Helpwriting.net ...
The principle of direct liability is an individual or business established on negligence or any results in harming or damaging to another individual or
their property. Hospitals or providers are liable for the conduct and treatments provided by their physician members. Any damage or treatment a
physician's provides is covered by the hospital. Enterprise liability is a legal matter that a related corporations or people can be held responsible for any
actions, damage or wrong

Features of Private Payer and Consumer-Driven Health Plans
Features of Private Payer and Consumer–Driven Health Plans
The following reading is to familiarize the reader with private payer plans and types of consumer–driven health plan (CDHP) accounts. Private payer
plans such as PPOs, HMOs, and Group HMOs are the most popular but there are also others to consider when making decisions on health coverage,
which are IPAs, POSs, and Indemnity plans. The CDHP accounts are made "for the consumer" and therefore consumers (patients) have a say in what
kind of plan they wish to have and sometimes consumers can build their own health plan according to their financial situations with savings account
options. After reading this information, the reader will have a clearer idea of the options available through ... Show more content on Helpwriting.net ...
The features of this type of plan are the same as a HMO except all members under this plan have no choice but to visit their specific HMO providers
and hospitals. The HMO pays the IPA for services, and then based on pre–arranged capitated rates or fees; the IPA pays the providers under this plan
(Valerius, et al 2008).
Point–of–service (POS) plans involve both HMO and PPO networks. Members have the choice of either a primary or a secondary network. Primary
networks are like HMOs, and secondary networks are like PPOs. In a POS plan, annual premiums and copayments are required from the members.
Although monthly premiums are higher, visits to non–network providers in the specialty fields are an added benefit to the member with some
coverage being provided by the POS plan. Structured as a tiered plan, the POS might pay different rates for specially designated providers, regular
participating providers, and out–of–network providers according to the plans guidelines (Valerius, et al 2008).
With Indemnity plans, all members are required to pay a premium, deductible, and coinsurance payments. This type of plan usually pays 70% to 80%
of the costs once the member's deductible has been met for the year. In some cases, deductibles are very high so that the member's premium is more
affordable. Many indemnity plans have managed care features as well as a way for payers to compete for employers' contracts and try to control costs
(Valerius, et

Hmo
HMOs: The Health Care of the Beast Many people are concerned about rising health care costs. In reaction to this, some individuals and companies
are gravitating toward the assumed lower prices of Health Maintenance Organization (HMO) health plans. HMOs spend billions of dollars each year
advertising their low cost services. While these savings look good on paper, there are many pages of small print. The explanation after the asterisk
indicates that not only do the HMOs lack lower costs, but they also short–change the patient in quality care. Much of the money spent on premiums
goes directly into the pockets of stockholders and less is then available for patient care. In addition, the main clinical decisions are made not by doctors,
... Show more content on Helpwriting.net ...
HMOs are not the only answers to cost control. Most physicians practicing in the United States consider their profession to be very much a form of art
(Kleinke). The definition of art infers that within its sphere there are many variations and preferences. After all, one should not ask Picasso to carve
like Michelangelo. Physicians too differ in their methods of treating patients. However when needless tests and procedures are done the treatment will
cost more. This is waste. Many suggest that cutting waste will lead to a cut in quality. This is not necessarily true. Consider the following: an otherwise
healthy forty–year–old male comes to a clinic complaining of a sore throat. This is a good nonspecific symptom, so naturally some tests are done.
Some blood is drawn, a culture taken, and an electrocardiogram performed. An EKG in this case is not medically necessary, but many physicians still
do not hesitate to order one. By eliminating useless procedures, lower cost can be maintained. To determine which procedures are useless, scientists
would need to perform ongoing studies of patients that fall under their investigative categories. For instance, every year about 80,00 Americans get a
carotid endarterectomy, a

Hmo In Healthcare
The management of health care insurance market is complex and it takes time to understand how it works. Choosing the right insurer for the right
person in mind with the right price takes lot of effort and explanation especially from experts who know what to do. HMO refer to as Health
Maintenance Organization. The organization has their specific network of hospital doctors and other healthcare providers who have agreed to accept
payment at a definite level for any services they provide. The plan permit HMO to retain costs in check for its members. The organization (HMO) is
one of the most popular forms of managed care networks. It is important to know that HMO enrolled 89 million according to American Association of
Health plans. One advantage

Staff Model Hmo vs. Group Model Hmo
Ashley Rassbach LP2: Staff Model vs. Group Model HMOs HMOs provide several benefits to both physicians and patients alike; however, both Staff
Model HMOs and Group Model HMOs offer different types of benefits for both. Group Model HMOs are centered around multi–specialty medical
groups that focus on the performance of the group as a whole; they tend to be a bit less structured than the Staff Model HMOs. Many Group Model
HMOs have ties to hospitals in the areas in which they practice, but are legally independent of those hospitals. New physicians to group practices must
sign a Non–Compete Clause to prevent stealing of patients and often face an entry barrier due to the reverence given to senior members of the HMO.
Staff Model... Show more content on Helpwriting.net ...
New physicians would be able to focus more on the quality of their practice as opposed to productivity due to being paid on a salary–basis in a large
organization that is better–equipped to train incoming physicians. Staff Model HMOs provide care in extensive health systems; therefore, there are
abundant resources available to physicians, both physical resources and the resource of additional physicians' minds and expertise. Each patient is
unique and has different values; therefore, each patient would be attracted to various HMOs for different reasons. Patients would be attracted to the
Group Model HMO because it is likely to be a bit more personalized because of a smaller practice and a more laid–back atmosphere. The younger
physicians in the practice would be more motivated to succeed; as a patient, that motivation is priceless. In addition, the ability of Group Model
HMOs to associate with local hospitals and other local healthcare facilities would be beneficial so that if, as a patient, you required some sort of
specialty care that your Group practice was unable to provide, you would be able to receive the necessary referral. Patients could be attracted to Staff
Model HMOs for a variety of reasons as well; because Staff Model HMOs are practiced in comprehensive medical facilities, all necessary resources are
located in one place. Unlike the Group Model, new physicians would be salaried and would therefore not feel the pressure to "push," patients

HMO Health Insurance
As a direct participant in my health insurance policy, I am insured by Humana. Furthermore, Humana is a Health Maintenance Organization.
Therefore, this particular health insurance is ran by a particular choice of a Primary Care Physician from a web of local health care providers. When
applicable, you will be referred to in–network specialists and hospitals. However, unless there is a serious or detrimental emergency occurring, HMO
plans usually does not have coverage over out–of–network care ("What Is An HMO," n.d.). When carrying an HMO type of insurance, there is less
hassle involved; this is because HMO health insurance does not require any claim forms to see a doctor. In contrast, the member of the HMO health
insurance only needs to display a card that shows proof of insurance at a ... Show more content on Helpwriting.net ...
Overall, my HMO health insurance has enabled me to become a more productive employee and more comfortable around my staff. If I was to change
something about my health insurance, I would preferably want my health insurance to cover medical expenses outside of my plan (5 Reasons an
HMO Plan Might Be Right for Your Company, 2017, p. 1). Each month, I pay minimal copayments after each medical service and an out
–of–pocket
maximum for coverage of all my medical services for the year. Before these payments, I have to pay a deductible fee to cover my health services
before my insurance company pays for anything. Regarding my research on health insurance, I will make sure to wait until I graduate from college,
relieve most of my debt, and have a family to take care of before I invest a large amount of money with little diversification. With this intention, I
would not invest in a health insurance plan to early because of the high–risk possibilities along with stacked

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

Health Insurance Research Papers
The American lawyer Elizabeth Edwards once said, "Successful health reform must not just make health insurance affordable, affordable health
insurance has to make health care affordable." There has been debate for years over health insurance. Who should get it? How much should it be to be
deemed affordable? Who gets to decide what is fair and what is not? The health care reform has been going on for decades and will continue to go on
for decades because of the vast spectrum of issues it has. Everyone wants healthcare insurance that is affordable, but also gives them the most
healthcare possible. It is hard to make everyone happy, but health insurance companies try to do what they can.
There are 3 types of managed care health insurance plans ... Show more content on Helpwriting.net ...
They have their own methods and stories of success. One of the main differences between the two is their network size. Aetna is called a nationwide
company and actually lives up to its name. Their business layout is set up in a way that they have a nationwide network of health professionals and
hospitals. On the other hand, Blue Cross Blue Shield is not actually nationwide. Yes, there is a Blue Cross Blue Shield in Florida, but this can be
completely different from the Blue Cross Blue Shield in Texas and any other state. These separate Blue Cross Blue Shields are small and independent
health insurance companies that want to use the name of the large and well–known company. Because of this, they pay a licensing fee and get to use
the trademark of Blue Cross Blue Shield. Each state has their own licenses and therefore the company is technically not nationwide. This makes Aetna
the winner in nationwide

Essay on The Problems with HMOs
The Problems with HMOs
It was no surprise when I interviewed my English class about HMOs, that out of 13 students, seven currently having HMO coverage, 77% felt HMO
healthcare inferior to traditional insurance. This group closely represents the U.S. population, as HMOs have become practically synonymous with
health care and the idea that Americans are no longer receiving the quality care they received from unmanaged plans. Managed care plans have
succeeded in dramatically cutting the rate at which medical spending in the United States has been growing. Does it matter that 100 years after
Lincoln freed the slaves that we have found another way to trade lives for money? HMOs have introduced an innovative way to provide health services:
At the beginning of the 1990s, there were nearly 600 HMOs across America and they were regarded as a practical alternative to escalating medical
costs. By 1998, it was clear that HMOs were out of control, leaving a trail of angry and neglected patients in their path. Physicians have also begun
speaking out against HMOs in increasing numbers. According to Dr. Daniel J. Esposito, the main problem with HMOs is that, "there are no economic
incentives to take care of people. The incentive is not to do anything" ("More Trouble With Managed Care" PG).
What happened? How could something, which started out so promising, have gone so terribly wrong? In a survey conducted by Harvard University in
conjunction with the Kaiser Family foundation, it was revealed that 51 percent of Americans polled believe that HMOs are responsible for the
deteriorating quality of their health care. Fifty–five percent expressed concern that HMOs were more preoccupied with cost–cutting measures than with
providing the best possible medical care for the patients they serve ("The HMOs Image Problem; Public Distrust Can be Cured By Ensuring Patient
Rights" 8). This certainly does not sound like the all–purpose solution to quality and affordable medical care the government was looking for when it
began

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

Sunnyside HMO: Servicing Ethical Dilemmas
Introduction Southside HMO serves 495,000 members throughout the eastern region of the United States. Servicing this amount of members means
that the company is providing quality health care. Given this amount of volume it is understandable that there will be concerns at times raised from
both our providers and the membership. It is essential that all issues and concerns be addressed in a professional, ethical and timely fashion while
maintaining the standard of care that our company has built its reputation on.
It has been brought my attention that some of our Sunnyside Hospital affiliated members have filed complaints that their primary care physician issued
referrals to designated specialists are not being approved. There are also complaints ... Show more content on Helpwriting.net ...
This educational plan will also be shared with our members and providers by the use of mailers, posters, and inserts.
It is my recommendation that performance measures be instituted as a means to know how to better service both the members and providers. These
measures will maintain and ensure the following (Kongstvedt, 2013): Transparency and accountability Quality improvement Education and
engagement of consumers Patient safety Research
Summary
With the implementation of the above guidelines, initiatives and protocols we will continue to provide quality health care for our members and assist
our providers with the tools needed to give their patients the care required. Our company will continue to be in compliance with all quality management
initiatives. Ultimately, our members and providers need to feel our company is not about the bottom line but the people it serves by providing quality

Comparing Universal Healthcare System with the United...
An American Healthcare Crisis Debate: Comparing Universal Healthcare System (a Canadian System) with the United States' HMO (with emphasis on
cost.)
Every single life on the surface of this earth has an equal right to existence. The life of an affluent American should not be worthier in the right to
existence than that of a poor American. Neither should is the life of a bishop be more important than that of a Muslim child. Every life is sacred and
equal. Without a healthy citizenry, no nation of people could fight enough to either demand for their freedom nor maintain the freedom that has been
already gained. It is within that context that I declare that the right to an affordable healthcare is as sacrosanct as the right to be ... Show more content on
Helpwriting.net ...
Long before the 1990s when Ms. Clinton fought for a Universal Healthcare system in America, the issue of America's healthcare had been a political
quandary. The enactment of the Republican administration's Health Management Organization Act of 1973 was a weapon meant to address that crisis,
yet, it did little to fix the problem. While the liberal Democrats are fighting for Universal Healthcare coverage for all Americans, the conservative
Republicans are fighting to maintain the current private health insurance, however, with some revamping of the system, which preserves the capitalistic
element of the status quo. The reason for the two opposing views stems from their differences in political ideologies, which theoretically is like pitting
socialism against capitalism. While the liberal Democrats' endorsement of Universal Healthcare system is socialistic in practice, the conservative
Republicans' fight to retain the private or market based plan is unarguably in support of their pro–capitalism stance. The truth, however, is that, though
almost every American believes in capitalism, yet, almost none would vote to disband the Medicare and the Medicaid programs, both of which are
socialistic. In that light, the argument of a pro–capitalist nation is negated, as we do already have a socialized healthcare program for the seniors and
the poor. Extending that concept to include

Health Care Plan For Healthcare Care
Managed care plans are the most common form of health care coverage offered in the United States today. One of the reasons that managed care
plans have become so popular is because employers are the ones footing the bills for most medical coverage. Managed Care plans work off the basic
premise that health care costs can be better controlled by controlling access to health treatments and services. The three main categories of managed care
plans is HMO, PPO, and IPA. Health Maintance Organization
Health Maintance Organization (HMO) is a type of managed care organization system, according to it provides a wide range of health insurance
services through a network of hospitals, physicians, and other health care providers having a ... Show more content on Helpwriting.net ...
In this case they should be ready to deal with referrals and pay more a substantial deductible, co–payment, or coinsurance for the use non –panel
providers. According to Mark & Mueller, (1996) "HMO members will pay premiums which is through an employer, which will be deducted from
their paycheck, some employers may pay the premium costs for you". Copayments in the other hand are received to cover medical services like
emergency expenses or specialized care. Deductibles is the amount you pay out of pocket before the HMO starts while maximum out of pocket
expenses is the maximum amount you have to pay for covered services during a certain period of time. HMO pays benefits only if you use physicians
and hospitals within the plan's network. HMO members normally do not have to file claims and wait for reimbursements.
Preferred Providers Organization
The preferred provider organization (PPO) is a combination of traditional fee–for–service and an HMO. Like an HMO, there are a limited number of
doctors and hospitals to choose from, according to Muino, (1992) "a preferred provider organization (PPO) is a health plan that has contracts with a
network of preferred providers from which you can choose". In a PPO plan you do not need to select a PCP and you do not need a referral to see other
providers in the network. If you receive care from a doctor in the preferred network you will be responsible for

Health Care History
One of the most important issues we have in America is the ability to have and receive health care, in our society, human health is one of the most
important values. This helps explain why the US spends 17% of its GDP on health care. The majority of Americans are vitally concerned about their
health, to the extent that people believe that health care institutions and finance mechanisms affect their personal health, they are vitally concerned
with these institutions and mechanisms. Many of us are also concerned about the provision and finance of health care for our fellow Americans, and
we believe that the health care system reflects the values and merit of our society. Unfortunately, many Americans have no health insurance and must
either pay... Show more content on Helpwriting.net ...
Then in 1970 there were 37 HMOs in 14 states with an enrollment of 3 million people. The HMO movement had achieved national significance, and
with that in the late 1960s and early 1970s political conservatives embraced the HMO concept as an alternative to socialized medicine. With support
from a broad coalition in Congress, President Nixon secured the passage of the HMO Act of 1973. The Act enabled individual HMOs to receive
qualifications from the federal government, and it required all employers to offer coverage from at least one federally qualified HMO to all
employees. The Act facilitate growth in HMO enrollment by helping to create several successful HMOs around the country, and it legitimized the HMO

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

Preferred Provider Organization (HMO)
Health Maintenance Organization (HMO)
An HMO delivers all health services through a network of healthcare providers and facilities. A primary care doctor to manage the care and refer to
specialists when we need one so the care is covered by the health plan; most HMOs will require a referral before we can see a specialist. The plan may
require us to pay the amount of a deductible before it covers care beyond our essential benefits. There are no claim forms to fill out.
Preferred Provider Organization (PPO)
We do not have to get a referral from a primary care doctor to see a specialist. Higher out of pocket costs if we see out of network doctors vs. in
network providers. More paperwork than with other plans if we see out of network providers.

Successful Patient Centered Medical Homes And Hmos
Successful Patient Centered Medical Homes and HMOs
Richard Jenkins
Trident University Abstract There are various models designed to enhance the quality of health care provided in today's society. Within the health care
system the objective is to provide quality care to the patient is the primary goal, however, over time due to such a strong concentration on this objective
expenses have been forgotten. Medical care has now grown to a ridiculous expense. Congress, medical professionals, administrators, and many others
are now devising various plans and models to attempt to conquer and eliminate such expenses. The patient centered medical home, managed care plans,
and accountable care organizations are just some of the ideas ... Show more content on Helpwriting.net ...
Within the health care system the objective is to provide quality care to the patient is the primary goal, however, over time due to such a strong
concentration on this objective expenses have been forgotten. Medical care has now grown to a ridiculous expense. Congress, medical professionals,
administrators, and many others are now devising various plans and models to attempt to conquer and eliminate such expenses. The patient centered
medical home, managed care plans, and accountable care organizations are just some of the ideas devised. The patient centered medical home was
developed to improve the quality of care provided within the health care system. This ideal focuses around exactly as it sounds, the patient. The
primary goals of the patient centered medical home model is to enhance primary care through means of better access, coordination of care, prevention,
quality, and safety (Smith, 2013). There are various methods used, but the most recognized is multiple care specialties operating under one physician.
Many various medical professionals and services form the patient care team within this system. The team is led by the patient's primary care physician.
The physician and care team will

Pros And Cons Of Hmo
Key information about HMO,PPO, and MCO These are all different types of organizations that are different forms of a health maintenance
programs.it's important to know the differences between all these programs and know the benefits so you the patient knows what works for you.
HMO An HMO is where you pay a certain premium every month and in return your HMO will help take care of your doctor visits, hospital stays,
emergency care, surgery, lab test, X–ray, and therapy. Pros–fixed low of pocket monthly cost –are encourage to seek medical help early before it
transcends into something worse –no limits on lifetime benefits Cons –are unable to see a specialist before seeing your primary care physician first
–are required to see treatment from HMO

Managed Care Vs Hmo Plan
HMO Plans requirements are that beneficiaries must see their health–care providers, doctors, and hospitals within the chosen plans network. With the
expectations of urgent care and emergency care situations. With an HMO plan the participants are required to have a primary care physician upon
enrolling on the plan. With these conditions; only a physicians can refer the plan holder out to see a specialist. But unlike a yearly check up that I
have recently had or my mammograms doesn't require me to be referred out. And most all of my medications are covered under the HMO plan.
On the other hand PPO plan has a managed care option for beneficiaries who decided to have a greater provider flexibility, with my PPO coverage
portion kicks in. Also

Health Care System Evolution Paper
Health Care System Evolution Paper
This paper will discuss how HMOs have influenced current health care systems. HMOs have been able to reduce health care cost in many ways and
have also faced many difficulties along the way. Many Americans years ago did not have health coverage and we are still seeing this today because of
the cost of these plans.
HMOs or Health Maintenance Organizations are health care plans that reduce health care cost. Members of an HMO are usually required to make a
co–payment when seeing a physician. A lot of time members have a deductible they will have to pay before they are able to see their physician too.
These are just some of the ways HMOs try to keep health care cost down.
There are some 75 million ... Show more content on Helpwriting.net ...
With a POS plan, members can use doctors who are within the network or those who are not in order to receive their care. If member do choose
doctors outside their networks they will have to pay more to have those services performed. With the POS plan members must have a primary care
physician. With a PPO plan members have more options over who they can see. Members do not need a primary care physician with this type of plan
(What is an HMO? 2009).
HMOs have been running strong for years but to remain viable they are going to have to make some changes. Considerable evidence points to
physician and consumer dissatisfaction with HMO's. Consumers are not satisfied with primary care physicians as gatekeepers, limited provider
choice, physician profiling, requirement of prior approval and constraints on covered treatments (Fang, Liu, & Rizzo, 2009). Studies have shown a
slight decline of the insured population covered by HMOs. In 2000–2001, 55 percent of the insured population was covered and in 2003 it dropped to
51 percent (Fang, Liu, & Rizzo, 2009).
President Obama signed into law a new health care plan that will help many Americans. With the way things were going, many people were not able to
carry health insurance and those companies that were carrying insurance had to drop coverage for many of their employees. Many doctors and big
HMO companies have made a killing over the years, and want to keep doing so. That is why many did not want to

HMO Regulation Essay
HMO Regulation Health Maintenance Organizations, or HMO's, are a very important part of the American health care system. They involve elements
such as beneficial health care programs like Medicare for seniors and Medicaid for the poor. HMO's are sometimes referred to as managed care
programs, which involves participation through clinics, physicians and insurance companies. Other essential parts of HMO's include prescription drug
plans, such as distribution and cost, and they are also important for information needed by emergency room residents in cases of emergencies. Although
HMO's are not always seen as positive and helpful institutions, they are definitely important when it comes to medical care. Most of the criticism comes
They provide the best possible treatment to their patients to get more people enrolled and to maintain current premiums paid by consumers using their
HMO's. Most HMO's are groups of doctors hired by insurance companies and are controlled or regulated by the hospitals who facilitate them. They
also limit what kind of care they receive. Most pressure comes from the government and its ability to influence hospitals to deny treatment. These
regulations are expensive and result in revision of private employee health care claims. This type of behavior results in increased spending by the public
and more people become uninsured, approximately 50 to 60 million people go without insurance for at least one month each year. Particular HMO's
face many additional problems due to attempted government control through regulations. One such institution is the United Health Group in New
York. The United Health Group said, "that it returns decision–making power over patient care to physicians on issues like admitting health plan
members to hospitals or providing other treatments." [4] This kind of decision is made to eliminate frustrating features of most doctors' work: like
getting insurance companies to approve medical decisions that the doctors think they should make. This is a problem because most hospitals are
influenced by government officials and make their decisions

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

Hmos: Summary And Analysis
Chapter 1271 of the Texas Insurance Code governs HMOs. Section D of Chapter 1271 is titled "Certain Benefits Required," and sets forth the basic
benefits that a health care plan offered by an HMO must contain. Included under Section D is Section 1271.155, which is titled "Emergency Care" and
sets forth the required coverage for emergency care. Section 1217.155(a) states that "[a] health maintenance organization shall pay for emergency care
performed by non–network physicians or providers at the usual and customary rate or at an agreed rate." Chapter 3 to Title 28 of the Texas
Administrative Code governs PPOs. Section 3.3725 provides regulations for the payment of certain out–of–network claims. Section 3.3725(a) states
that "[i]f an

What's The Difference Between A Hmo
The difference between a HMO and a PPO. A HMO is an insurance plan that that is more to accommodate your finical needs but there are
restrictions on which doctors that you can see and you also pay a fixed monthly fee, but unlike the PPO you are not required to file a claim with
your insurance provider. A PPO is a little bit more flexible, fewer restrictions, and that also comes with a higher cost. You would also be covered
under the PPO if you go outside of your insurance network plan and unlike the HMO the PPO requires that you file a claim with your insurance
provider. I would chose to go with the HMO insurance plan simply because not everybody is the richest person in the world and we all know that
money does not simply grow on trees, some

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