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Chapter 11 power point HIT 212
- 1. The Blue Plans, Private Insurance and Managed Care Plans Chapter 11
- 2. Healthcare Reform Cost of healthcare High tech equipment Expensive medications Uninsured Americans Fraud Inefficency
- 3. Managed Care Systems EPO “Exclusive” Regulated by insurance statutes FMC Member physicians bill foundation directly Reimbursement is proportional to number of medical services delivered
- 4. Managed Care Systems IPA Contractual arrangement to treat HMO patients Discount of up to 30% PPO Coinsurance requires patient to pay 20-25% of allowed amount “network discount applied” Pre-certify
- 5. Managed care Systems PPG Flexible Portion of physician income covers joint expenses Physician owned POS Primary care Physician Use network Providers
- 6. Quality Improvement Organization Medically necessary, appropriate and meet standards of care AKA Professional or Peer Review Organizations Review and recommend action
- 7. Utilization Review/Management Appropriate and efficient use of resources Cost effective manner
- 8. Preauthorization/prior approval VERY IMPORTANT! Unknown to patients Must be medically necessary service ALWAYS CALL!