Managed Care Overview - Assignment Example

Managed Care Overview March 12, Managed Care Overview Managed care can be provided through six different models or techniques, ly: Health Maintenance Organization (HMO), Independent Practice Association (IPA), Preferred Provider Organization (PPO), Point of Service (POS), Private Fee-for-Service (PFFS) and Indemnity Insurance Plans. The basic function of all these types of managed care organizations is to reduce costs of medical care provision and enhancement of the quality of medical care. HMO has gatekeepers known as Primary Care Physician (PCP) who are responsible for taking care of all the members, referring to specialists and authorize in non-emergency hospitals.

The members can change the providers by filling the form and submitting it to the HMO. IPA, on the contrary, provides assistance to HMO by way to legally contracting with physicians to provide their services to its members. PPO provides a network of physicians that is accessible to the HMOs or IPAs to connect with and charge a fee for it. POS is an upgraded plan that has elements of each of HMO, IPA and PPO. However, it is flexible as the members are allowed to use the services or move to another choice of service.

PFFS is a combination of managed care and health insurance. They include a large number of physicians and hospitals and they are all paid for their services. The member however, has to choose the plan they want depending upon their needs and budget. HMO is more traditional and has set rules as it is based on Health Maintenance Organization Act of 1973. IPA and PPO both work as network providers to HMO members. POS and PFFS both are flexible plans in terms of budget plans to its members. The managed indemnity plan also now includes managed care in the shape of certifications to the admissions in non-emergency situations as well as utilization reviews.

The patient can take a second opinion in case of doubt by informing the provider and making a formal request for it if it is included in the grievance policy (‘USAMCO’, 2013). The insurance card requires particulars of the applicant, any licenses or previous attachment with any provider, health related certifications and identity proofs through mail. In case a provider wants to quit the service of providing access to managed care to the members, it can under the HMO Act, 1973 file the related form and request for closing the provision of service (‘FAQ’, 2013).

In PFFS, the providers make payment to physicians once the service has been provided. A formal letter detailing the problem that provider is not accepting the guidelines or fee schedules is an acceptable method to communicate members problems. I would facilitate the relationship between patient and provider by managing the communication between the two and clarifying any problems that arise in the process to close the deal in a successful manner beneficial for both parties.References‘USA MCO’, (2013).

Quality of care. Retrieved March 15, 2013 from http://www.usamco.com/grievfile.htm‘FAQ’, (2013). FAQ. Retrieved March 15, 2013 from http://www.usamco.com/faq.htm