Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 0
Chapter 11
The Blues Plans,
Private Insurance, and
Managed Care Plans
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 1
Learning Objectives
• Define a prepaid health plan (PHP).
• Identify types of managed care health
plans.
• List two types and two different
functions of foundations.
• State the provisions of the Health
Maintenance Organization Act of 1973.
• Explain health maintenance
organization (HMO) benefits and
eligibility requirements.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 2
Learning Objectives (cont’d.)
• State reasons for a quality
improvement organization.
• Define independent practice
associations.
• Name the elements of preferred
provider organizations (PPOs).
• Identify four types of authorizations for
medical services, tests, and
procedures.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 3
Chapter 11
Lesson 11.1
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 4
Private Insurance
• Blue Cross/Blue Shield
• Pioneers in private insurance
• Largest insurance company in the
U.S.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 5
Prepaid Group Practice
Health Plans
• Pioneers
• Ross-Loos Medical Group became
CIGNA
• Kaiser Permanente
• Direct contact
• Individual practice model
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 6
Health Maintenance
Organization Act of
1973
• Created authority for federal
government to assist HMO
development by:
• providing grants, loans, and loan
guarantees to offset initial operating
deficits of new HMOs that meet federal
standards.
• requiring most employers to offer an HMO
to employees as an alternative to
traditional insurance plans.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 7
Health Care Reform
•
•
•
•
•
•
growing number of uninsured
costs to employers
government deficits
rising costs of high-tech medicine
patient costs
fraud
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 8
Managed Care Systems
• Health Maintenance
Organizations
•
•
•
•
•
Prepaid group practice model
Staff model
Network HMO
Direct contact
Individual practice model
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 9
Managed Care Systems (cont’d.)
•
•
•
•
MCO
HMO
EPO
FMC
•
•
•
•
IPA
PPO
PPG
POS plan
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 10
Chapter 11
Lesson 11.2
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 11
Exclusive Provider
Organization (EPO)
features similar to HMO:
• Members must choose care from
network providers (emergency
exceptions)
• Generally, no reimbursement for
out-of-network care
• Regulated under insurance
statutes
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 12
Exclusive Provider
Organization (EPO)
features similar to PPO:
•
•
•
•
•
•
Enrolled population
Limited provider panel
Gatekeepers
Utilization management
Capitated provider reimbursement
Authorization system
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 13
Exclusive Provider
Organization (EPO)
features:
• Flexible benefit design
• Negotiated fees
• Fee-for-service payments
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 14
Foundations for Medical
Care (FMC)
• First established in 1954, in
Stockton, CA
FMC Operations
• Comprehensive type of foundation
• Claims-review type of foundation
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 15
Independent (or
Individual) Practice
Association (IPA)
• Physicians are not employees,
and do not receive salaries
• Capitation or fee-for-service
program
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 16
Preferred Provider
Organization (PPO)
• Freedom to use any physician or
hospital
• Members receive highest level of
benefits when using preferred
providers
• Coinsurance and deductibles
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Slide 17
Silent PPOs
• Also called blind or phantom
PPOs, discounted indemnity
plans, nondirected PPOs,or
wraparound PPOs
• Provider income reduced
• Complicates the appeal process
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 18
Physician Provider
Group (PPG)
• Physician owned (unlike IPA)
• Joint ventures with hospitals, labs,
etc.
• Can combine services for member
physicians, cutting business costs
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 19
Point-of-Service (POS)
Plan
• HMO cost management
• PPO freedom of choice
• Members choose services from
participating and nonparticipating
providers, with different benefit
levels
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 20
Triple-Option Health
Plans
• Members choose from HMOs,
PPOs, or “traditional” indemnity
insurance
• Members can change plans
• Cost-containment measures
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 21
Other Plans
• Provider-Sponsored Organization
(PSO)
– Owned and maintained by a hospital
or provider group
• Religious Fraternal Benefit
Society (RFBS)
– Managed care plan associated with
a church, group of churches, or
convention
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 22
Chapter 11
Lesson 11.3
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 23
Quality Improvement
Organizations
• peer review
• utilization review
• churning
• turfing
• buffing
• concurrent review
• Discuss pre-admission certification
• What do you do about insurance when
planning patient’s discharge?
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 24
Preauthorization/Prior
Approval
•
•
•
•
formal referral
direct referral
verbal referral
self-referral
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 25
Managed Care Plan
Reference Guide
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
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Plan Administration
•
•
•
•
patient information letter
medical records
scheduling appointments
encounter form
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 27
Financial Management
(Payment)
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•
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•
•
•
•
deductibles
copayments
payment mechanisms
contract payment time limits
scheduling appointments
monitoring payment
fee schedules
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Slide 28
Financial Management
•
•
•
•
•
statement of remittance
accounting
fee-for-service
year-end evaluation
explanation and coordination of
benefits
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Slide 29
Fee-for-Service
• handling accounts similarly to feefor-service
• copayment
• adjustment
• overpayment
• capitation versus fee-for-service
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 30
Regulatory
Considerations
• Individual or employer paid?
• Employee Retirement Income
Security Act (ERISA)
• liability issues
• disability issues
• state versus federal jurisdiction
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 31