Hosam Mohamed-
HMOs
-offer comprehensive health care services to members for a fixed monthly fee by contracting with or employing physicians, hospitals, and other health care professionals to provide medical care to enrollees.
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a, c, e
In regards to HMOs, select all that applies:
a. coverage outside of network is not covered
b. patients are fined if they use providers outside of network
c. utilizes a gatekeeper (PCP) to coordinate medical needs
d. coverage outside of network is covered, but costs more
e. providers are placed at financial risk in some capacity
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staff model
_______ is a type of HMO characterized by direct ownership of healthcare facilities and direct employment of physicians.
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physicians can only provide care to patients in HMO they are contracted with; staff model
Describe a closed panel plan and which type of HMO does this fall under?
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c
Which form of HMO covers the physicians salaries?
a. Group model
b. Network model
c. staff model
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Group Model
- a type of HMO characterized by contracts with large, multispecialty groups offering services exclusively to the HMO on a capitated basis
-physicians are not paid on salary, instead take on financial risk through contracts
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Network Model
-contracts with several large multi-specialty groups for services
-open-panel
-networks receive payment under capitation and they, in turn, pay physicians under a variety of mechanisms
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Independent Practice Association (IPA)
-usually a very small group of physicians or an independent practice
-can see patients not enrolled in HMO
-for patients under HMO, providers may be reimbursed on discounted fee-for-service
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Open Access HMO
-members may access any provider in the HMO without going through a PCP
-physicians share at least some level of risk for costs
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Preferred Provider Organizations (PPO)
-affiliations of providers that seek contracts from insurance plans
-usually have nonexclusive arrangements with PPO; can see patients from other plans
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financial incentive
PPO provide ________ to patients so they will receive care from providers in the preferred network.
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HMOs
What is typically seen as more restrictive by patients, PPOs or HMOs?
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Point of Service Plan (POS)
-functions similarly to HMO in that you pick a PCP who manages and coordinates your care within network.
-different in that each time you need health care you can either decide to stay in or out of network
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managed health insurance
-includes traditional indemnity and service benefit plans that utilize cost controls
-employers are moving away from plans like this
