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The Blue Plans, Private Insurance and Managed Care Plans
CHAPTER 11
HEALTHCARE REFORM
Cost of healthcare
High tech equipment
Expensive medications
Uninsured Americans
Fraud
Inefficency
MANAGED CARE SYSTEMS
EPO
“Exclusive”
Regulated by insurance statutes
FMC
Member physicians bill foundation directly
Reimbursement is proportional to number of medical services delivered
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
MANAGED CARE SYSTEMS
PPG
Flexible
Portion of physician income covers joint expenses
Physician owned
POS
Primary care Physician
Use network Providers
QUALITY IMPROVEMENT ORGANIZATION
Medically necessary, appropriate and meet standards of care
AKA Professional or Peer Review Organizations
Review and recommend action
UTILIZATION REVIEW/MANAGEMENT
Appropriate and efficient use of resources
Cost effective manner
PREAUTHORIZATION/PRIOR APPROVAL
VERY IMPORTANT!
Unknown to patients
Must be medically necessary service
ALWAYS CALL!