2da parte de Cap12

Traditional Health Insurance

• Pay for all or share cost of services

• Fee-for service plans

• Flexibility for pt

• Fee schedule amounts determined by UCR

Managed Care Organizations

• Negotiate lower prices with doctors/hospitals

• pt must choose a PCP

• need referral for specialist

• preauthorization for some services

Models of Managed Care Organizations

care is coordinated through a network of providers/hospitals, HMOs, PPOs, EPOs

Health Maintenance Organizations (HMOs)

• choose PCP and stay in network

• referral required for specialist

• usually no deductible or co-insurance

• copayments for office visits/prescriptions

Preferred Provider Organizations (PPOs)

• no PCP required, out of network providers can be seen

• no referral required, preauthorization needed for expensive services

• lower deductible/co-insurance if network provider is used

• copayment required for office visits/prescriptions

Exclusive Provider Organizations (EPOs)

• must see network providers, no PCP required

• no referral needed

• usually no deductible or co-insurance

• copayments for office visits/prescriptions

Regular Referral

3 to 10 working days

Urgent Referral

about 24hrs

STAT Referral

emergencies, can be approved online

Utilization Management

care review by healthcare professionals who dont provide care, are empoyed by insurances

Utilization Review Committee

review individual cases to see if services are medically necessary

Health Insurance ID Card

• company

• plan name and type

• suscriber’s name, covered dependents

• suscriber’s id #

• copay amounts

• group #

• health plan contact #

Precertification/ Preauthorization

• call # on back of pt’s insurance ID card

• provide insurance services requested and diagnoses

• document call in pt’s health record, w/precertification #

Worker’s Compensation

• insurance for who is injured/ill relating to the job

• covers medical care/rehab, weekly income replacement, death benefits to dependents

Disability Insurance

• income replacement if pt has disability that isnt work related

• short term disability unable to work 9 to 52 weeks

• long-term when short-term benefits are exhausted, pay until pt returns to work or until specified

Life Insurance

provide specified amount upon insured’s death either to their state or to designated beneficiary

Long-term Care Insurance

cover broad range of maintenance/health for chronically ill, disabled, delayed developmentally; inpatient or outpatient

Liability Insurance

cover loss to a third party caused by the insured (automobile, bussiness, homeowners)

Affordable Care Act

works to reduce overall healthcare spending in the long run