CCMA~ Healthcare Payment Models-->Ancillary Services

fee for service

providers and medical facilities bill insurance and patients for services provided. every examination, medical service, test, and procedure has an associated procedural code and charge.

model info

patients only pay for services they use, the risk is that it can lead to unnecessary visits, tests, and procedures for the profit of those providing care

value-based plans

the goals are summarized in the Quadruple Aim

• improved patient outcomes

• improved patient satisfaction

• lower cost

• health care professional well-being

managed care

an umbrella term for plans that provide healthcare in return for present scheduled payments and coordinated care through a defined network of providers and hospitals.

capitation (partial or full)

patients are assigned a per-member, per-month payment. payment rates are tied to expected usage regardless of how often the patient visits. like bundled payment models, providers are incentivized to help patients avoid high-cost procedures and tests to maximize compensation.

health maintenance organization (HMO)

this plan contracts with a medical center or group of providers to provide preventive and acute care for the insured person. Generally require referrals to specialists, as well as precertification and preauthorization for hospital admissions, outpatients procedures, and treatments

preferred provider organization (PPO)

plans have more flexibility than HMO plans. an insured person does not need a PCP and can go directly to a specialist without referrals.

point-of-service (POS) plan

great deal of flexibility for patients. they can self-refer to specialists and do not need an assigned PCP. the cost depends on whether the providers they see are within the plan’s panel

general practitioners (GPs)

medical doctors who treat acute and chronic illnesses and provide patients with preventive care and healthy education. may take a holistic approach that considers the biological, psychological, and social aspects

family practitioners

offer care to the whole family, from newborns to older adults. familiar with a range of disorders and diseases. preventive care is their primary concern

internists

provide comprehensive care for adults, often diagnosing and treating chronic, long-term conditions, they also offer treatment for common illnesses and preventive care. may focus on pediatric or adult medicine rather than provide care across the lifespan

speciality health care services

used when a disease or diagnoses escalates beyond the area of expertise of a PCP. specialist are providers focused on diagnosing and treating diseases and disorders of specific body systems.

allergist

evaluates disorders and diseases of the immune system

endocrinologist

diagnoses and treats hormonal and glandular conditions; often works with patients who have diabetes

hematologist

blood and blood producing organs

hepatologists

studies and treats diseases related to the liver, biliary tree, gallbladders, and pancreas

nephrologist

manages diseases and disorders of the kidney

obstetrician

provides care of patients during and after pregnancy

orthopedist

injuries of the bones, joints, muscles, tendons, and ligaments

otolaryngologist

ENT doctor, ear, nose,a DNA throat

ancillary services

adds convenience for patients and increases revenue for organization. meet a specific medical need for a particular population

urgent care

provides an alternative to the ER. they cost less, have a shorter wait time and conveniently located. flexible hours and appropriate for non-life threatening acute injuries and illnesses

labroatory services

perform diagnostic testing on blood, body fluids, and other specimens to conclude a diagnoses for the provider

diagnostic imaging

machines such as x-ray equipment, ultrasound machines, magnetic resonance imagining (MRI), and computerized tomography (CT)

occupational therapy

assist patients who have conditions that disable them, debelo[mentally, emotionally, mentally, or physically. help the patient compensate for the loss of functions and rebuild to a functional level

physical therapy

assist patients in regaining mobility and improving strength and range of motion, often impaired by an accident, injury, or disease