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Ch 11 Study Packet

Health Care Reform, IPA-PPO-POS, 3 Managed Care Organizations, & Definitions

QuestionAnswer
Capitation Payment in which physicians & hospitals are paid a fixed fee over a period of time
Carve Outs Medical services that are not in the managed care contract and may be contracted separately
Network Facilities Managed care plans that require laboratory and radiology tests performed at plan specific facilities
Utilization Review Reviewing and establishing necessity of medical care resources
About an IPA Plan It is the most rigid. You can only stay within the network. And it is a fix-fee for service
About a PPO Plan You can choose to stay in and out of the network. If you stay in the network, it is cheaper.
About a POS Plan This is a combo of the IPA and the PPO Plan. It has a larger network and it offers the flexibility, but more discounted services
Forces & Trends towards Health Care Reform in the US. (part 1) 1Not every one has Ins. because cant afford it or dont see the value. 2Expensive for businesses-premiums are too high. Thats where it goes back to the individual paying for it. 3Different plans to Different treatment like medication/technology.
Forces & Trends towards Health Care Reform in the US. (part 2) 4Medical Malpractice-Defensive Medical. 5Fraud and Insufficiency
Managed Care Organization' structure or administration that are designed to contain costs while delivering health care services to subscribers. How do these issues affect the medical office? 1Preauthorization (1for coverage 2If it is medically necessary for physician Ins) 2Facility Patient go to (the Network and what the options are) 3Scheduling Issues (record/info. system, financial system)
Created by: lorireid1980
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