Review managed care contracts for different payment plans (PPO, HMO, Fee for ser
ID: 138711 • Letter: R
Question
- Review managed care contracts for different payment plans (PPO, HMO, Fee for services, etc.) and describe provider incentives and risks under each of the following reimbursement methods:
- Cost-based
- Charge-base (including discounted charges)
- Per procedure
- Per diagnoses
- Per diem
- Global pricing
- Capitation
- Review managed care contracts for different payment plans (PPO, HMO, Fee for services, etc.) and describe provider incentives and risks under each of the following reimbursement methods:
- Cost-based
- Charge-base (including discounted charges)
- Per procedure
- Per diagnoses
- Per diem
- Global pricing
- Capitation
Explanation / Answer
* Different payment plans
* PPO (Prefered provider organization)
It is a type of plan included in medicare part C and it given by a private insurance
company.accourding to this plan if you approach doctors,hospitals included in
this plan less payment is needed and payment is more if approach doctors and
hospitals outside of plan.
* HMO ( Health maintainance organisation)
* It include variety of health care services focus on a large population and this plan
covered only if you see doctors and hospitals inside of plan coverage.
* Fee for services
* This plan give payment seperately for each service and fee based on quantity
rather than quality.
Providers incentives and risk in following reinbursement methods are
a) Cost based
In this method provider give payment as per cost of care of patients in hospital
if cost of care is higher provider needed to pay higher amount and if less then
pay low amount.
b) Charge based (including discount charges)
* In this method payment by provider based on billed charges and they use
methods like bargaining,discount when paying more patients at same time
to reduce charges.
c) Per procedure
*In this unique payment for each procedure and used commonly in the
outpatient setting which help the provider to reduce pay total high cost
of care.
d) Per diagnosis
* In this provider paying based on patient diagnosis otherthan procedure
but in some diagnosis like cancer,organ failure cost is higher compared
other diagnosis.
e) Per diem
* In this payment given by provider per day for health services and providers
have a risk of different rate per day in different units.( Icu,dialysis etc).
f) Global pricing
* In this payment given by provider for services over a period of time and
providers may need to pay higher amount if surgery and other costly
procedures happended during that period of time.
g) Capitation
* This payment method is similar to global pricing in this provider give
payment for services for a month or weeks and providers have risk of
spend more money if high level of services provided in short time.
eg:Payment given for patient who seek treatment three month in CCU.
.
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