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Cards In This Set
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1.1 Managed Care
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1.1 well managed- accessible, timely, with continuity
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1.2 Essence of Value
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1.2 Quality of Care and Service + Outcome / Cost
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1.3 Staff Model
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1.3 Physicians are employees of HMO
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1.4 Group Model
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1.4 HMO contracts physicians who are employed by the group. Ex. Kaiser Permanente
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1.5 Network Model
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1.5 HMO contracts with more than one group practice.
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1.6 Independent Practice Association (IPA) or Organization (IPO)
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1.6 Corporation created and operated by a group or association of private physician providers who contract out services for one or more health plans. Compensated on a capitation basis by HMO. IPA's compensate practitioners by discounted fee for service or combination of FFS and primary care capitation.
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1.7 Mixed Model
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1.7 Combination of IPA's medical groups, staff physicians, individual physicians under contract with HMO.
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1.8 Foundation Model
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1.8 Non-profit corporation that owns the health plan...
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1.9 Direct Contract Model
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1.9 HMO contracts directly with individual physicians; greater financial risk is assumed by HMO.
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1.10 Open-access model
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1.10 HMO permits self referral to specialist in the approved network of the contracted group for a higher co-payment.
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1.11 PPO Characteristics
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1.11 Does not accept capitation risk. Has selective provider panel. Direct Contracting. Negotiated payment rates. Utilization management and claims review with controls. Consumer choice.
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1.12 PPO Models
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1.12 Provider-sponsored plans
Carrier-sponsored plans
Broker Model
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1.13 Consumer-Directed Helath (CDH) Plan
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1.13 PPO model with more benefit choices; lower premium, high-deductible health plan with savings option.
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1.14 Point-of-Service (POS) Plan
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1.14 Open-ended plan with a hybrid option to choose between HMO, PPO, and indemnity-style benefits at the point of care. Enrollee may choose outside HMO provider network without referral authorization.
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1.15 Fee-for- Service (FFS)
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1.15 Reimbursement based on actual costs or charges using UCR (usual, customary, reasonable) charge scales.
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