Key Differences Between Traditional Indemnity Insurance And Managed Care

As far as insurance plans go, generally there are three plans a patient will have, they are Health Maintenance Organization (HM0), Preferred Provider Organization (PPO) and Point-of-Service (POS).

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

In order to, differentiate between utilization management and case management using the seven case management standards, it is first important to define each individual component. To begin with, a key component of quality and cost effective care is Utilization Management (UM). Utilization management is a way to assure that the appropriate care is medically efficient, a suitable use of health care services, proper procedures, and is applicable with provisions aligned in the health benefits plan. Case Management engages quality services in a timely coordination of patients’ specific needs in an approach that promotes positive outcomes by means that are cost effective. Case management may be developed during a single health care setting that may then transition throughout the care continuum. The seven standards are key components that described to maximize benefits and minimize the opposition.

It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical

Managed care organizations should have arrangement with both the medical insurers and providers to provide treatment for a contracted rate. Hospital should advertise the services they offer to members of healthcare plans through their healthcare provider by emphasizing on the technology, staff, and other quality of care they provide. Worker compensation plans are similar to commercial plans but treats injured employees. Hospital must contract with all workers compensation plans and must also negotiate coordination of benefits with other insurance carriers of the injured person to full compensate services. For Self pay patients hospital can reach out to them by having pre negotiate rates for treatment when payments are made in advance for certain procedures. Hospital should have system to accept payments when made in any

Revenue determination is an important tool for health care organizations because it allows for efficient management of payment systems. This paper will look at the different components that form the payment-determination bases of revenue determination. Moreover, the difference between specific and bundled service payments will be discussed. Lastly, the three ways health care providers control their revenue function will be highlighted.

This assignment will critically analyse and justify the decisions based around a fictitious patient using a clinical decision making framework highlighting its importance to nursing practice. The chosen model will demonstrate clinical decision making skills in the care planning process. The patient’s condition will be discussed in-depth explaining the pathophysiology, social, cultural and ethical issues where appropriate in the care planning and decision making process. Any vulnerability that the patient may experience will be discussed and dealt with in the care planning and decision making process. The supporting evidence based literature will be analysed and

Depending on the insurer and the type of service provided, third-party payers pay providers by different means

Patients seek medical attention for preventative measures, as well as, diagnostic measures. Patients must have a trusting rapport with their collaborative medical team, as the nurses and the doctors are the people who they trust their lives with. Patients do not always present to hospitals, urgent cares, walk-in clinics, or even doctor’s offices only when they are sick; patients visit to ensure their good health will continue, treatment regimens are of benefit, changes that may be needed in regimen. When someone thinks of a patient they may think of some of these characteristics: illness, disease, hospital, medications, health, and prevention.

What I understand of case management is that it helps Social Workers in helping their clients, meaning social workers take actions to manage the various aspects of cases they are working on. Case management is also a shared process of assessment, planning, facilitation and advocacy for decisions and services to meet an individual’s need through communication and available resources. Case management examines the person’s physical, emotional, environmental state, and promotes quality and cost-effective outcomes. In addition, in Case management the worker helps to empower the clients to become self-sufficient. Moreover, Case management is structure into six principles

Patient's decision-making is influenced by several factors. Patients may change their decisions, from accepting or refusing treatment depending on the available treatment options. The capacity of the individual to make informed medical decisions can differ as the patient's status changes cognitively, emotionally, and/or physically and as the proposed treatment interventions change. Treatment refusal is a common situation faced by clinicians. Patients do not usually refuse the medical advice if the advice is of good intention. When patients refuse an advice, it indicates some underlying reasons related to the patients or family, factors associated with the physician as well as social and organizational issues.

Managed care is the most dominant healthcare delivery system in the United States and available to most Americans. Employers and government are the primary financiers of managed care. The managed care sector includes approximately

Bundled Pricing: As quoted by Zezza, Guterman and Smith in 2012, “In this type of payment system, a single payment is made for an episode of care—a defined set of services delivered by designated providers in specified health care settings, usually delivered within a certain period of time, related to treating a patient’s medical condition or performing a major surgical procedure.” Encouraging the physicians, hospitals to work together and coordinate the care of patients, to decrease re-hospitalizations, to improve the transition of care and to ensure proper care delivery after discharge is the ultimate goal of this payment plan (Zezza et. al., 2012).

There are many illnesses and diseases causing people to have a poor quality of life. Diseases such as diabetes (type I and II), are increasing in alarming numbers due to poor management by both healthcare teams and patients. According to Wikipedia (2009), the role of case manager was implemented to help coordinate a patient’s care to both improve continuity and quality of care. Assigning case managers to individuals with diabetes significantly reduce emergency room visits, blood sugar levels, and secondary

According to IC & RC, Case Management is defined as, “activities intended to bring services, agencies, resources, or people together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contacts” (Herdman, John W., 6th Ed.). Case management is a concerted effort of various professionals in the human social services network that assess’, plans, implements, coordinates, monitors and evaluates options required to meet the client’s health and human service needs. It is characterized by advocacy, communication, resource management and promotes quality cost-effective intervention outcomes. The Case Management Process centers on the client and the client’s support system. It is holistic in its approach to the management of the client’s individual and specific situation and that of the client’s support system. It is adaptive both to the case manager’s practice setting and to the healthcare setting in which the client receives services. Case management is not a profession unto itself however; it is a cross-disciplinary and interdependent specialty practice within the health and human services profession. Everyone directly or indirectly involved in healthcare benefits when healthcare professionals and