Summary Financial Resource Management in Healthcare – C428 Final Paper

Document Content and Description Below

Financial Resource Management in Healthcare – C428 Final Paper A1. Fiscally Sustainable Strategies A financially sustainable strategy that can be discussed is switching from a fee-for-service ... plan to a managed care plan. There are three different types of managed care organizations: • Health Maintenance Organizations (HMOs) • Preferred Provider Organizations (PPOs) • Point-of-Service Plans (POS) HMOs are the most common type of managed care organizations. HMO’s are business engagements between physicians, insurers, and hospitals. HMOs usually have little to no deductible and low-cost premiums, however HMOs are restrictive in when and whom the patient can see for care. HMO’s require patients to pick a primary care provider (PCP) innetwork and see that provider for all their care. If a patient wants to see a specialist, they need to first get a referral from their PCP. HMOs keep costs low by restricting whom the patients can see as all services are kept within the network and out-of-network visits are usually denied passing the whole cost onto the patient, except for emergency care. Preferred Provider Organizations are another common managed care organization that is growing in popularity. Healthcare insurers contract with a large network of providers and hospitals to create the preferred provider network. With PPO insurance, you’ll have access to more doctors, specialists, clinics, hospitals, and other healthcare facilities. You will not be required to select a primary care physician, although it is highly recommended that you do, and you do not need physician generated referrals to see a specialist. To provide such flexibility and the greater pool of providers and facilities, a PPO with generally have much higher premiums 1 / 2 Financial Resource Management in Healthcare – C428 Final Paper deductibles, and copays than an HMO. PPOs will also usually cover out-of-network care but at a discounted rate, commonly around 60-70% with the other part being the responsibility of the patient. Point-of-Service plans are a hybrid of the previous two plans, as with the HMO patients must choose and in-network primary care provider but can choose to receive care outside the network as well. POS plans will pay less for out-of-network appointments, but more if you are referred to an out of network provider by your PCP. For example, you have a POS plan that pays 80% of an in-network visit, 60% for out-of-network visits, and 75% of out-of-network visits that your primary care provider referred you to. You get the benefits of lower premiums like the HMO, but the flexibility of choosing your providers like a PPO. A1a. Recommended Strategies Determining which plan to move to in the future, Seamus Company must examine the costsavings, tax implications and advantages and general fiscal management improvements that each managed care organization (MCO) presents. Seamus Company must also balance such cost savings benefits with the quality of life improvements, or lack thereof, that may come with each plan. In looking at the 3 different plan options with switching to an MCO, in terms of sheer costsavings the HMO is the better plan. HMOs have much lower deductibles that both the PPO and POS plan, decreasing the portion of costs that Seamus Company is responsible for. Every plan discussed however will bring a lower cost responsibility for Seamus Company in terms of deductibles and fixed premiums. With large HMOs and PPO plans the insurance companies will [Show More]

Last updated: 2 years ago

Preview 1 out of 10 pages