Chapter 11 The Blue Plans, Private Insurance, and Managed Care Plans

1. Insurance Handbook for the Medical Office 13th edition Chapter 11 The Blue Plans, Private Insurance, and Managed Care Plans

2. Insurance Plans State the difference between a traditional indemnity insurance plan and a managed care plan. State the provisions of the Health Maintenance Organization Act of 1973. Explain health maintenance organization benefits and eligibility requirements. List features of an exclusive provider organization. List two types and two different functions of foundations. Lesson 11.1

3. Insurance Plans (cont’d) Define independent practice associations. Name the features of preferred provider organizations. Explain the features of a point-of-service plan. Explain how the Employee Retirement Income Security Act affects managed care insurance. Lesson 11.1

4. Private Insurance • Blue Cross/Blue Shield • Pioneers in private insurance • Largest insurance company in the U.S.

5. Prepaid Group Practice Health Plans • Pioneers • Ross-Loos Medical Group became CIGNA • Kaiser Permanente • Direct contact • Individual practice model

6. Health Maintenance Organization Act of 1973 • Created authority for federal government to assist HMO development by: • Providing grants, loans, and loan guarantees to offset initial operating deficits of new HMOs that meet federal standards • Requiring most employers to offer an HMO to employees as an alternative to traditional insurance plans

7. Health Maintenance Organizations • Prepaid group practice model • Staff model • Network HMO • Direct contract model

8. Exclusive Provider Organizations • Features similar with HMO • Members must choose care from network providers (emergency exceptions) • Generally, no reimbursement for out-of-network care • Regulated under insurance statutes

9. Exclusive Provider Organizations • Features similar to PPO • Enrolled population • Limited provider panel • Gatekeepers • Utilization management • Capitated provider reimbursement • Authorization system

10. Exclusive Provider Organizations • Features • Negotiated fees • Fee-for-service payments

11. Foundations for Medical Care • Foundations for Medical Care (FMC) First established in 1954, in Stockton, CA • FMC operations • Comprehensive type of foundation • Claims-review type of foundation

12. Independent Practice Organizations • Physicians are not employees, and do not receive salaries • Capitation or fee-for-service program

13. Preferred Provider Organizations • Freedom to use any physician or hospital • Members receive highest level of benefits when using preferred providers • Coinsurance and deductibles

14. Silent Preferred Provider Organizations • Also called blind or phantom PPOs, discounted indemnity plans, nondirected PPOs, or wraparound PPOs • Provider income reduced • Complicates the appeal process

15. Physician Provider Groups • Physician owned (unlike IPA) • Joint ventures with hospitals, labs, etc. • Can combine services for member physicians, cutting business costs

16. Point-of-Service Plans • HMO cost management • PPO freedom of choice • Members choose services from participating and nonparticipating providers, with different benefit levels

17. Triple Option Health Plans • Members choose from HMOs, PPOs, or “traditional” indemnity insurance • Members can change plans • Cost-containment measures

18. Employee Retirement Income Security Act • Regulates all managed care insurance paid by the employer or supplemented by the employee • 85% of claims that are non-Medicare/Medicaid/workers’ compensation • Regulated by Department of Labor • Any case relating to employee benefit plans (EBP) falls under federal jurisdiction

19. Medical Review and Management of Plans State reasons for a Quality Improvement Organization program. Define a carve out. Identify four types of referrals for medical services, tests, and procedures. State the purpose of creating a managed care plan reference guide. Describe types of payment mechanisms used for managed care plans. Lesson 11.2

20. Quality Improvement Organization • Peer review • Utilization review • Churning • Turfing • Buffing

21. Management of Plans • Contracts • Carve outs • Medical services not included in the contract benefits • Paid on a fee-for-service basis

22. Plan Administration • Patient information letter • Medical records • Scheduling appointments • Encounter form

23. Preauthorization or Prior Approval • Formal referral • Direct referral • Verbal referral • Self-referral

24. Managed Care Guide

25. Financial Management • Payment • Deductibles • Copayments • Payment mechanisms • Contract payment time limits • Monitoring payment

26. Financial Management • Statement of remittance • Accounting • Fee-for-service

27. Financial Management • Year-end evaluation • Withhold • Capitation versus fee-for-service

28. Questions?