Managed Care Case Study

1. There are two main types of third party payers: private insures and public programs. Private payers sell insurance as a product in order to invest into health benefits, where the provider gets paid for the delivered healthcare service. Commercial insurers, Bleu Cross Blue Shield and self-insures are the main private insures in the country. BCBS is a set of independent companies that are required to follow the rules of the main nationwide association in order to be part of it. Commercial insures is delivered by companies who were created specifically to sell healthcare insurance. Both BCBS and commercial insures have coverage under group policies. Self-insurance is offered either by employers or organizations that set and gather the premiums and carry accountability for the expenses the payee spends on healthcare service. The main insurer of public insurance is the government. The major public programs are Medicaid and Medicare. Medicaid is the program that allows families, individuals and other specified categories of people to have low-cost or free coverage of health service. Medicare is the government health insurance that is available for individuals 65 or older, younger people with disabilities and individuals who suffer from End – Stage Renal Disease. 2. Managed care is the system of health care where the insurer and health provider collaborate with each other in order to reduce the cost of care and improve the quality of health care. Managed care established, as a reaction to unmet financial and public needs. In 1920’s the second-party payment system run into the problem when patients who obtained health care service couldn’t afford to pay the bill afterwards. The first prototype of managed care was introduced by Baylor University Hospital, back to 1929, which provided its instructors with $6 per year prepaid hospital care. The major development of managed care began in 1973 when President Nixon signed the Health Maintenance Organization Act, which guaranteed funding for eligible HMO’s. Managed care extended the financial risk that was shared by patient and provider, where healthcare providers became part of the financial risk – sharing. New health programs were introduced as well. At that time managed care developed more clear aspects, which explained the benefits that were covered, …show more content…
The primary characteristics of managed care are the following: utilization review, underwriting, claims administration. Managed care plans control the cost of health services using utilization management, by evaluating the appropriateness of medical services under the requirements of the health plan. Managed care plans take risk, buy paying for medical services that are not definite on the time individual get insured. It is required for health plan to validate that the coverage for medical services is active and it was provided to the patient, as well as to the expanse was paid for the services. Managed care is also characterized by requirements of using providers in the network, prepaid premiums and promoting preventive care
4. There are main types of managed care plans: HMO, PPO and point – of – service. Health maintenance organization provides its members health benefits where individual have to pay monthly premium in order to use the benefits. In order the benefits to be covered by HMOs (unless it’s an emergency service) the patient must use health provider within the network. Copay may or may not be require for visit to health service provider. HMOs also offer preventive