Managed Care Case Study

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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 …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

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