HMO Network Analysis

HEALTH MAINTENANCE ORGANIZATION (HMO): An alternative to traditional insurance programs that consists of a medical center or group of providers who will provide medical services to subscribers for a fixed monthly or annual premium. HMO plans have a plethora of rules for deductible amounts, coinsurance, and copayments. They offer unlimited medical attention to subscribers, which means they also encourage preventative healthcare services, and the subscriber chooses a primary care physician (PCP), who manages a member’s health care. HMO’s enter into contractual arrangements with healthcare providers and form a provider network, and the members must see providers solely from this network if they have their health care paid for by HMOs. HMOs are
They give their subscribers a list of the providers they work with, and if the member receives treatment from someone not in the PPO network, they must pay the difference between the PPO’s rates and the outside provider’s rate. Thus, they differ from HMOs in that they do not have PCPs and members do not have to use in-network providers, but they are encouraged to do so though financial incentives (i.e. lower deductibles, lower copayments, and higher reimbursements). PPOs are less restrictive than HMOs in terms of the choice of healthcare providers for members, but they usually require greater out-of-pocket payments from
EPOS are priced lower than a PPO to the employer, but EPO’s premiums are usually more expensive than an HMO’s premiums.
INDEPENDENT PHYSICIAN ASSOCIATION(IPA): A group model HMO represents providers who have formed an organization to provide prepaid health care to individuals and/or groups who purchase the coverage. Subscribers must solely use the affiliated members of the IPAs.
PHYSICIAN-HOSPITAL ORGANIZATION (PHO): Physicians working with hospital to create an integrated medical system for patients, which then makes arrangements for insurance with a commercial carrier or HMO.
SELF-INSURED PLAN (SIP): A health plan in which the payer is an employer or other group, the employer may contract with an organization to manage and pay the claims for the employees’ medical services. Self-insured plans are overseen by the Employee Retirement Income Security Act (ERISA) at a federal level, regulating all MCOs that have been contracted as third-party administrators for a self-insured employer. Medical office specialist have to recognize the type of MCO policy and its specific