1. Who are the first, second, and third parties in healthcare situations? The first party is the patient himself or herself or the person, such as a parent, responsible for the patient’s health bill. The second party, often called providers is the physician, clinic, hospital, nursing home, or the healthcare entity rendering the care. The third party is the payer, and uninvolved insurance company or health agency that pays the physician, clinic, or other secondary party provider for the care or services rendered to the first party. 2. Compare the UCR and the CPR payment systems.
The usual, customary, and reasonable (UCR) is one version of discounted fee-for-service payment method. The UCR is a type of fee-for-service payment method in which the third party payer pays for fees that are usual for the individual providers practice, customary for the community, and reasonable for the situation. Customary, prevailing, and reasonable (CPR) is another version of discounted fee-for-service payment method in which the third-party payer pays for fees that are customary, prevailing, and reasonable. They are both based on data from past claims, and are becoming rare. 3. Describe the two purposes of managed care.
Reducing the cost that third-party payer must reimburse the providers for healthcare is one of them, for example, having patients obtain prior approval for surgery. Ensuring continuing quality of care is the second by providing one primary care provider to coordinate all aspects of healthcare. 4. Why have many insurers replaced retrospective health insurance plans, with group plans such as HMOs and PPOs? To help control the cost, with HMOs you have a fixed rate for the coverage you received for medical care and with PPOs you have a primary care provider that manages your healthcare and quality of the healthcare you receive. Both HMOs and PPOs have a prepaid health plan and physicians that are under contract with an organization. 5. What are advantages of...
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