Managed Care
Health coverage systems controlling cost and utilization through contracted networks, primary care gatekeeping, utilization review, and provider risk-sharing - HMO, PPO, EPO, and POS designs.
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Practice This Concept
A point-of-service (POS) health plan combines features of which two managed care delivery models?
HMO-style gatekeeper coordination with PPO-style out-of-network coverage — A POS plan merges the two dominant managed care models: it uses an HMO-like primary care physician (PCP) who coordinates care and issues referrals within the network, while also permitting members to seek care from out-of-network providers, usually at a higher deductible and coinsurance level. The gatekeeper element keeps utilization and cost down, while the out-of-network option adds member flexibility. Under the examination outline for individual medical plans (AH-III.A.1a), POS plans are classified alongside HMO, PPO, and EPO as a distinct delivery type, so recognizing this hybrid structure is a tested point.
National insurance concept
The managed care process that requires a physician to obtain the plan's approval before admitting a patient to the hospital is called:
Precertification, also called pre-admission certification — Precertification, also known as pre-admission certification or prior authorization, is a utilization review step in which the insurer or managed care organization approves a proposed hospital admission, procedure, or treatment before it occurs. If the member does not obtain precertification, benefits may be reduced or denied. Utilization review tools are used by managed care plans to control costs and ensure that care is medically necessary, appropriate, and provided in the most cost-effective setting.
National insurance concept
- Medical ExpenseA point-of-service (POS) health plan combines features of which two managed care delive…
- Medical ExpenseThe managed care process that requires a physician to obtain the plan's approval before…
- Medical ExpenseA point-of-service (POS) plan is best described as a managed care model that:
- Medical ExpenseA point-of-service (POS) plan is best described as a managed care arrangement that:
- Medical ExpenseA point-of-service (POS) plan blends features of which two managed care arrangements?
- Medical ExpenseWhich managed care technique controls health care costs by evaluating the medical neces…
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