Primary Care Physician (PCP)
The network physician managing an HMO member's care, providing referrals to specialists; usually an internist, family practitioner, or pediatrician.
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Practice This Concept
Under a capitation arrangement between an HMO and a primary care physician (PCP), the PCP is paid:
A fixed periodic fee per enrolled member, regardless of how many services the member uses — Capitation is the hallmark financing method of HMO-style managed care: the HMO pays the primary care physician a fixed monthly (per-member) amount for each enrolled member, whether or not the member uses any services. Because the payment does not rise with service volume, the PCP has an incentive to provide appropriate, cost-conscious care and coordinate referrals. This is part of the individual plan-type material (AH-III.A.1a) that contrasts the financing of HMO delivery models with the fee-for-service payment common to other arrangements. Understanding who bears utilization risk under capitation is a recurring exam distinction.
National insurance concept
A member of a Point-of-Service (POS) health plan wants to see a specialist who is outside the plan's network. Under the typical POS structure, what must the member do first?
Obtain a referral from the primary care physician (gatekeeper) before seeing the out-of-network specialist — A POS plan is a managed care hybrid: like an HMO it requires the member to select a primary care physician who acts as a gatekeeper, and like a PPO it allows care outside the network. The tradeoff is that using an out-of-network specialist ordinarily requires a referral from the primary care physician, and out-of-network care carries higher cost-sharing. Because the gatekeeper-referral mechanism is preserved, the member must obtain that referral before the out-of-network visit.
National insurance concept
- Medical ExpenseUnder a capitation arrangement between an HMO and a primary care physician (PCP), the P…
- Medical ExpenseA member of a Point-of-Service (POS) health plan wants to see a specialist who is outsi…
- Medical ExpenseA point-of-service (POS) plan combines features of an HMO and a PPO. Which statement co…
- Medical ExpenseAn HMO pays a primary care physician a fixed amount each month for every member assigne…
- Medical ExpenseA Point-of-Service (POS) health plan is best described as:
- Medical ExpenseA point-of-service (POS) health plan combines features of which two managed care delive…
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