Utilization Management
The umbrella of prospective, concurrent, and retrospective review processes managing the appropriateness of care delivered.
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Practice This Concept
An HMO operates with a panel of physicians who are employed directly by the HMO or are under exclusive contract with it, and members must receive care from these providers. This arrangement is best described as a:
Closed-panel HMO — A closed-panel HMO delivers care through physicians who are either salaried employees of the HMO (staff model) or under exclusive contract (group model). Members must use these participating providers, which gives the HMO strong cost control through prepaid capitation and tight utilization management. An open-panel HMO, by contrast, contracts with private physicians in the community who also see non-HMO patients.
National insurance concept
Which feature is characteristic of a traditional indemnity (fee-for-service) medical expense plan?
The insured is free to choose any physician or hospital and the plan pays a stated share of covered charges after the deductible. — Traditional indemnity, or fee-for-service, medical expense insurance gives the insured complete freedom of provider choice. The policyholder selects any physician or hospital, receives the care, and the insurer reimburses a stated percentage of covered charges (typically after a deductible, subject to coinsurance and a maximum). There is no provider network, no gatekeeper, and no utilization management requirement to obtain a referral. This is the classic contrast to managed care plans such as HMOs and PPOs, which build networks and controlled access into the delivery system, and it is a core individual medical plan-type distinction in the A&H outline.
National insurance concept
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