Health And Medical Insurance – Comparing Managed Care Health Plans

Medical Insurance programs have been forced to take action to contain expenses  of quality heathcare delivery as heathcare expenses  have skyrocketed. Medical Insurance premiums, deductibles and co-payments have steadily increased, and health care insurance businesses have implemented certain strategies for reducing heathcare expenses . “Managed care” describes a group of stratgies aimed at reducing the expenses  of heathcare for health care insurance businesses.

There are two basic kinds of managed care plans; health maintenance organizations, or HMOs, and preferred provider organizations, or PPOs. So which health insurance plan is best? How do you select what kind of health care insurance best suits the heathcare needs of you and your family?

Both HMOs and PPOs contain expenses  by contracting with health providers for reduced rate on heathcare services for its’ members, often as much as 60%. One important difference between HMOs and PPOs is that PPOs often will cover the expenses  of care when the provider is out of their network, but generally at a reduced rate. On the other hand, most HMOs offer no coverage for heathcare services for out-of-network providers.

Both Health Maintenance Organization (HMO) and PPOs also control heathcare expenses  by use of a gateway, or primary care provider (PCP). Medical Insurance policy members are assigned (or select) a primary care practitioner (physician, medical provider assistant, or nurse practitioner). generally a family practitioner or internal medicine medical provider for adult members or a pediatrician or family care practitioner for childern. The primary care provider is responsible for coordianting health delivery for plan members. Care by specialist medical providers require referral from the primary care provider. This cost containment strategy is intended to avoid duplication of services (for example, the cardiologist ordering tests that have already been done by the PCP, or a sprained ankle being referred to an orthopedic) and avoid unnecessary specialist referrals, tests and/or procedures.

Health Maintenance Organization (HMO) and PPO programs also contain expenses  by requiring prior approval, prior authorization, or pre-certification for numerous elective hospital admissions, surgeries, costly tests and imaging procedures, durable medical equipment and prescription drugs. When such services are required, the provider must submit a request to the health care insurance policy review department, along with medical records that justify the service. The request is reviewed by the health care insurance company to determinewhether the services are justified as “medically necessary” according to the health insurance plan policy and guidelines. Review is generally performed by licensed nurses, and, if the reviewer agrees that the service is necessary, approval is given and the service will be covered by the health care insurance plan.

As heathcare expenses  continue to rise, numerous indemnity health care insurance programs, or “fee for service” programs are being forced to adopt some managed care strategies in order to provide quality heathcare and keep health care insurance premiums affordable. And as long as heathcare expenses  continue to rise, the distinctions among PPO, Health Maintenance Organization (HMO), FFS and other health care insurance programs will become blurred. Rest assured, however, that managed heathcare is here to stay