Differentiating Management Care Terminology

Running head: DIFFERENTIATING MANAGEMENT CARE TERMINOLOGY 1 

PPO 

PPO is a health plan that stands for “Preferred Provider Organization”. Members of a PPO plan are encouraged to use the insurance company's arrangements and connections of preferred doctors. In addition, members do not need to choose a primary care physician. The advantages of this plan are that it is flexible since it has a large network, a person does not need a referral, and a person can go out of the network. On the other hand, one disadvantage of this plan is that premiums and deductibles are normally higher compared to other plans such as HMO. 

HMO 

HMO is a health plan that stands for “Health Maintenance Organization”. It requires a referral from an individual’s primary care physician before they can see a specialist. The advantages of this plan are; it has lower premiums and lower costs compared to PPO. The disadvantages are that an individual must have a referral so as to see a physician, and it is not flexible since there is a restriction on the network of doctors and hospitals. 

IPA 

IPA stands for “Independent Physician Association” and it is a business body which is managed and owned by an association of self-governing physician practices. Its objective is to reduce overhead and practise business project like contracts with various employers, Accountable Care Organizations as well as Managed Care Organizations. The advantages include; it has a suitable arrangement of the medical practitioner’s financial incentives, and it is efficient in practice administration, organization and management. On the other hand, the disadvantages include; it has underfunded capitation revenue which puts it at the risk of bankruptcy, and physicians can be caught between financial benefit and the best care for their patients. 

Physician Referral and an Insurance Authorization 

A consultation is given by a doctor whose advice on the assessment or management of a specific issue is asked for by another doctor or other suitable sources. On the other hand, a referral is a procedure of sending a patient to another doctor or specialist for health care services or consultation because the referring doctor deemed it necessary. This happens when the referring doctor is not prepared or qualified to treat the patient. 

A referral form has two sections; the administrative section and the medical section. The administrative section includes the following information; Name of the primary healthcare centre, Patient name, Family medical record number, Direction of the referral, Date of the referral and Name with the signature of the physician. The medical section includes the following information; Personal history: (name, age and gender, Principal complaints, Medical history, and Examinations. 

Insurance authorization is a procedure for examining and evaluating medical health services to make sure that they meet the medical appropriateness before the medical services are rendered. On the other hand, insurance verification is a process that makes sure that the health care benefits of a patient cover the necessary procedures. Therefore, it is the duty of an insurance verification specialist to validate and confirm the coverage levels as well as letting individuals know about the information on their benefits (Gabel, 2005). 

Pre-authorization is the necessary process which permits healthcare providers to verify coverage and secure approval or sanction from the payer for a proposed treatment or healthcare service. On the other hand, pre-certification is the process of verification for a certain medical procedure before it is performed or for admittance of the patient to a hospital. 

Reference

Gabel, J., Bartlett, R., Kennedy, B., Winking, B., Nauman, G., Turek, J. (2005). Health care eligibility verification and settlement systems and methods. Retrieved on January 27, 2019. https://patents.google.com/patent/US8751250