1. Define Managed Care. Describe and analyze the different governmental and private health insurance reimbursement methods.
Managed care is medical coverage that contracts with explicit medical services suppliers to reduce administration costs while improving the nature of those administrations to patients (Edwards, 2020). Medical care reimbursement is how private health guarantors or government offices pay for medical services providers’ administrations. The private payer classification incorporates employer-based inclusion and independently bought health care coverage. Private payers, by and large, require a coinsurance, copay, or a deductible that the patient pays straightforwardly to the provider (Newbrander & Eichler, 2018). The governmental payer class includes the central government as the payer of medical care.
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2. Define managed care and describe the four major goals.
Managed care is a healthcare delivery framework that seeks to lower costs and improve outcomes using a network of providers cooperating to help patients’ general health needs (Phelps, 2017). The four significant objectives of characterized managed care incorporate (Kieny et al., 2017);
Establishing associations with providers and administrations to provide a designated set of services to their members- by regulating patient admittance to specialized care and eradicating unnecessary services.
Establishing criteria for their members to utilize the Managed Care Organizations reduces healthcare program costs and better manages health services utilization.
Establish measures to estimate cost control by coordinating medical care delivery and installment frameworks through prepaid charges and regulating medication costs by executing pharmacy benefits management plans.
Provide incentives to encourage health service resources through restricting provider charges by setting up fixed rates for physicians and hospital administrations.
3.Discuss the four cost-control methods of MCOs
Cost controls incorporate service management tools, financial incentives, episode-of-care reimbursement, and medical utilization and necessity (Amelung, 2019).
Service management tools utilized in controlling expenses include deciding clinical need and usage survey. In addition, doling out the primary care provider as guardian to particular administrations through references and earlier approvals is another method for controlling expenses through service management.
Episode-of-care reimbursement is reliant upon capitation and worldwide installments.
Financial incentives utilized by MCOs, both positive and negative, incorporate monitoring the healthcare settings, number of visits each day, cost-sharing, and utilization of conventional drugs for remedies.
Medical necessity and utilization contain and screen utilization of medical care benefits by assessing the requirement for and power of the assistance preceding it being given.
References
Amelung, V. E. (2019). undefined. Springer Texts in Business and Economics , 253-255. https://doi.org/10.1007/978-3-662-59568-8_18
Edwards, R. (2020). undefined. Managed Care Quality , 1-20. https://doi.org/10.1201/9781003075974-2
Kieny, M. P., Bekedam, H., Dovlo, D., Fitzgerald, J., Habicht, J., Harrison, G., Kluge, H., Lin, V., Menabde, N., Mirza, Z., Siddiqi, S., & Travis, P. (2017). Undefined. Bulletin of the World Health Organization , 95 (7), 537-539. https://doi.org/10.2471/blt.16.187476
Newbrander, W., & Eichler, R. (2018). Managed care in the United States: Its history, forms, and future. Recent Health Policy Innovations in Social Security , 83-106. https://doi.org/10.4324/9781351307444-7
Phelps, C. E. (2017). undefined. Health Economics , 295-324. https://doi.org/10.4324/9781315460499-11
