Managed care falls into three main categories: health maintenance organizations (hmos), preferred provider organizations (ppos), and point-of-service (pos) models. An HMO provides discounted coverage in exchange for requiring the patient to work with a specific network of doctors under the direction of a primary care physician. A PPO allows the patient to get care outside the network, but charges the patient less money if they stay in the network. a pos model takes elements of both models and tailors them into a plan that gives the patient flexibility while saving money.
Reading: What is pos health insurance
how does a point of service model work?
In an HMO, the patient must coordinate all medical care through a Primary Care Physician (PCP), who will refer the patient to other doctors or specialists if he or she believes the patient needs more care than he or she can provide. The same can be true in a pos model, meaning that the patient can still reap the benefits of being part of an HMO even without being completely tied into it. These benefits include cheaper care and more coverage from the third-party insurance organization that the health care provider network contracts with. preventive care benefits may also be available. but all of these benefits depend on the contract the patient agrees to, and a patient may not need to designate a pcp.
In a ppo, the patient can get care outside the network and does not need to go through a pcp to plan treatment, although doing these things has an additional cost. this is also possible in a pos model. The patient can choose to pay more out of pocket for her to see a specialist without seeing her doctor, or she can stay in-network and save money.
Essentially, a pos model allows the patient the freedom to choose to receive treatment through an hmo plan or a ppo plan depending on their needs and preferences. being covered by a pos plan can be more expensive than being covered by an hmo, but less expensive than being covered by a ppo. a pos model allows patients more control over their plans and allows them to determine for themselves which doctors to trust and which treatments will work best.
why use a pos plan?
A pos plan is a good option for patients who want to be able to choose their treatment options, even if it means potentially paying more out of pocket. If they want the security of low-cost care through an HMO, they can. If they want to be able to go outside the network to see a specialist or other provider, they can do so and still have at least some of their care covered by the plan. They also have the freedom to see any PCP they want, although it will still be cheaper to see one with an in-network contract.
However, coverage through a post plan tends to vary depending on how the patient chooses to receive their care each time. if they stay in-network, they can expect predictable costs. but if they don’t, they can expect more unpredictable out-of-pocket costs that are based on the terms of the pos contract and the ways that out-of-network providers bill.
how decoration can help
Medicaid has been using managed care models heavily for its beneficiaries in recent years, and managed care is a common form of coverage that employers provide as part of employee benefits. But it can also be confusing, and if a health care organization or its billing staff don’t know how to work with it, it can lead to problems with reimbursement. If your healthcare organization needs help understanding healthcare models to foster a well-oiled revenue cycle management system, contact us today!
See also: AARP Health Insurance | Insure.com