Question

CHAPTER 16 Basics of Health Insurance 315 of different at a fixed have sepa association thcare pro providers er fee-for- 5. Rather ae HMO nt's PCP with the annually the cost Preferred Provider Organization APPO is a managed care nework that contracts with a group of providers the providers are on a predetermined list of charges for all services, including those for both normal and complex proce- dures. The PPO model of managed healthcare preserves the fee-for- service concept that many providers prefer. Typically, the patient's Financial responsibilities represent on average 20% to 25% of the allowed charge, but this depends on the patient's health insurance benefits. A provider who loins PPO does not need to alter the manner of providing cure and continues to treat and bill the patients on a fee-for-service basis. When a patient covered under a PPO plan comes for treatment, the provider treats the patient and bills the PPO. Patients do not need to visit their PCP to obtain a referral to a specialist for more specialized care and they have more control over healthcare choices. PPOs furnish their subscribers with a list of participating providers and healthcare facilities from which they can access in- network healthcare at PPO reduced rates. Rates are quite often lower than those charged to non-PPO patients. Although patients have the option to visit a specialist when they feel the need, they are still required to obtain preauthorization for referrals for more expensive medical therapy such as formulary medi- cation and some medical testing, al group oviders eers and an IPA associa- in one capita- fferent CRITICAL THINKING APPLICATION 16-3 Henry Hudson called Jodie; he was upset because he received o patient statement balance. He told Jodie that he has full coverage insurance through his employer and did not know why he had a balance. What information con Jodie share with Henry to explain his financial responsibility? 6-2 with etes. that noint- d to Exclusive Provider Organization An EPO combines features of an HMO (e.g., an enrolled group or population, PCPs, and an authorization system) and a PPO (e.g., flexible benefit design and fee-for-service payments). Patients with EPO coverage will not be covered for services outside the designated network of providers (unless there is an emergency), but may not need to obtain a referral for specialized care. EPO plan members are not required to choose a PCP as HMO members are. Professional Courtesy Professional courtesy occurs when the health provider decides to reduce or eliminate the patient's financial obligations for healthcare provided. Pro- viders used professional courtesy to eliminate the patient's financial respon- with or hod mode

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Answer 1

The information that Jodie can share with Henry is that it might be because the organisation is not in network with preferred provider organisation . Because of which patients have to pay for their medical services out of their pocket . A preferred provider organisation is a plan in which preferred healthcare which are in network provide services at low cost.