Question

1. Review managed care contracts for different payment plans (PPO, HMO, Fee for services, etc.) and describe provider incentives and risks under each of the following reimbursement methods:
   1. Cost-based
   2. Charge-base (including discounted charges)
   3. Per procedure
   4. Per diagnoses
   5. Per diem
   6. Global pricing
   7. Capitation

Answer 1

* Different payment plans

                        * PPO (Prefered provider organization)

                                     It is a type of plan included in medicare part C and it given by a private insurance

                                     company.accourding to this plan if you approach doctors,hospitals included in

                                     this plan less payment is needed and payment is more if approach doctors and

                                     hospitals outside of plan.

                        * HMO ( Health maintainance organisation)

                               * It include variety of health care services focus on a large population and this plan

                                  covered only if you see doctors and hospitals inside of plan coverage.

                     * Fee for services

                                * This plan give payment seperately for each service and fee based on quantity

                                   rather than quality.

Providers incentives and risk in following reinbursement methods are

                               a) Cost based

                                        In this method provider give payment as per cost of care of patients in hospital

                                        if cost of care is higher provider needed to pay higher amount and if less then

                                        pay low amount.

                                 b) Charge based (including discount charges)

                                         * In this method payment by provider based on billed charges and they use

                                           methods like bargaining,discount when paying more patients at same time

                                           to reduce charges.

                                c) Per procedure

                                          *In this unique payment for each procedure and used commonly in the

                                                    outpatient setting which help the provider to reduce pay total high cost

                                                    of care.

                                 d) Per diagnosis

                                               * In this provider paying based on patient diagnosis otherthan procedure

                                                  but in some diagnosis like cancer,organ failure cost is higher compared

                                                  other diagnosis.

   e) Per diem

                                            * In this payment given by provider per day for health services and providers

                                               have a risk of different rate per day in different units.( Icu,dialysis etc).

                                 f) Global pricing

                                            * In this payment given by provider for services over a period of time and

                                               providers may need to pay higher amount if surgery and other costly

                                              procedures happended during that period of time.

                                    g) Capitation

                                                * This payment method is similar to global pricing in this provider give

                                                  payment for services for a month or weeks and providers have risk of

                                                   spend more money if high level of services provided in short time.

                                                     eg:Payment given for patient who seek treatment three month in CCU.

                                                    

                                   .