Question

11. Under managed health care, participating providers (e.g., physicians) negotiate specific a reimbursement mechanism which determines how they will be paid for the services they deliver. Select one:

a. true b. false

Answer 1

Answer: False

• A managed care organization (MCO) is a group of health care providers who offer medical services effective in cost, utilization, and quality. WellCare, HealthNet are examples of managed health care organizations in the US.
• Healthcare providers are paid by insurance or government payers through a system of reimbursement.
• Different models of reimbursement practice by MCO's.
• Fee for Service (FFS), Capitation, and Bundled Payments / Episode-Based Payments are the most common traditional reimbursement methods.
• Health care providers can't negotiate the reimbursement method practiced by managed care organizers in which the healthcare provider works.

Three primary types of managed care organizations:

1. Health Maintenance Organizations (HMOs),
2. Preferred Provider Organizations (PPOs), and
3. Point of Service (POS) plans.Oct 6, 2015

Among these, Health maintenance organizations follow the capitation method of reimbursement. This payment method pays a fixed amount of money per-member-per-month (PMPM)to a care provider for covered services rather than based on specific services provided.

Although other organizations prefer to follow fee for service reimbursement. Providers are paid based on the services performed by them.

So, reimbursement systems are fixed by a particular managed care organization but cannot be negotiated by doctors.

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