Assignment: Health Maintenance Organizations.

HMOs are organized healthcare systems that are responsible for both the financing and the delivery of a broad range of comprehensive health services to an enrolled population. HMOs act both as insurer and provider of healthcare services. They charge employers a fixed premium for each subscriber. An independent practice association (IPA)-model HMO provides medical care to its subscribers through contracts it establishes with independent physicians. In a staff-model HMO, the physicians would normally be full-time employees of the HMO. Individuals who subscribe to an HMO are often limited to the panel of physicians who have contracted with the HMO to provide services to its subscribers.

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Preferred Provider Organizations

Preferred provider organizations (PPOs) are entities through which employer health benefit plans and health insurance carriers contract to purchase healthcare services for covered beneficiaries from a selected group of participating providers. Most states have specific PPO laws that directly regulate such entities. Common characteristics of PPOs include:

Select provider panel

Negotiated payment rates

Rapid payment terms

Utilization management (programs to control the utilization and cost)

Consumer choice (allows covered beneficiaries to use non-PPO providers for an additional out-of-pocket charge [point-of-service option])

In PPOs, a payer, such as an insurance company, provides incentives to its enrollees to obtain medical care from a panel of providers with whom the payer has contracted a discounted rate.

Exclusive Provider Organizations

Exclusive provider organizations (EPOs) limit their beneficiaries to participating providers for any healthcare services. EPOs use a gatekeeper approach to authorize non–primary care services. The primary difference between an HMO and an EPO is that the former is regulated under HMO laws and regulations, whereas the latter is regulated under insurance laws and regulations. Characteristics of EPOs include the following:

Primary care physicians are reimbursed through capitation payments or other performance-based reimbursement