Exam (elaborations)
C428 Financial Recourse Management in Healthcare
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Summary Financial Recourse Management in H C428 Financial Recourse Management in Healthcare- C428 Performance Assessment RCP1-Task 1 A1
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Financial Recourse Management in Healthcare- C428Performance Assessment RCP1-Task 1
Jeanene Devine Lopez
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, A1.
As Chief Financial Officer of Seamus Company, the decision to move away from a fee-
for-service model towards a managed care organization has been reviewed. To support the
company goals, the proposed managed care strategies are as followed: Preferred Provider
Organization, Health Maintenance Organization, and Exclusive Provider Organization.
The first of the three fiscally sustainable strategies are the Preferred Provider
Organization (PPO). Preferred Provider Organization is a combination of cost-saving
strategies like a Health Maintenance Organization, but with some additional features of the
traditional insurance plans. When choosing a PPO plan, the recipient is allowed to select his
or her own providers, however beneficiaries are encouraged to use providers that take part in
the plan. This approach is a cost sharing strategy that encourages members to visit participant
physicians within the PPO plan, although not enforced. This is how an organization has the
ability to cut healthcare costs is by coming to an agreement with assigned providers. A
preferred provider pays an increased cost share for services that are provided within the
network rather than those services provided outside the network, which may result in higher
premiums and employees’ deductibles. That is why a Preferred Provider Organization costs
tend to be more expensive verses other insurance plans.
Another strategy is the Health Maintenance Organization (HMO). Health Maintenance
Organization is one of the most popular insurance plans. It can be organized either as public
or private entities. HMO was developed to encourage healthier lifestyles as well as
preventive medicine, which will consequently reduce the overall healthcare costs and
hospital admission rates. Unlike its Preferred Provider Organization counterpart, an HMO
plan designates the participant with his or her primary care physician. This is just one of
several methods that an employer can do in order to control costs. In a Health Maintenance
Organization, an employer pays a flat rate monthly premium for services and employees pay
smaller co-payments. Since participates are assigned their primary care physician (PCP), the
physician has the responsibility for the overall medical needs of the patient. If beneficiaries
are in need of care, they must first seek his or her PCP first, however if an issue is beyond the
PCP expertise, the PCP will refer the beneficiaries to the appropriate physician within HMO
network. This helps keep costs very low for both the organization and its members.
The final sustainable strategy is the Exclusive Provider Organization (EPO). Exclusive
Provider Organization can be considered a mixture of the HMO and PPO plans. Within this
insurance plan are contracted physicians and hospitals to whom the EPO has arranged
discounted rates to offer its beneficiaries. Exclusive Provider Organization offers an array of
health services such as doctors, hospitals, specialists, x-rays, laboratory, pharmacies, and
more. Under an EPO plan, a participant has to seek care exclusively by the network providers
or risk out of pockets expenses. There is however one exception to that rule and that would
be in an emergency situation such as stroke or heart attack. An EPO makes things simpler to
see a specialist; this is because the plan typically does not require members to have a referral
from his or her primary doctor. This unique feature sets itself apart from the Health
Maintenance Organization. Unlike PPO members, EPO members lower costs by negotiating
This study source was downloaded by 100000839832718 from CourseHero.com on 03-27-2022 14:14:38 GMT -05:00
https://www.coursehero.com/file/77520101/Financial-Recourse-Management-in-Healthcaredocx/
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