...While managed care can be beneficial for most parties, it can also be a nightmare for a healthcare provider. The idea behind managed care is that the managed care network is in charge of the rates and the networks in which the recipient of the insurance policy can receive care (Medline Plus, 2014). This can sometimes mean that healthcare is not the full focus and that the care system is more of a business which can lead to complications for the provider (Welch, n.d). Managed care is a multi-faceted and complicated system. At its very barest and basic definition it is “a healthcare plan or system that seeks to control medical coast by contracting with a network of providers” (Dictionary, 2015). This means that the network providers control...
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...Course Project 4 - Medical Office Procedures 15-4 Obtaining Managed Care Referrals. In order to do this, you will need a telephone, patient’s medical record, name and telephone number of patient’s primary care provider. The method will use to do this is to call the patient primer care provider’s office for the person that will be in charge of the referrals. You will also give them the patient’s information, this will also include their name and birth date. Also, inform them of the referral to the doctor, including the reason that the patient needs to se the doctor. You will need to ask if any information from the patients file that maybe needed to process the referral. Make sure that you check to see when to expect the referral and if need be providing the office fax number for transmittal. Make sure you document the phone conversation and place it in the patients file. Final step, make sure notify the physician and the patient of the phone call content. 15-4 Obtaining Managed Care Referral Things you will need are telephone, the patients’ medical record, also you will need the name and number of the patient’s primary care provider....
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...any relationship between charges, payor and physicians. The data that is used in this research analysis to find the proper equation model for the relationship between payor, physicians and charges and number of days stay at the hospital, is from the Bryant/Smith Case 42 Hospital Charges (Appendix 1). As described in the case, the hospital’s revenues are determined largely by the patients’ insurance coverage. The data being used are for normal delivery of babies. The null hypothesis test states that there is no relation between the patients with managed care insurance and patients with commercial insurance. This means there is no difference between the patients with either insurance. The alternate hypothesis states that patients with managed care insurance are paying more than patients with commercial insurance. The 95% confidence level was chosen to calculate hypothesis test, and regression analysis. Based on the hypothesis test, that was conducted to compare the difference between the two different insurances, it is concluded that patients with managed care insurance are paying more charges than the patients with commercial insurance. Hypothesis test was also conducted to check whether there is a difference between the charges related to physicians. It was concluded after doing the test that, physician#2 has the highest charges among all the physicians. Linear Regression Analysis is conducted to see if there is any relationship between the DAYS and CHRGS, PHYS, and/or PAYOR...
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...hospital’s operation and sees to it that it remains profitable. This case analysis was conducted to: evaluate the physician’s performance in order to know whoever deserve to be granted an “admitting privileges”; to check which insurance have better coverage when it comes to payment of charges; and to determine what are the factors that affects the hospital’s revenue in order so make predictions if ever the Board keep the hospital operational what will the expected the profit and find ways on how to increase it. In the evaluating the physician’s performances we were able make an assumption that as the number of admission increases the total charges made also increases. Through comparison we found out that among the nine physicians Physician #10 delivered the most number of admissions and made the highest amount of total charges. Also, by further analysis we have strong evidence that out of the nine physicians, Physician #2 charges the most amount per patient which also contributed an increase in the hospital’s total collection. With these findings, we made a recommendation to the hospital’s Board that Physician #10 and #2 deserved to be awarded “admitting privileges”. It is said that the hospital’s revenue depend mostly to the amount that the patient’s insurance is willing to pay. As we analyzed the given data we derived with a conclusion that most of the patients that were admitted in the hospital have Managed Care Insurance. Consequently this finding tells us that the large amount...
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...Assignment 2 Financing and Restructuring Health Care Dr. David Tataw HSA 500 Health Services Organization January 28, 2012 Abstract: This paper analyses the Financing and Structuring Health Care by analyzing four important notions. Firstly it Identifies and describe the three main types of health insurances in the U.S. Secondly it explains the three methods for categorizing health insurance in the U.S. This is followed by a synthesis of the pros and cons of managed health care for the health care provider, insurer, and patient. Finally the papers describe the impact of managed care on both the Medicare and Medicaid programs. Identify and describe the three main types of health insurances in the U.S. Rodts (2010) talks about the new Healthcare system in US and the challenges it brings for healthcare providers but there is always challenge when one has to select the certain type of health cover for himself. It is therefore important to understand main types of health insurance in the US. While Hall (2010) outlined the three different types of reinsurances brought about by the health reform, Health Insurance Info (2010) notes that are a number of different types of health insurance coverage designed to meet the needs and budget of a variety of individuals. In essence, health insurance is a risk management tool that ensures you and your family has access to the healthcare you need, when you need it without causing a tremendous financial burden. The cost of health insurance...
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...document. Type the abstract of the document here. The abstract is typically a short summary of the contents of the document.] | Contents Executive Summary 3 Introduction 3 Analysis and methods section 3 Do charges incurred by a patient depend on the type of insurance the patient has? If so how? 5 Do charges incurred by patients depend on which doctor treats them? If so how? 5 Bibliography 7 Appendix 8 Executive Summary Hospital are required to bill for individual items or services provided to a patient. Patients admitted to hospitals are charged for their room, supplies, drugs, labs, x-rays, operating room time and other care. It is important to know that hospitals submit a bill to the insurance company for all the services provided to the patient and the payor determines the amount owed to the hospital based upon the insurance company’s contract with the hospital for specific services [ (Henry Ford Health) ]. Introduction The purpose of this case study is to understand the relationship between hospital charges for certain physicians and insurance carriers. Cost finding and cost analysis are the techniques of allocating data that we were provided as part of the case study. The information that we are going to use to analyze cost between Commercial Care and Manage Care insurance includes: * DAYS the number of days the patient spent in the hospital. * CHRGS is the total expenses charged to that patient. * PHYS is a code identifying the...
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...babies. From those files, we obtained the number of days the patient spent in the hospital, the total expense charged to that patient, the physician code identification, and the type of insurance the patient carried. The analysis revealed that when we compare patients on managed care and commercial insurance alone, we are 95 % confident that patients with managed care does pay more than patients with commercial insurance. We are 95 % confident that physician 2 is the most expensive physician. The strongest relationship using linear regression is the relationship between hospital charges and the length of stays. II. The introduction I remember watching a documentary about an insurance company called Health Net and how it got started. It was by a physician who during the early 80’s made a lot of money ordering all the possible tests for his patients, from lab tests to scans, etc. Then when managed care came along he got upset with managed care telling what is standard procedure and why unneeded ordering will be covered by the patient’s insurance plan. Well now that he was losing money, he decided to that it this is where health care is going then he will go where the money is and open up his own insurance company, which is now Health Net. Well even though manage care health insurance has stepped in, physician at the hospital still have the control over hospital cost, admitting, ordering medication, length of stay, procedure, etc. Even though physicians have this much control, they...
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...SUBJECT REVIEW Regression Methods in the Empiric Analysis of Health Care Data GRANT H. SKREPNEK, PhD ABSTRACT OBJECTIVE: The aim of this paper is to provide health care decision makers with a conceptual foundation for regression analysis by describing the principles of correlation, regression, and residual assessment. SUMMARY: Researchers are often faced with the need to describe quantitatively the relationships between outcomes andpre d i c t o r s , with the objective of ex p l a i n i n g trends, testing hypotheses, or developing models for forecasting. Regression models are able to incorporate complex mathematical functions and operands (the variables that are manipulated) to best describe the associations between sets of variables. Unlike many other statistical techniques, regression allows for the inclusion of variables that may control for confounding phenomena or risk factors. For robust analyses to be conducted, however, the assumptions of regression must be understood and researchers must be aware of diagnostic tests and the appropriate procedures that may be used to correct for violations in model assumptions. CONCLUSION: Despite the complexities and intricacies that can exist in re gre s s i o n , this statistical technique may be applied to a wide range of studies in managed care settings. Given the increased availability of data in administrative databases, the application of these procedures to pharmacoeconomics and outc o m e s assessments may result in...
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...Achieving and Maintaining Accreditation in Managed Care Name: Institution: Devry Table of Contents Introduction………………………………………………………………………………………3 Background……………………………………………………………………………………….3 Importance of accreditation…….………………………...………………………………………3 Accreditation Bodies……………………………………………………………………………...4 Literature review………………….…………………………………………………………….....4 Challenges that are experienced in achieving and maintaining accreditation…………………..…5 The role of the URAC as an Accreditation Body………………………………………………....5 How the URAC accredits healthcare institutions….........................................................................6 Quality assessment and control solutions in accreditation ……………………………………......8 Implementation of quality improvement and accreditation solutions…………………………......9 Justification…………………………………….…………………………………………………10 Summary and conclusion……………………….…...……………………………………………10 References ………………………………………………………………………………………..11 Achieving and Maintaining Accreditation in Managed Care Managed healthcare organizations and professionals encounter numerous challenges on a yearly basis in the course of offering services, whereas the state, stakeholders, and clients (patients) expect to be reassured that bodies that render managed healthcare services are well equipped to meet their demands. Accreditation is, therefore, a detailed evaluation process through which an independent professional...
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...mail-order medicines in the United States. This merger reflected fundamental changes taking place in the pharmaceutical industry. GROWTH IN MANAGED CARE Managed care plans typically provide members with medical insurance and basic health care services, using volume and long-term contracts to negotiate discounts from health care providers. In addition, managed care programs provide full coverage for prescription drugs more frequently than do traditional medical insurance plans. Industry experts estimate that by the turn of the century, 90% of Americans will have drug costs included in some kind of managed health care plan, and 60% of all outpatient pharmaceuticals will be purchased by managed care programs. The responsibility for managing the provision of prescription drugs is often contracted out by the managed care organizations to PBMs. The activities of PBMs typically include managing insurance claims, negotiating volume discounts with drug manufacturers, and encouraging the use of less expensive generic substitutes. The management of prescription benefits is enhanced through the use of formularies and drug utilization reviews. Formularies are lists of drugs compiled by committees of pharmacists and physicians on behalf of a managed care organization. Member physicians of the managed care organization are then strongly encouraged to prescribe from this list whenever possible. Drug utilization reviews consist of analyzing physician prescribing patterns...
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...Effectiveness of Nurse Communication, Spring 2012 ▪ Assessing the risks for business continuity and patient safety ▪ Study of the culture, processes, and models of communication used in hospitals Methodologies Used: Delphi, Focus Group interviews for Needs Analysis and Requirement Gathering Factors Affecting Employees’ Compliance to IT Security Policies, Fall 2011 ▪ Reviewed the various threats to information systems in an organization and the theoretical models explaining the factors that influence an employee’s adherence to IT policies. ▪ Completed a literature review of factors that affect employees’ compliance to security policies in IT industries and the measures to be taken by the senior management to improve compliance. Quality Assurance in Managed Care Organizations, Fall 2011 As a part of my course in Medical and Health Informatics, I evaluated all the features of a managed care and accountable care organization. Issues and challenges involved in assuring quality in Managed Care Organizations Specialities • MANAGERIAL SKILLS: IT PROJECT MANAGEMENT, CLIENT INTERFACING SKILLS, PROCESS MODELING, OPERATIONS STRATEGY AND MANAGEMENT, STATISTICAL DATA ANALYSIS,...
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...Pearson BTEC Level 4/5HNC/D Diploma Health and Social Care Unit 9: Empowering Users of Health and Social Care Services https://www.netessays.net/viewpaper/130575.html http://hndassignments.co.uk/courses/unit-9-empowering-users-health-social-care/ Student name Assessor name Fidelia Chukwuenweniwe Date issued Submission date Re-assessment date 17/02/2016 Task 1 and Task 2 Thursday 14th April 2016 Task 3 and Task 4 Thursday 28th April 2016 Assignment title Empowering Users of Health and Social Care Services Learning Outcome Learning Outcome Assessment Criteria In this assessment you will have the opportunity to present evidence that shows you are able to: Task no. LO1 Understand how the design and review of services promotes and maximises the rights of users of health and social care services 1.1 Explain how the current legislation and sector skills standards influence organisational policies and practices for promoting and maximizing the rights of users of health and social care services 1 1.2 Analyse factors that may affect the achievement of promoting and maximising the rights of users of health and social care services 1 1.3 Analyse how communication between care workers and individuals contribute to promoting and maximizing the rights of users of health and social care services 1 LO2 Understand how to promote the participation and independence of users of health and social care services 2.1 Explain factors that may contribute...
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...are to include creating a medical call center that will be improved and have better customer service as well as exceeding the patients' expectations. Our agents will provide high-quality healthcare advice, products or assistance to residents of the area. We will serve our community’s needs. Forming a health care facility that fully capable to survive on its own cash flow within 10 months or less. To increase the number of call volume by 50% per year through improved customer service. To establish a creative website that includes online booking capability, as well complete information about the practice, hours, demographic information, health information and much more Mission The mission of the call center is to create the health and wellness of the local people by providing them with access to high-quality medical care for people young and old. The center is committed to providing these services exceed the expectations of each our patients, resulting in a successful and respectable business. Keys to Success Patients are the key to making the healthcare function. The call center main focus is on patient care. Educating the patients on the importance of preventative care helps prevent other diseases from taking over their bodies. Giving the patient their yearly checkup allows the doctor to discover if they educate patients. Figure out ways to inform your patients that it is time for them to come take their daily medication. Staff and Office Organization Observe that your...
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...Managed Care Staci Berry MHA614 Policy Formation & Leadership In Health Organizations Instructor: Judy Roberts April 2, 2013 Managed Care In this paper we will discuss managed care. We will find and discuss the definition of managed care. This paper will also explain the different types of managed care plans that are available to Americans. This paper will provide examples of the different types of managed care plans available. It will also explain how each plan works. We will also talk about why rising exposure to health care costs are threatening the well-being of American families. According to Harrington and Estes, managed care is a term that has been overused and really does not have a specific meaning. “Originally, it referred to health care delivered with a capitated financing mechanism. Then it included health care delivered through contracting networks. Currently it refers to most any health are delivery that is different from fee-for-service health care delivery” (Harrington & Estes, 2008 pg.42). When dealing with managed care usually there is a panel of providers that the individual can use. If they go outside of this panel they will be more likely to have to pay a higher copayment or deductible. Some characteristics of a managed care health plan delivery system include: “explicit standards for the selected health car providers, it also puts emphasis on preventive care, as well as provides financial incentives to ensure the use of the...
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...Healthcare officials are trying to transition special needs children to a managed care system without threatening health outcomes and quality of care. According to Knapp, Madden, Sloyer and Shenkman, children with special needs make up “approximately 13.9%” of the United States’ children population (2011, p.1). Therefore, shifting special needs children healthcare programs from a fee-for-service model to a managed care system needs to focus primarily on three components: care coordination, the roles of pediatricians, and accessibility to specialty and primary care providers. Coordination of care is necessary to ensure that these special needs children receive the services at a directed time, rather than during a time of emergency....
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