| Health insurance plans have been forced to take | | | | strategy is intended to avoid duplication of |
| action to contain costs of quality health care | | | | services (for example, the cardiologist ordering |
| delivery as health care costs have skyrocketed. | | | | tests that have already been done by the PCP, or |
| Health insurance premiums, deductibles and | | | | a sprained ankle being referred to an orthopedic) |
| co-pays have steadily increased, and health | | | | and avoid unnecessary specialist referrals, tests |
| insurance companies have implemented certain | | | | and/or procedures.HMO and PPO plans also contain |
| strategies for reducing health care costs. | | | | costs by requiring prior approval, prior |
| "Managed care" describes a group of stratgies | | | | authorization, or pre-certification for many elective |
| aimed at reducing the costs of health care for | | | | hospital admissions, surgeries, costly tests and |
| health insurance companies.There are two basic | | | | imaging procedures, durable medical equipment |
| types of managed care plans; health maintenance | | | | and prescription drugs. When such services are |
| organizations, or HMOs, and preferred provider | | | | required, the provider must submit a request to |
| organizations, or PPOs. So which health plan is | | | | the health insurance plan review department, |
| best? How do you choose what type of health | | | | along with medical records that justify the service. |
| insurance best suits the health care needs of you | | | | The request is reviewed by the health insurance |
| and your family?Both HMOs and PPOs contain | | | | company to determine whether the services are |
| costs by contracting with health providers for | | | | justified as "medically necessary" according to the |
| reduced rate on health care services for its' | | | | health plan policy and guidelines. Review is usually |
| members, often as much as 60%. One important | | | | performed by licensed nurses, and, if the |
| difference between HMOs and PPOs is that PPOs | | | | reviewer agrees that the service is necessary, |
| often will cover the costs of care when the | | | | approval is given and the service will be covered |
| provider is out of their network, but usually at a | | | | by the health insurance plan.As health care costs |
| reduced rate. On the other hand, most HMOs | | | | continue to rise, many indemnity health insurance |
| offer no coverage for health care services for | | | | plans, or "fee for service" plans are being forced |
| out-of-network providers.Both HMO and PPOs also | | | | to adopt some managed care strategies in order |
| control health care costs by use of a gateway, or | | | | to provide quality health care and keep health |
| primary care provider (PCP). Health insurance plan | | | | insurance premiums affordable. And as long as |
| members are assigned (or select) a primary care | | | | health care costs continue to rise, the distinctions |
| practitioner (physician, physician assistant, or nurse | | | | among PPO, HMO, FFS and other health insurance |
| practitioner). usually a family practitioner or internal | | | | plans will become blurred. Rest assured, however, |
| medicine doctor for adult members or a | | | | that managed health care is here to stay.Kay |
| pediatrician or family care practitioner for childern. | | | | Lowe holds a Master's degree in health care and |
| The primary care provider is responsible for | | | | has 30+ years experience in the health care field. |
| coordianting health delivery for plan members. | | | | She is also webmaster for Health-Infosource.com, |
| Care by specialist physicians require referral from | | | | a website dedicated to disseminating health |
| the primary care provider. This cost containment | | | | information. |