Part 1
A Managed Care Plan is a health insurance plan with a contractual agreement (Vines et al., 2017). These agreements include doctors, hospitals, and other health care institutions that make up the designated plan network (Vines et al., 2017). There are advantages and disadvantages to managed care (Vines et al., 2017). The main focus of these plans are to provide healthcare coverage at reduced cost (Vines et al., 2017). Preferred Provider Organization (PPO), Point of Service Program (POS), Exclusive Provider Organization (EPO) Program and Health Maintenance Organization (HMO) are some of the major managed care organization (MCO) plans (Vines et al., 2017). I have used an HMO, PPO, and EPO.
There are many types of HMOs including a Group Model HMO, Open Access HMO, Network Model HMO, Staff Model HMO, Individual Practice Association HMO (Vines et al., 2017). Many years ago, when I started my nursing career, I had an HMO group. The HMO is one of the most restrictive state and federally regulated managed care plans (Vines et al., 2017).
An HMO has contracted medical services to provide treatment to its consumers through selected medical centers, hospitals, other health care professionals, and a service network of group providers (Vines et al., 2017). I (the subscriber) chose a network primary care physician (PCP) as the gatekeeper for coordinating the health care services I need (Vines et al., 2017). HMO’s rules include specialty professional service authorizations obtained through PCP (Vines et al., 2017).
If the professional service is not an emergency service or HMO approved, HMO will not pay any fees (Vines et al., 2017). The benefit of HMO is to provide a wide range of healthcare benefits at a low cost, with little or no out-of-pocket costs or co-payments (Vines et al., 2017).
Part 2
The Medical Office Specialist (MOS) is an important member of a health care organization. The MOS functions to act as a liaison between the patient and the care provider. Job duties performed by a MOS include scheduling appointments, maintaining patient records, processing billing, and insurance paperwork (Vines et al., 2017). The MOS must be friendly and organized. It is beneficial for the MOS to understand managed care, health insurance, and the coverage provided, including deductibles, co-payments, and enforce the patient’s bill of rights and responsibilities (Vines et al., 2017). The patient’s bill of rights states the patient has the right to expect safe, respectful, equitable delivery of care and treatment of pain regardless of race, religion, gender identity, age, socioeconomic status, or cultural beliefs (National Institutes of Health, 2021). Patients have the unequivocal right to expect that all their personal health information will be protected by the Health Insurance Portability and Accountability Act (HIPAA) law, kept private and confidential (National Institutes of Health, 2021). Patients have the right to obtain accurate and informed consent, including benefits, risks, potential death, risks of incapacity, and alternative options prior to the delivery of any medical, surgical procedure, or delivery of medical care (National Institutes of Health, 2021).The patient has the right to request and be provided with all personal health related information includes procedures, diagnostic data, and test results (National Institutes of Health, 2021). Patients have the right to participate or refuse treatment (National Institutes of Health, 2021). The patient must be informed of the consequences of the refusal (National Institutes of Health, 2021). The patient has the right to participate or refuse to participate in research (National Institutes of Health, 2021). Patients have the right to expect that their health information will be distributed to designated medical service providers (National Institutes of Health, 2021). They have the right to make decisions about their health and the direction of treatment they choose (National Institutes of Health, 2021)
