UNDERSTANDING MANAGED CARE INSURANCE PLANS
UNDERSTANDING MANAGED CARE INSURANCE PLANS
Understanding managed care insurance plans is an extremely important process in your role as a medical office specialist or billing and claims specialist. As a healthcare professional, you’ll work with or be affected by managed care every day at work.
To understand the specifics of insurance plans, you first have to understand the evolution of health care and how managed care came about. In this lesson, we’ll discuss how managed care came into play and its role in controlling the costs of health care for members enrolled in different programs. The goals of managed care were to create a healthcare system where patients were provided the highest levels of care at the most cost-effective prices. The costs of a managed care insurance plan will depend upon the type of program that a member, or patient, enrolls in. You may even be familiar with some of the programs—HMOs, PPOs, and POS plans.
In addition to understanding managed care insurance plans, we’ll also discuss the importance of your role in collecting information on patients visiting your healthcare facility. You can have a direct role in correct patient information and whether the facility is adequately and accurately reimbursed. If it sounds like a big responsibility, that’s because it is! Don’t worry, though, we’ll walk you through understanding more about your role in this lesson and throughout the course.
History of U.S. Health Care
The history of health care is complicated, and it has taken a great deal of time to get where we are today. Over many years, the United States has worked to find an adequate healthcare payment system and appropriate reimbursement for providers. As you can imagine, it’s difficult to find something that provides exactly what everyone needs.
In 1977, the U.S. government gave power to an agency called the Health Care Financing Administration (HCFA, pronounced “HIC-fuh”), created under the U.S. Department of Health and Human Services. On July 1, 2001, the name HCFA was changed to the Centers for Medicare and Medicaid Services (CMS) to reinforce the agency’s mission to serve Medicare and Medicaid beneficiaries.
This agency has come to be very powerful in healthcare operations in the United States due to the growing number of Americans, especially children, who are uninsured. Subsequently, the government passed numerous laws and policies that have affected healthcare billing and reimbursement. Many of the new requirements and guidelines have made the profession of medical billing quite challenging.
