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Medical Billing Terminology You Should Know: Managed Care Plans

March 3, 2015

Managed Care PlansAs most patient you may be confused with your insurance – managed care plan. The insurance company contracts with a certain set of members, physicians, hospitals, eye-care professionals, dentists, etc. to help keep your costs down for your premiums. These are what is known as in-network providers in your plan. When you visit these providers you have the least out-of-pocket expense because they have already contracted to accept an accepted payment from your insurance company.

Health Maintenance Organization Plans

These are the most restrictive plans, and members need to go to providers in the HMO network in order to get their medical expenses covered. 

Preferred Provider Organization Plans

In these plans you can go to a provider either in-network or out-of-network, but your reimbursement from the insurance company will be at the higher rate if you go to an in-network provider. This means less out-of-pocket expense for you, but it does give you more of a choice in who you see.

Point Of Service Plans 

These plans combine characteristics of both a HMO and a PPO. In this plan you must choose a PCP or Primary Care Physician within your insurance company’s network of providers for your Point of Service provider to monitor your health care. In this case your primary care physician can make referrals to out of network providers and your insurance should pay much of the cost of this referral as long as your PCP does it. This plan makes your primary care physician your gatekeeper for your health care. 

It is your responsibility to see if your provider and the providers you see are in-network with your insurance or out-of-network. Another thing to keep in mind before you choose plans is that if you do go out-of-network, you will be responsible for submitting your bills to your insurance company to get reimbursed, and you will need to handle all of the paperwork yourself. When you go in-network, the in-network physician’s office that you go to will handle all of this paperwork and billing for you, so you don’t need to worry about it. You also will be getting the most bang for your hard-earned dollars since reimbursement will be higher in-network.

Now you should have a better understanding of how your choice can impact your healthcare management and what in-network and out-of-network mean. If you have any further questions about these choices of HMO, PPO, and POS plans, please do not hesitate to contact us.


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