Physician reimbursement and hospital use in HMOs
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Physician reimbursement and hospital use in HMOs by Gerald B. Meier

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Published by Dept. of Health, Education & Welfare, Health Care Financing Administration in Washington .
Written in English


  • Utilization,
  • Medical Fees,
  • Medical fees,
  • Health Insurance,
  • Medical Economics,
  • Health insurance,
  • Health Maintenance Organizations,
  • Hospital utilization,
  • Insurance, Health, Reimbursement,
  • Hospitals,
  • Health maintenance organizations

Book details:

Edition Notes

Statementauthors, Gerald B. Meier, John Tillotson ; prepared by InterStudy
SeriesHealth care financing research & demonstration series -- report no. 8., Health care financing research & demonstration series -- report no. 8.
ContributionsTillotson, John K., United States. Health Care Financing Administration, InterStudy (Center)
LC ClassificationsRA413.5.U5 M444 1978
The Physical Object
Pagination83, [102] p. :
Number of Pages102
ID Numbers
Open LibraryOL25601077M

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Payment Model Pros Cons Straight salary/minimum-income guarantee or salary plus bonus/incentive. Most often seen in large HMOs, academic settings, and large corporate- or physician-owned practices, these closely related models are perhaps the most straightforward because the income level is set and physicians know how much they’ll earn.. When a bonus or incentive is added in, physicians. Physician recruitment: An incubation model in which a hospital supports the recruitment of a physician through income guarantees, tuition payments, provider plan development, etc. Professional services agreement (PSA): A hospital purchases a practice’s ancillaries (technical component services) and compensates the practice’s physicians for. The goal of this volume was to create a book that was general enough to serve as an introduction for members of the health care field and sophisticated enough to appeal also to researchers. To achieve this, editor Jonathan Moreno enlists the aid of a diverse group of professionals: health care providers, economists, historians, philosophers.   If the office cannot be converted to hospital-based, then the physician will continue to bill the technical fee using the physician fee schedule. With exception to vascular studies, the hospital-based reimbursement difference is significant, as illustrated in Table 1. The reason payment is different for hospital-based services is because.

Reimbursement: Payment regarding healthcare and services provided by a physician, medical professional, or agency. Capitation: A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services rather than based on specific services typical reimbursement method used by HMOs. Whether a member uses the health service once or more than . Medicaid. On average, this comprises 17% of overall physicians' revenue. This is a state program, with 42% funded by the state and 58% on average funded by the federal government. Third-Party Reimbursement for PAs PAs work to ensure the best possible care for patients in every specialty and setting. Their rigorous medical education, versatility, and commitment to collaborative care help practices function efficiently while providing increased revenues and enhanced continuity of care Medicare, Medicaid, TRICARE. Capitation payments control use of health care resources by putting the physician at financial risk for services provided to patients. At the same time, in order to ensure that patients do not receive suboptimal care through under-utilization of health care services, managed care organizations measure rates of resource utilization in physician.

A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than diagnostic. internally. The HMOs use ClaimCheckÒ from McKesson. ClaimCheck Ò is widely utilized in the healthcare financing industry, and is updated by the vendor from time-to-time. The HMOs may adopt the vendor’s updates as they occur. See the remainder of this .   At Pennsylvania-based Geisinger Health System, where I was CEO for 15 years, changing our model for physician reimbursement was one way we aimed to combat such practices and achieve value-based care. exercise the most control over patient choice and provider treatment options. HMOs follow a set of care guidelines patients must follow in order to receive maximum benefits. A structure common to many HMOs is the requirement for a patient to choose a primary care physician. The primary care physician acts as a gateway to all medical services.