What is an HMO?
Health Maintenance Organization - HMO's are both insurers and health care providers. They accept responsibility for a specific set of health care benefits offered to customers and provide those benefits through a network of physicians and hospitals.
Many people today are using HMO's. According to a New York Times article (Freudenheim, M. "Health Care in the Era of Capitalism," New York Times, April 2, 1996), an estimated 58 million Americans are enrolled in HMO's, and another 81 million are enrolled in other types of managed care. A July 8, 1996 Reuter's article says that more than 4 million Medicare beneficiaries and 12 million Medicaid recipients are in HMO's and other managed-care plans.
What kinds of HMO's are there? Staff model HMO's own and operate physician-staffed health centers that offer a broad range of medical care including laboratory, x-ray, vision, and pharmacy services.
Group practice HMO's contract with medical groups to provide health services to HMO members.
group model HMO
A health maintenance organization (HMO) that contracts with a group of physicians with multiple specialties who are employees of the group practice. Also known as a group practice model HMO.
health maintenance organization (HMO)
A healthcare system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.
health promotion programs
Programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes. Also known as preventive care programs or wellness programs.
Indemnity and Traditional Insurance
Traditional insurance, also known as Indemnity or Fee-for-Service, allows members to select any healthcare provider for services. Traditional insurance offers the most freedom of choice and control over healthcare, but benefits are maximized when using a participating Blue Cross Blue Shield company.
The integration of financing and delivery of healthcare within a system that seeks to manage the accessibility, cost and quality of that care.
managed dental care
Any dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.
medical advisory committee
The MCO (managed care organization) committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation and changes in authorization procedures. Medical advisory committees also review data regarding new medical technology and examine proposed medical policies.
network model HMO
A health maintenance organization (HMO) that contracts with multiple group practices of physicians or specialty groups
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
URIBEL- methenamine, sodium phosphate, monobasic, monohydrate, phenyls alicylate, methylene blue, and hyoscyamine sulfate capsule Uribel i...
procedure code and description 71250 - Ct thorax w/o dye - average fee payment - $180 - $190 71275 CTA chest (noncoronary) 71260 CT ...
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...
Procedure code and description 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ele...
Procedure code and description 95004 Percut Tests w/ Extrac Immed React # Allergy testing - Percut allergy skin tests - Percutaneous ...
Coverage Indications, Limitations, and/or Medical Necessity This LCD describes conditions under which the coverage of nail avulsion/ex...
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...