HSM420 Discussions Week 2

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HSM420 Discussions Week 2
Why do managed care organizations seek to establish a provider network? What are the primary…

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HSM420 Discussions Week 2

HSM420 Discussions Week 2

All Students Posts 63 Pages

Provider Networks – 31 Pages

Why do managed care organizations seek to establish a provider network? What are the primary reasons for contracting with providers?  Can an MCO survive without a provider network?…

In a small town, how large can the provider network be?  It is often stated that the small town insured individuals complain about having to drive many miles to receive care. What is the average mileage an individual has to drive to receive care?  In many areas, patients have to travel 30 miles or more to receive basic care.  What can MCOs do to entice providers to practice in such areas?  You stated that purpose of managed care is to provide health care services.

To whom are these services to be provided?  Healthcare should be regarded as a right; however, it is being managed as a privilege.  Managed care was to make healthcare affordable, but unfortunately, the premiums continue to rise.  How are we to receive what is a right if we are unable to afford it? With knowing that an MCO cannot survive without a provider network, does this make the providers the authority?  Are they able to dictate reimbursement rates?  Since MCOs control costs, do providers feel the need to avoid certain testing or services to ensure that they remain compliant with the MCO?  Are providers foregoing quality care for compliance?  With an MCO, who benefits more a provider network or the patients?…

Legal Issues in Provider Contracting – 32 Pages

Describe and discuss the key issues associated with provider payment that should be addressed in any managed care contract.  The way that providers are reimbursed has been simplified.  Why are some providers having issues with receiving payment?…

This form of reimbursement seems to be simple enough.  However, how are services administered outside of the bundle requirements paid?  Are providers allowed to bill additional services?  Overbilling/fraudulent billing is one of the major contributors to our healthcare deficit.  What more can be done to prevent such acts?  What is the grace period for errors?  Are providers being penalized for these errors?

Can you tell us what prompted the implementation of the ICD-10 codes?  Do you think that we should revert back to more of an indemnity environment?  Should we allow providers to determine pricing?  What are some examples of medical records being compromised?  What are the consequences?  What are more incentives that can be offered to encourage individuals to seek preventative care?…