Although MCOs are responsible for contracting with providers

Although MCOs are responsible for contracting with providers to deliver services to their members, MCOs have various networks they offer to their employer group customers to achieve different goals, like local/national networks, cost control, limited/expansive access... There are costs associated with each of these options, whether a higher or lower cost. If you are working for an employer in making the health care purchasing decisions: What options do employers have for compensating providers? What role does reinsurance play in provider reimbursement? What limitations exist (e.g., state or federal laws)? Provide examples to support your ideas.

Solution

In Managed Care Organisation, the employee group Customers are the members who received services from the providers or sponsors in exchange for fees. say these providers are contracted with the Health care organisation or doctors or physicians who give services to customers on fees based. The sponsors are such as HMO( Health Maintainenece organisation) and PPO ( preffered Provider Organisation) who managed care plan insurance for the Subscription fees charges from memebers.

If I am working for an employer in making the health care purchasing decisions , the options do members have for compensating providers are:

1). they received the preventive measures which avoid any health issues and Unnecesary administrative Expenditure.

2). the Outpatient care is increased, the Unnecesary test and expensive test are avoided, taking second opinion from experts before hospitalisation and giving treatment, reviewing the history of Patient health care, give free of cost medical and physical checkup to the members.etc.

3) as compared to traditional insurance policy , the option in health managed services in giving the choosing the helath care services and doctors of their choice is less.

Q2. In providing reimbursement the , the 80% of the expenditure are bear by the Managed services. and the remaining 20% is by Individual depending upon the plan.

Q3. Limitation: The changed regulatory and competitive environment will lead to significant changes in the retail distribution channels. Unlike other financial products, insurance is a complex product and one which plays a key role in the long term financial well being of a customer. Before the agents can advise their clients on which insurance solution is most appropriate for them, they will have to understand the financial standing of their customer, his financial commitments, his risk profile, etc

It is for this very reason that, as per IRDA, all agents need to undergo some mandatory training before being allowed to sell a life and Health insurance product. The 100-hour training pre-licensing covers the technical aspects of insurance and the selling/advisory skills required to be an agent.