Discuss the types of data and reports that would be useful t

Discuss the types of data and reports that would be useful to the medical director for managing specialist utilization; discuss how this might differ in different types of health plans?

Solution

Depending on how many plans are offered in your area, you may find plans of all or any of these types at each metal level – Bronze, Silver, Gold, and Platinum.

Some examples of plan types you’ll find in the Marketplace:

In the medical management area, committees serve to diffuse some elements of responsibility and allow import input from the field into procedure and policy or even into case-specific interpretation of existing policy. Examples of committees are: credentialing committee, medical advisory committee, utilization review committee, pharmacy committee, peer review committee

Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won\'t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.

Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.