Health Insurance Matrix
Origin: When was the model first used?
What kind of payment system is used, such as prospective, retrospective, or concurrent?
Who pays for care?
What is the access structure, such as gatekeeper, open-access, and so forth?
How does the model affect patients? Include pros and cons.
How does the model affect providers? Include pros and cons.
In 1932 the American Medical Association (AMA) adopted a strong position against prepaid group practices, favoring instead indemnity-type insurance that protects the policyholder from expenses by reimbursement (Jones & Bartlett, 2007). As one of the first health policies in the U.S., indemnity plans are considered …show more content…
Although it is recommended. If a patient goes out-of-network they’ll typically have to pay the majority of costs. Unless the primary care provider makes a referral to an out-of-network provider, in which case, the medical plan will pick up the tab (Small Business Majority, n.d.).
Patients can easily go out of network. They have geographic flexibility that allows them to access doctors virtually anywhere. Compared to an HMO, patients have more choices. On the other hand, deductibles can be costly (Gustke, C., 2013). Provider’s in-network require a small copay. Out-of-network providers require patients to appease a high deductible. POS’s might not be worth it if you never use out-of-network providers. Out-of-network care requires patients to submit their own claims. Reimbursement can takes months to recover.
POS’s are very similar to HMO’s and PPO’s. POS plans may have restrictive guidelines for health care providers. Some POS plans require the use of a primary care physician (PCP). PCP’s are responsible for routine care, all referrals, obtaining precertification for in-network services, and filling out paperwork for in-network care.
Preferred provider organizations
Preferred provider organizations (PPO) originated in the 1970’s. PPO’s were created from the rules of fee-for-service care. PPO’s steer employees to cooperating doctors and