PS healthcare assignment 2

PS healthcare assignment 2

PS healthcare assignment 2

You are a new graduate, and you just started work at a medium-sized hospital with an attached clinic. You have been asked to review the five different types of health care insurance plans and the characteristics of each to make sure the central business office (CBO) is up-to-date on all the rules and regulations. It is important to be familiar with these plans and the characteristics of each because they play a vital role in the reimbursement process for your health care organization. Discuss the following:

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  • List the five different types of health care plans and 2–3 characteristics of each.
  • Explain why it is important to understand the differences in these plans.
  • What are some of the similarities between the plans?
  • What are some of the differences?
  • Would an out-of-date policy from one of these plans affect the facilities reimbursement? If so, how?

Part 2- reply to this post with 150 words

The 5 health care plans and their characteristics:

HMO- A network of providers that agree to lower cost for services, but at a standard quality of care. Members don’t have to worry about duplicate fees for services already rendered.

PPO- Members are able to see any doctor that they choose. Members do not need a referral to see a specialist.

POS-Members have the flexibility when choosing a PCP. A balance of choosing a PCP and having lower premiums.

EPO-Less PCP choice for lower rates. Smaller co-pays with smaller network.

Fee for service-Members have more service control but at a higher rate. Members pay out of pocket and get file claims for reimbursement. PS healthcare assignment 2


It is important to understand the difference between the type of healthcare plans. The skinny of it comes down to revenue. Each plan has a way of billing, and some have regulations that determine incentives. With an HMO, if the provider is able to treat the patient at a lower cost, and they get well; the government gives the provider an incentive. A PPO can allow a member to request duplicate diagnostic testing without it being denied. A POS combines an HMO and PPO where they have lower cost for care, but at a limit. With an EPO if the member has a service outside of the network, the cost will fall on the member. A fee for service plan only provides a service once it is paid for. Again, it all comes down to capital. The business of healthcare is costly. The burden is on the party that does not fully understand the operations of the plan.

The similarities between the plans are that the member has the choice of services. They can select a PCP, and have preventive health at low to no cost. They are able to select services within the network. The EPO combines the PPO and HMO benefits with a smaller network to receive health care. The difference between the plans are how billing will be handled. Some plans do not allow the member many options for services. The fee for service plan is a plan of its own. The member must pay prior to the service being provided. Unlike the other plans, where the member has an employer or they pay a premium.

If a medical office had an out of date policy for billing of each plan, that would directly affect the business. The service would not be reimbursed due to old ICD codes. The cost for healthcare has regulations and those that are not followed will come with penalties. This will snowball down and affect everything from employees to the office management. An office would need a skilled and knowledgeable manager to ensure that the policies are up to date and followed. To ensure that healthcare is a continued service.

Part 3- reply to this post with 150 words

PPO – Preferred Provider Organization

This type of plan has an annual deductible that must be met before the insurance company starts paying. You are encouraged to use a network provider but you don’t have to stay with one you have the freedom to choose also you can see a specialist without having a referral.

The good side to this is the freedom of finding someone you are happy with instead of being stuck with someone you don’t care for. The down side to this one is its all out of pocket until you meet your deductible.

HMO – Health Maintenance Organization

With this plan the employee has the least of flexibility when choosing providers and must have a referral before seeing a specialist. The insured has to pay a co pay. PS healthcare assignment 2

POS – Point of Service

With this plan you have to choose a provider in the network. When being seen you must pay your co pay at time of visit.

EPOs – Exclusive Provider Organization

This plan requires you to choose a network provider, but in the case of an emergency you are able to go without being in jeopardy of insurance not paying. The insured will have a Primary Care Provider and will have to pay a co pay at time of service.

This is the plan we currently have through Tricare, We pay a yearly fee of apx. 500.00 bucks, and when I see my PCP I don’t have to pay anything, when I go to an Urgent Care or a specialist (with referral) I have to pay 30.00 bucks. This works for us due to the ongoing visits to a PCP.

Indemnity Health Insurance Plans

This is a fee for service plan, the member may be responsible for deductibles and co pays. The insured will pay everything out of pocket and then file a claim for reimbursement.

While researching this assignment I realized how important and also difficult it is to understand all the different plans and coverages out there. If I am sitting at a desk providing customer service or taking payments at a hospital payment window, I have go to be able to answer questions to the patients when I tell them how much I will need to collect from them for the treatment, hospital stay, medication etc. I can speak from experience because I have been on the other side of the counter asking “why am I having to pay such and such amount”

I think out of date policies would affect the patient due to higher costs, deductibles and less coverage. As far as to the clinic I think maybe a delay in payments, but there are so many programs and electronic means that may not even be an issue. There are a ton of steps when it comes to medical billing/coding and its important that when billing the coding is done correctly, if not this can cause delays in payment while going through the adjudication process.

Part 4 400-600 words

Accurate coding and billing are essential to a health care facility and to a physician’s financial survival. Coding is a complex task that ties to charges and revenue generation. Failure to capture all charges associated with a patient encounter can result in significant revenue loss. Medical necessity also plays a vital role in the contract with the facility or physician in terms of receiving payment from the third party payer (e.g., an insurance company).


For this Discussion Board, you will define medical necessity, and you will describe the criteria to determine it.


Once the patient has an established diagnosis and the services and procedures have been ordered, you will code out this information and place it on the claim for payment.

It is important for health care professionals to understand this process to receive accurate reimbursement.

For this part of the discussion, you will be identifying the coding systems that are utilized to support the diagnosis, services, and procedures.

List and discuss the coding system that is utilized to code out the patient’s conditions or diagnosis. Provide an example of a diagnosis with the appropriate code as an example, and respond to the following questions:

  • What is the coding system replacing the diagnostic system?
  • Will it be implemented this year? Explain your answer.

Next, identify what coding system is utilized to capture the services and procedures that the patient has received (both levels). List an example of a service or procedure with the appropriate code as an example, and respond to the following questions:

  • Why is it important to assign the correct codes to the diagnoses, services, and procedures that a patient has received?
  • What are the repercussions of submitting incorrect coding and billing errors to the third party payers? PS healthcare assignment 2


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