PHSC 2 Lecture Notes - Lecture 10: Managed Care, Health Maintenance Organization
Document Summary
Value of service based on the basic resources needed to provide it (e. g. people, supplies, equipment, space, insurance, business functions) Admin costs & uncompensated care = ,000. Combination of cost plus profit and anticipated increases in cost. Average charge/visit @ 1,000 visits/month = . 00. Medicaid may pay , medicare may pay , healthnet may pay. and blue cross may pay (due to a multi year agreement with a special inflation clause) Your insurance cost (premium + out of pocket) Provider fee schedule and anticipated loss ratio . And this is how your insurer determined the price you will pay based on your risk group. Will need to negotiate for best payment from each one. Will have variation in requirements among plans. Different providers covered in network which influences referrals to specialists, rx, labs, etc. Provider may be able to average high and low payers through cost shifting and cross subsidization.