ALPHABET SOUP in Wisconsin Health Care - HMO, PPO, POS and FFS

MILWAUKEE - (MPA-PPR) -- The date of implementation of the Affordable Health Care law is October 1, 2013 -   Open Enrollment.  The Open Enrollment is a six month process from October 1, 2013 - March 31, 2014.  Full implementation begins January 1, 2014.

PREPAREDNESS

Milwaukee Professionals Association LLC (MPA LLC) continues to inform the stakeholders of how they can best prepare for "decision making" in their selection of health care insurance from the marketplace.

What they can put into their Health Care shopping cart that can help avoid "unintended consequences".

Recognizing and defining ACRONYMS are necessary steps to navigate the NEW law and all its evolving parts.  We will start with four (4) acronyms of comprehensive managed care.  They are:  HMO, PPO, FFS and POS.  The managed care providers are to share comprehensive plans with savings and quality to the marketplace.

HMO

Health Maintenance Organizations (HMOs) is health care service restricted to its list of physicians for primary care and referrals to other health care specialists in their network.  You can go outside of the network to another network but, you are required to pay the bulk of the health care services.

Monthly insurance premiums usually cover most visits to the primary care physician, medical treatment and preventive care; with no individual or family deductible for the client.

PPO

Preferred Provider Organizations (PPO) is a health care service for the public that has a list of physicians and hospitals within its network.  It is more flexible than the HMO in visits outside of the HMO network  with some coverage.  What is offered?  Is there a co-payment?  How much it will cost? What is the process for reimbursements and/or partial payment by the PPO?  These are questions you, the client must find out.

YOU, the client/customer/beneficiary, must do your homework for your benefits.

POS

Point of Service is health care service that combines the HMO and PPO plans.  You must select a physician that belongs to a HMO or PPO to be your primary care physician.  Cost is again dictated by in-network health care practitioners and providers vs one in another when it comes to cost - less cost is with a health care provider within the network you initially choose.

It is important to know that there are other areas of clarity needed relating to dental, vision, prescription drugs, etc.

FFS

Fee-For-Service 

Fee-for-Service (indemnity plan) is the oldest and most expensive health service plan and preceded the managed care organizations - Health Maintenance Organizations and Preferred Provider Organizations.  HMO and PPO organizations are the most popular.

In the health insurance and the health care industries, FFS occurs when doctors and other health care providers receive a fee for each service such as an office visit, test, procedure, or other health care service.^[3] Payments are issued retrospectively, after the services are provided.^[4] FFS is inflationary, raising health care costs.^[4] It creates a potential financialconflict of interest with patients, as it incentivizes overutilization^[5]—treatments with either an inappropriately excessive volume or cost.^[6] FFS does not incentivize physicians to withhold services.^[7] When bills are paid under FFS by a third party, patients (along with doctors) have no incentive to consider the cost of treatment.^[8] Patients can welcome services under third-party payers, because "when people are insulated from the cost of a desirable product or service, they use more".^[9] Evidence suggests primary care physicians who are paid under a FFS model to treat patients with more procedures than those paid under capitation or a salary.^[10] FFS incentivizes primary care physicians to invest in radiology clinics and perform physician self-referral in order to generate income.^[11]

Private-practice physicians and small group practices are particularly vulnerable to declining reimbursement for patient services by government and third-party payers. Rising regulatory demands, such as the purchase and implementation of costly EHR systems, and increasing vigilance by government agencies tasked with identifying and recouping Medicare fraud and abuse, have bloated overhead and cut into revenue. Wikipedia

See table of all four types - At Your Service UC
Visit INSURANCE.COM and MEDICAID.gov,  for more information.