1. Compare and contrast payment methodologies between FFS and MCO plans.
2. Problems that MCOs have experienced when implementing capitation arrangements in specialty care practices. © BrainMass Inc. brainmass.com March 21, 2019, 9:16 pm ad1c9bdddf
https://brainmass.com/health-sciences/health-care-management/fee-for-services-and-managed-care-organizations-368896
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FFS or fee for service is a payment system in which the health
insurance either pays the provider directly or reimburse the insurer for
each service received or ‘covered’ medical expense incurred based on
the usual and customary fees charged in the local area (BCBS, 2010). A
few words in this statement are key to understand how it works.
First, it is a payment for services after they have been incurred.
Second, the services must be covered by the health insurance, which
means that only those authorized by the insurance will be reimbursed.
With the non-covered services generally the patient has two options: (a)
either the client/patient does not receive the service, or (b) the
patient has to pay the provider of services directly for the full cost
the services. And the third key element is that the insurance pays based
on usual and customary fee charges in the local area. This means that
the insurance has set certain amount according to the area that is
usually based on a benchmark established by what Medicare and other
insurances pay for the same services. A provider in New York bills for
the same service as a provider in Arizona to the same insurance. The
provider in New York will get a higher reimbursement than the provider
…
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