Page 88 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

 The hospital charges must be reasonable and customary

 The physician fees are within the fee schedule

 Then, effect the payment, either to the claimant, to the employer or directly to

the hospital.
 Apply co-payment or deductible, if applicable in the final computation of the

claim payable.

The remittance advice must provide the details of the treatment and the amount

payable as entitled by the benefits. The details of any ineligible expenses not payable

must also be shown together with reasons

5.1.2 MANAGED-CARE ORGANISATIONS

An MCO is a health care company. It is often called a "health plan." It is a group of

doctors, hospitals and other providers who work together to meet your health care

needs. Managed-Care Organizations originated in the United States in the 1930s,

when the first prepaid group practices were established. The original type of

managed-care was to improve the quality and continuity of the care as a means of
providing preventive healthcare services. However, managed-care has evolved in

response to the escalation of healthcare costs in meeting the consumers' needs and

changes in medical practice.
Accordingly, managed-care systems will integrate the financing and delivery aspects

of appropriate healthcare services and have the following common elements:

 Explicit standards for the selection of healthcare providers

 Formal programs for ongoing quality assurance and utilization review
 Significant financial incentives for members to use providers and procedures

covered by the plan

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