Page 91 - MEDICAL AND HEALTH INSURANCE
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MEDICAL AND HEALTH INSURANCE
Capitation
It is a common approach to pay a capitation amount, especially for primary care, upon
the outpatient general practitioner visitation. The primary care physician in the
network would be paid a fixed amount of money per member per month regardless
of the number of visits to the clinic. The incentive would be to keep the members
healthy with fewer visits.
Case rates
Managed-care organizations may contract with providers on a 'case rate' basis. Similar
to global fees, this is a negotiated fixed rate for certain specialty treatments like
coronary artery bypass grafting, amongst others.
Fee-for-service
The fee-for-service managed-care arrangement is unlike the traditional fee-for-service
payment. The fees are mutually agreed with elements of cost control through
negotiated fees and global fees. Negotiated fees are the agreed fees, predetermined
upfront for each service. Global fees are set negotiated fees that are all-inclusive for
the entire range of services provided for a specific episode or episode of care. An
example of global fees is those associated to prenatal care, from diagnostic tests to
regular visits related to pregnancy.
Diagnosis related group (DRG)
Diagnosis related group payment is a flat rate fee for all inpatient, services related to
a diagnosis and a single episode of care.
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