Managed Care Insurance: Billing Practices

Choosing the right health insurance plan for yourself can be a complicated matter as there are such a wide range of policies, providers and options. If you are interested in quality medical care for as little money as possible, a managed care insurance policy may be right for you. Managed car insurance policies control the financing and delivery of health care services to members by providing their them with a service network of doctors, hospitals and other medical necessities.

There are three different types of managed care insurance policies, and the billing for all of them differ based on the type of policy you choose to select.

Managed Care Billing Types

  • HMOs (Health Maintenance Organizations) – The HMO has a group of doctors, health care practitioners and hospitals under contractual obligation. Members in an HMO can only seek medical treatment from doctors under their plan and must go through a referral process to access more specialized treatment options. The members are billed with a monthly premium for this type health care plan. Depending on the exact plan and premium being paid, members typically have to make a low or no co-payments for their doctor visits (which must be paid in advance) and get reduced costs on their prescriptions.
  • PPOs (Preferred Provider Organizations) – PPOs have the basic core root of an HMO as there is a service network of doctors offering quality medical care at a more affordable rate. However, PPOs also have a flexible feature that allows members to seek the attention of doctors without having to go through the typical referral system of an HMO. PPO policyholders are billed monthly for their premiums, which tend to be a bit higher then HMO. Additionally they may be subject to co-payments and may require larger “out-of-pocket” expenses from the members.
  • POS (Point-Of-Service Plans) – POS plans are like a combination of an HMO and PPO, and are often called hybrids. Typically, when members seek medical attention within the service network of the policy, they will have to make low co-payments for their doctor visit. When they choose to go outside of the network, they will have to pay for their medical attention out of pocket, fill out a form and then wait for reimbursement. There would be a deductible that would have to be met and then a coinsurance plan would take affect.

The way you are billed for a managed care health insurance plan depends on what type of plan you opt into and the premium amounts you pay. It is important to investigate your managed care health insurance option thoroughly to figure out exactly how you will be billed for your coverage.