Open Panel Hmo Case Study

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An open panel HMO is a managed care plan that contracts (either directly or indirectly) with private physicians to deliver care in their own offices. Examples would include a direct contract HMO and an IPA. The principle control elements in an open-panel HMO are the use of the primary care physician “gatekeeper”, the lack of benefits if the member receives services from nonparticipating providers (other than for emergencies), and a much more aggressive utilization management system (Kongstvedt, 2007). The professional relationship with the physicians in the network is very important in managed care. The flood of managed care plans, together with increasing interventions by third-party payers’ has limited providers’ ability to cost shift to…show more content…
The first step would be to employ provider relations representatives. In most plans, there are people who are fully responsible for maintaining communications with the physicians and their office staff. Their job includes obtaining feedback from the physicians and office staff, updating them on changes, troubleshooting, maintaining and managing the contracts and other required documents, and to keep things running properly. This function is extremely important and the provider relations staff must be experienced. It is important for them to represent the physician’s point of view to plan management, but they should not side against the health plan unless they are truly at fault. They want to minimize problems, not increase them. Managing provider relationships has been aided through the use of information technology. It allows for tracking of issues, maintenance of contract information, recording all contacts, storing images of paper documents, etc. The provider relations function should be viewed as that of business partner. In a health plan, neither the plan nor the physician is always right. Provider relations should be proactive instead of reactive (Kongstvedt,
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