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When providers agree to accept an insurance company's plan, the contractual agreement includes many details, including fee schedules which dictate what the insurance company will pay the provider for covered procedures, and other rules such as timely filing guidelines.
Resource-based relative value scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all health maintenance organizations (HMOs).
Provider revenues are fixed, and each enrolled patient makes a claim against the full resources of the provider. In exchange for the fixed payment, physicians essentially become the enrolled clients' insurers, who resolve their patients' claims at the point of care and assume the responsibility for their unknown future health care costs.
Traditional Medicare directly compensates providers on a fee-for-service basis. [1] Plans are offered by integrated health delivery systems, labor unions , non profit charities, and health insurance companies, which may limit enrollment to specific groups of people (such as union members).
If the PPO plan is an 80% coinsurance plan with a $1,000 deductible, the patient pays 100% of the allowed provider fee up to $1,000. The insurer will pay 80% of the other fees, and the patient will pay the remaining 20%.
In the United States, an independent practice association (IPA) is an association of independent physicians, or other organizations that contracts with independent care delivery organizations, and provides services to managed care organizations on a negotiated per capita rate, flat retainer fee, or negotiated fee-for-service basis.
These prepaid plans burgeoned during the Great Depression as a method for providers to ensure constant and steady revenue. In 1970, the number of HMOs declined to fewer than 40. Paul M. Ellwood Jr. , often called the "father" of the HMO, began having discussions with what is today the U.S. Department of Health and Human Services that led to the ...
With indemnity dental plans, the insurance company generally pays the dentist a percentage of the cost of services. Restrictions may include the co-payment requirements, waiting period, stated deductible, annual limitations, graduated percentage scales based on the type of procedure, and the length of time that the policy has been owned.