RCP Task
WGU
Financial Resource Management in Healthcare (C428)
A. Create a report (suggested length 5–8 pages) that includes the following:
1. Recommend three strategies to move away from a fee-for-service model:
PPO (Preferred Provider Organization): This option will allow employees to
select their provider and does not require a referral for specialists, which is a
significant benefit. PPOs encourage using their in-network providers by providing
maximum benefit reimbursement for those using them. The benefits of a PPO
plan will also extend to out-of-network providers. However, the coverage for
those costs is lower than with an in-network provider. Insurance premiums can
vary from plan to plan, and often, the premiums paid by employees are more
expensive than other healthcare coverage options.
HMO (Health Management Organization): This option involves contracting with
specific providers and utilizing management to control the costs to the plan and
beneficiaries. HMOs are more limited and require prior authorizations and
, referrals for care. This type of plan only covers out-of-network providers.
However, the premium cost to its beneficiaries is often lower, and following the
utilization management process prevents unnecessary costs to the organization.
POS (Point of Service): This option combines the benefits of both PPO and HMO
plans. It provides flexibility to the beneficiaries by allowing in-network and out-
of-network coverage. As with PPO plans, members' out-of-network costs are
higher but will enable the freedom of choice. Like HMO plans, referrals from a
primary care physician for treatment and specialists are often required. Costs to
beneficiaries are lower when choosing in-network care.
WGU
Financial Resource Management in Healthcare (C428)
A. Create a report (suggested length 5–8 pages) that includes the following:
1. Recommend three strategies to move away from a fee-for-service model:
PPO (Preferred Provider Organization): This option will allow employees to
select their provider and does not require a referral for specialists, which is a
significant benefit. PPOs encourage using their in-network providers by providing
maximum benefit reimbursement for those using them. The benefits of a PPO
plan will also extend to out-of-network providers. However, the coverage for
those costs is lower than with an in-network provider. Insurance premiums can
vary from plan to plan, and often, the premiums paid by employees are more
expensive than other healthcare coverage options.
HMO (Health Management Organization): This option involves contracting with
specific providers and utilizing management to control the costs to the plan and
beneficiaries. HMOs are more limited and require prior authorizations and
, referrals for care. This type of plan only covers out-of-network providers.
However, the premium cost to its beneficiaries is often lower, and following the
utilization management process prevents unnecessary costs to the organization.
POS (Point of Service): This option combines the benefits of both PPO and HMO
plans. It provides flexibility to the beneficiaries by allowing in-network and out-
of-network coverage. As with PPO plans, members' out-of-network costs are
higher but will enable the freedom of choice. Like HMO plans, referrals from a
primary care physician for treatment and specialists are often required. Costs to
beneficiaries are lower when choosing in-network care.
