N108: Transition to the Registered Professional Nurse

N108: Transition to the Registered Professional Nurse Role Study Guide of 171 payments for services; therefore, third party payers have the power to demand changes in the healthcare system. When they were first established, these agencies did not see their role in healthcare as anything beyond a financial relationship. As healthcare cost rose, these agencies began looking for ways of controlling costs to maintain their competitive place in the insurance market and have set increasingly rigid criteria for payment for services. The standard rates set for payment for procedures tend to place some restraints on charges. By determining whom they will pay for services, insurance companies reduce the choices available to those who carry insurance, and subscribers usually must select from the choices available if they wish to be reimbursed. Third party payers therefore exert a more powerful influence over institutions and care providers than do individual subscribers. Direct Pay In this type of payment system for healthcare services, the patient pays directly out of pocket for services rendered and pays a fee for each service that is delivered. The cash-only model is based on the idea that rather than charging higher, so-called retail rates for uninsured patients while negotiating discounted rates with insurance companies for covered patients, it's fairer and possible to offer flat and reasonable rates to all. For the patients that have the means to do this, it's an outstanding model of the patient-centered medical home. Cash-only doctors are predicted to grow in the coming years, which will provide self-pay patients with more options and more savings when it comes to paying for their healthcare needs. Whether uninsured or with a high-deductible health insurance plan, this form of payment has managed to cut the cost of providing care simply by opting out of insurance contracts. Preferred Provider Organization (PPO) A PPO is a group of providers that forms a company with a healthcare agency to provide care to an insurance company or any employer at a discounted rate. The monthly premium is higher for each individual subscriber, because there is a greater choice of healthcare providers. One physician or provider can be a designated provider for several PPOs at once. Subscribers choose their provider based on which plan they choose to join. Preferred Provider Arrangement (PPA) A PPA offers more choices to an individual subscriber. The PPA provides a contract to individual healthcare providers rather than an entire healthcare agency like a PPO. The subscriber may stay with his chosen provider if he chooses a more expensive PPA. Independent Practice Association (IPA) An IPA subscriber pays a fixed monthly premium to receive care in a provider’s office. The IPA pays the provider as a third-party payer. Some IPAs may pay a fixed rate to the healthcare provider or refund money to the subscriber if payments exceeded costs. Physician/Hospital Organizations (PHO) Hospitals and groups of physicians may enter into business to provide healthcare to a variety of ©2017 Achieve Test Prep Page 97

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