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Hmo Health Care - What You Should Know About HMO Health Care

how hmos are run how hmos are regulated

In the United States, a Health Maintenance Organization (HMO) is a type of medical insurance that emphasizes long-term care, and as a rule, it is not as costly as a traditional major medical plan. Every enrollee selects a primary care physician (PCP) to provide preventive care and coordinate the patient’s treatment if hospitalization or the expertise of a specialist is required.

Reducing expenses in an HMO

Costs related to HMO health care are controlled by not covering certain services that are considered to be unnecessary, or by having patients visit physicians who are within a network. HMOs also deal with large numbers of patients and through negotiation, they can provide less expensive health care than other medical insurance plans.

How HMOs are run

In most cases, PCPs, who must follow the HMO’s restrictions and guidelines, determine what treatment is necessary for the patient and what is not. At times, they must also refer the patient to a specialist to provide care that is essential to the patient’s well-being. Women are often able to select their OB/GYN, and a referral is not required for visits to the emergency room.

How HMO health care began

The Health Maintenance Organization Act, which became law in 1973, states that any employer with at least 25 employees must provide HMO options that are federally certified if they provide traditional health care choices. HMOs are regulated by both the state and federal government, and they are also granted a state license that is called a certificate of authority (COA), as opposed to an insurance license.

How HMOs are regulated

On both the state and federal level, mandates are issued that require HMOs to offer certain products to their patients. However, HMOs have sometimes been sued, with the injured parties claiming that the limitations of HMO health care interfered with providing them with proper health care. However, the responsibility of an HMO for negligence on the part of a physician sometimes depends on the screening process they have in place.

If an HMO only employs providers who must meet certain high-quality standards and emphasizes this with its patients, a court may decide that an HMO is negligent in choosing its physicians, and hospitals are often held accountable in this way as well. Yet, there are also cases when an HMO is protected from being sued for malpractice, despite the way it dispenses care. Also, under the Employee Retirement Income Security Act (ERISA), the case usually rests on whether the harm suffered by the patient was the result of the physician’s actions (or lack thereof) or the way in which the HMO is managed.

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