They must be referred by the primary care physician to see a medical specialist and the specialist must be within the approved network, the plan normally costs less than the PPO plans, however the co-pay is significantly high. On the other hand, the PPO provides its participants with more information concerning the cost of sharing providers in and out of the network (Kongstvedt, 2007). The PPO commonly negotiates a lower overall fee arrangement with physicians, hospitals, clinics and other health care providers. For this reason; utilization management is another common characteristic of PPO so that they are able to control the cost of health care. With that being said, PPO allows participants to make their own opinion as to whether or not they would like to be covered by network providers or non-network providers. If the participant chooses to go outside of the network for services, their cost sharing rate will increase compared to those participants that choose to stay with the network services.
More so, with the indemnity plan, participants are allowed to use any medical provider of their choice while they receive care, however they are faced with paying annual deductibles for their coverage until the insurance reimbursement procedures take effect. After the payment of the deductible, the plan will then pay a percentage of its participants medical coverage while the participant is responsible for the remaining balance. There is also a cap on how much the insured would pay back towards the plan.
Cooper-Pearsons focus was on recruiting highly intellectual men and women right out of college and willingly paid great amounts of salary for joining the company, these individuals do not have families and insurance is not so important to them at that time, but after developing a family of their own these individuals seek for coverage and when those needs are not meet they turn to other companies. For these reasons, I believe that the company should turn to a stable managed care plan in order to maintain their staffs; one of the approaches would be an improvement on customer care. The PPO plan happens to carry this message in mind since they give individuals the opportunity to make their own decisions. The plan is not as cheap as HMO, but it gives the participant the rights that they all want, and if Cooper-Pearson Sports Marketing would like to retain their employees, it is discernable that the PPO plan is the best choice for them.
I will also recommend that the company adopt a managed care physician credentialing in order to assist them with reducing employee turnover. Both the HMO and PPO plans must select and retain qualified health care providers to provide quality services to their customers. With credentialing, the agencies must review and verify the information of the health care providers, who are interested in participating in their plan. The main reason for this process is for the Managed Care Organization (MCO) to maintain that the individuals meet the minimum requirement for providing care to their subscribers (Carefoote, 1998).
Carefoote, R. L. (1998). Medical Management-Credentialing. Retrieved from http://www.mcres.com/mcrmm08.htm Kongstvedt, P. (2007). Essential of Managed Health Care. 5th Edition. Jones and Bartlett: Sudbury, MA.