All right, welcome. My name is Divine. This is episode 658 of the Divine Intervention podcast.

Right. And into this podcast, we're going to be finishing up the series on health insurance, right?

Again, if you miss part one and part two, you should go back and listen to those.

I think you'll find those to be really helpful with your studying. So, let just jump right into it, right? So again, we've talked about a bunch of things. So let's maybe go into the discussion of just a few more kind of higher points that pop up on the exams, right? So let's talk about also managed care plans. I think that's kind of a useful thing to know right so first um so

managed care plans right so let's kind of talk about these i think as i discussed them you understand

what why classify them as managed care plans right so the first one is going to be a hMO a health

maintenance organization right so this is super restrictive it can be pretty effective but it is super restrictive right

basically if you're a member of this kind of plan you know you must choose a primary care

physician and then that primary care physician is like the referee right they're like the

gatekeepers right if you want to see any kind of specialist you need to get a referral from the

PCP right you need to get a referral from the PCP right you need to

get a referral from the PCP right generally they don't cover out of network care right so if a person is

not if a physician is not within the HMO you're not getting covered right so out of network care

generally not covered except for like an emergency right but it's like you're like man divine this is so

restrictive what do i get uh in exchange for this well the thing you're going to get in return is

the premiums are pretty low right uh the premiums are pretty low right and hMOs they tend to use

capitation to ppcps remember we talked about capitation with the last podcast where it's like oh

you get paid a fixed amount per patient right and uh we said that underutilization can be the bugable with that method of

reimbursement. All right. So again, if they give you a question on your exams about a patient

that, you know, for example, needs to say a cardiologist hasn't got her in a referral from

her PCP, right? And they're telling you that, oh, the HMO is not willing to pay for it. Then they ask you, like, what should this primary care physician do? Well, the primary care physician picked the answer that talks about, you know, helping the patient to navigate the referral process, documenting medical necessity, so that person can get the care that they need right all right so next let's talk about

a pPO a preferred provider organization right so what in the world do i mean by a pPO right

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