HMO's must provide adequate health services.
Health maintenance organizations (HMO) are healthcare organizations that attempt to reduce healthcare costs while maximizing the healthcare benefits received by the patients. These HMO's provide health services to patients who cannot normally afford health services. These HMO's must follow strict rules when providing care for their patients. Some of these rules are particular to a given area, while other rules extend throughout the United States.
County Permission
In order for a HMO to be created, the HMO must get permission from the county that the HMO is a part of. The requirements for becoming an HMO vary from county to county. The way in which HMOs can operate depends on whether or not the HMO does business with Medicare and Medicaid recipients, so counties often take those factors into consideration.
Basic Care
The HMOs must also provide certain core services to be allowed to operate. These services include inpatient hospital care, laboratory tests to diagnose problems, cancer treatments, vaccinations, checkups, diabetes services, mental health care, physical therapy and hospice care.
Standards
These HMOs must comply to certain basic rating standards that are applied to the services that these HMOs provide. Quality medical services catch serious medical conditions early on, listen to concerns that patients have and provide urgent care when patients need them.
Financial Matters
Health organizations must have a certain amount of reserves, deposits and net worth in order to become HMOs. They are required to report their financial information and auditors occasionally come to assess whether or not the HMO is operating efficiently.
Appeals
HMO's can deny medical services in certain cases. When the HMO decides that a patient does not qualify for a particular medical treatment, the patient can appeal this decision by following a two-step process. The patient must first file an appeal to the decision within 180 days. A decision on the appeal must be made quickly, usually within five business days, since the medical circumstances might be urgent. If the appeal is rejected, a more formal appeal can be made that can take 20 days.
Independent Health Care Appeals Program
When an HMO makes a decision that the Independent Health Care Appeals Program (IHCAP) disagrees with, the IHCAP can make a binding decision regarding the patient care. The HMO must comply to the IHCAP's decision.
Disclosure
Covered patients must have all medical information disclosed to them regarding their own medical condition. The HMO must tell the covered patient all of the treatments that are available to resolve the medical condition.
Maternity
Patients who are receiving maternity treatment and are in their third trimester must continue to receive medical care from the HMO until after the postpartum care has been completed. Primary care physicians must continue to provide care to patients until the end of the care plan period.
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