GUIDE TO INFORMATION LISTED IN THE ANNUAL BI DIRECTORY OF HMOS/POSS AND PPOSPosted On: Dec. 28, 1997 12:00 AM CST
The 11th annual Business Insurance directory of managed care organizations contains more than 1,800 listings, including 160 health maintenance organizations, 230 HMOs offering a point-of-service contract, 125 POS plans and 1,336 preferred provider organizations.
The directory is published as an editorial service; there is no charge for organizations to be included.
HMOs/POSs or PPOs are listed alphabetically under the state in which they operate. When an HMO/POS or PPO operating in multiple states provides consolidated figures for regional operations within its network, the consolidated listing is marked with an asterisk and accompanied by a footnote. The names, addresses, telephone numbers and any services or information different from the consolidated entry are listed for the regional HMOs/POSs or PPOs in the state in which they operate, with a reference to the consolidated listing.
Each listing begins with the name, address, telephone and fax number of the HMO/POS or PPO. A bar heading indicates whether the organization is an HMO, a combined HMO/POS plan, a POS plan or a PPO. If the organization provides only specialized services, the specialty is noted in the heading.
The complete HMO/POS listings begin with information on staff and facilities as of June 30, 1997. Under the staff/facilities heading, staff includes the number of primary practitioners (defined as general practitioners, internists and pediatricians) affiliated with the network. Unless noted, only practitioners with whom the HMO/POS contracts directly are provided. Listed next is the percentage of board-certified practitioners, the average number of patients per practitioner and the number of specialists.
The number of participating hospitals, the number of pharmacies, and the number primary care locations under direct contract is also provided. Information on users as of June 30, 1997 was requested, including the number of employer/payer groups contracting with the HMO/POS, the number of employees with single coverage, the number of employees with family coverage, the number of employees and dependents in employer groups, Medicare/Medicaid enrollment and total membership served by the HMO/POS.
Gross revenues from HMO/POS operations for the first six months of 1997 and for the calendar year 1996 are listed next.
Information on operations follows, including the name of the parent company/owner, operational date, federal qualification status, states in which the product is licensed and information regarding accreditation by the National Committee for Quality Assurance in Washington.
The HMO/POS model type is listed next. Group model HMOs contract with physicians who are employees of a group practice. Independent practice associations (IPAs) contract with independent physicians who are able to maintain private practices along with the HMO/POS contract. Staff model HMO/POSs directly employ salaried physicians to serve patients. Network models contract for service with more than one group practice of physicians. HMO/POS plans may be a mix of more than one model type.
The tax status, either for profit or not for profit of the HMO/POS is also listed.
Service area by state and county follows. If the HMO/POS contracts for service with another established HMO/POS, the partner and service area are given here.
The services or types of coverage provided directly by the HMO/POS are listed next. These include general medical, dental, mental health, vision, prescription drug, workers compensation and any others reported. The listings note whether services are available unbundled and if the plan design may be customized to meet employer specifications.
Available rating options and community rates as of June 30, 1997 (if provided) are reported along with the availability of self-insured managed care products, point-of-service contracts and non-federally qualified programs to employers. Information on enrollment options, such as Federal Health Care Financing Administration contracts and individual enrollment is also included.
Names and titles of officers and the name of a contact person for those requesting further information complete each listing.
The complete PPO listings begin with information on staff and facilities as of June 30, 1997. Under the staff/facilities heading, staff includes the number of primary practitioners (defined as general practitioners, internists and pediatricians), affiliated with the network. Unless noted, only practitioners with whom the PPO contracts directly are provided. Listed next is the percentage of board-certified practitioners, the average number of patients per practitioner and the number of specialists. The number of hospitals and pharmacy locations under direct contract are included as well.
Information on users as of June 30, 1997 was requested, including group health and workers compensation. Group health lists the number of employer/payer groups, employees with single coverage, employees with family coverage and employees and dependents in employer groups with access to the network. Workers compensation lists employer/payer groups and total employees with access to the network, if given. Total users includes all group health plan employees and dependents, workers compensation and individual members. An employee is counted once if enrolled under both contract types.
Information on operations follows, including the name of the parent company/owner, operational date, and for profit or not for profit tax status. AAHC/URAC accreditation status is also noted, including, where applicable, health utilization management standards, health network standards, workers compensations utilization management standards and workers compensation network standards.
Service area by state and county follows. If the PPO contracts for service from another established PPO, the partner and service area are given here.
The services or types of coverage provided directly by the PPO are listed next, including general medical, dental, mental health, vision, prescription drug, workers compensation and any others reported. The listings also note whether services are available unbundled, if the PPO plan design may be customized to meet employer specifications and if individual enrollment is allowed.
The compensation heading contains information on how the PPO negotiates hospital charges, how it is compensated and how it charges for its services.
Utilization review methods used by the PPO and how they are provided are detailed next. Unless noted otherwise, standard utilization review procedures include: preadmission hospital review, precertification, concurrent hospital treatment review, length of stay determination, discharge planning, retrospective review, second surgical opinion, hospital bill audits, outpatient service predetermination and case management.
Officers and a contact for those seeking more information complete each listings.
Anyone wishing to determine the states in which multistate managed care organizations operate should refer to the alphabetical index of networks on page XXX. The index lists HMOs/POSs or PPOs operating directly or indirectly in three or more states.
A table of contents specifying the page upon which each state's listings begin has been provided on page 1.
Information for the directory was gathered from responses to a Business Insurance questionnaire. Although every effort has been made to obtain complete and accurate information, Business Insurance is unable to verify all information and relies on the responses provided by the HMOs/POSs and PPOs.