Yiyiphi i-Ofisi yezoNyango zezeMpilo efuna ukuyazi
Ukuqonda izicwangciso ze-inshorensi zempilo kwenza abasebenzi basebefesini bonyango bakwazi ukunxibelelana ngokufanelekileyo nezigulane malunga neentlawulo ze-inshorensi zezempilo kwaye baxoxe ngeenkcukacha zegulane ze-akhawunti kunye nabameli be-inshorensi.
Ukuba nolwazi olusisiseko lwaluhlobo ngalunye lwe-inshorensi luyakunciphisa ubunzima bokufaka izicelo zamabango kunye nokuqokelela iintlawulo. Kukho iintlobo ezimbini ezibalulekileyo ze-inshorensi yezempilo:
- Insurance Insurance
- IziCwangciso zokuNakekela
Insurance Insurance
Izicwangciso ze-inshorensi yokuzihlawula zenza iintlawulo kwiofisi yezobugcisa ngokusekelwe kumzekelo wemali-yeenkonzo. Ngomrhumo-wenkonzo, iofisi yezobugcisa ihlawulwa isamba esisetyenzisiweyo nganye kwifom okanye iseyunithi yenkonzo enikwe. Ukutyelela iofisi, iimvavanyo zebhabhi, i-x-ray, okanye enye inkonzo iyahlawulwa ngokwemivuzo yeshedyuli. Le ndlela yokuhlawula ivumela iofisi yezobugqirha ukuba ifumane ukuhlawulelwa okuphezulu kwiqendu ngalinye lokunyamekela.
Izigulane ezinesiqinisekiso sokuhlawula izibonelelo eziphuma kwiifokethi kwaye zifuna ukuhlawulwa kwiinkonzo ezifakwe kwi-inshorensi. Iofisi yezokwelapha ibandakanyeka kuphela kwiinkonzo ezifuna ukugunyazwa kwangaphambili .
Ukongezelela, izicwangciso zezibonelelo:
- Amalungu awayekho kwinethiwekhi yamagqirha
- Akukho kuthunyelwa okufunekayo kwiingcali zokutyelela
- Iintlawulo zenziwe ngokusekelwe kwintlawulo eqhelekileyo, yesiko kunye neyengqiqo (UCR).
IziCwangciso zokuNakekela
Ukulawula izicwangciso zokunyamekela kufuna ukulawula iindleko zempilo yabasebenzi ngamalungu ayo ngokucwangcisa nokucwangcisa ngononophelo lwamayeza, iingcali kunye nezibhedlele. Kukho iintlobo ezine zolawulo lokunyamekela:
- Imibutho yezoMpilo (ii-HMO)
- Imibutho yabanikezeli abathandayo (ii-PPOs)
- Imibutho yeeNkonzo eziPhambili (i-EPOs)
- Izicwangciso ze-Point-of-Service (POS)
Ulwahlulo oluphambili phakathi kwezi ntlobo zezicwangciso zonyango olulawulwayo lubhalwe apha ngezantsi.
Imibutho yezoLondolozo lweMpilo (i-HMOs)
Isiqalo esibonakala sisona sininzi kunye nesicwangciso se-HMO yindlela yokuhlawula i- capitation . Iintlawulo zemiqathango yesigulane, okanye iintlawulo ze-caption, zizinzileyo, iintlawulo zenyanga zifunyenwe yi-ofisi yezobugulane kwisigulane. Eli nani lihlala lifana naluphi na ukutyelelwa kwesigulane okanye iindleko zendleko ezithathiweyo kwaye nangona bengenakunyamekelwa nonke. Ezinye iimpawu ze-HMO zi:
- Akuncinci kubaboneleli bee-network ngaphandle koxakeka
- Ukudluliselwa okufunekayo kubone ingcali
- Ugunyaziso oluphambili lufunekayo kwiinkonzo ezithile
- Amalungu akanayo ama-copay amancinci kunye namancinci
2. Iinkampani ezibonelela ngempahla (i-PPOs)
I-PPOs zifana nezicwangciso zokuhlawulela ngeendlela ezininzi. Zombini iiPPO kunye nezicwangciso zokuhlawulela zihlawulwa yindlela yokuhlawula ngeenkonzo. Ngomrhumo-wenkonzo, iofisi yezobugcisa ihlawulwa isamba esisetyenzisiweyo nganye kwifom okanye iseyunithi yenkonzo enikwe. Ukutyelela iofisi, iimvavanyo zebhabhi, i-x-ray, okanye enye inkonzo iyahlawulwa ngokwemivuzo yeshedyuli. Le ndlela yokuhlawula ivumela iofisi yezobugqirha ukuba ifumane ukuhlawulelwa okuphezulu kwiqendu ngalinye lokunyamekela. Ezinye iimpawu zePPO zi:
- Ababoneleli nabangaphandle be-network bavunyelwe, izigulane zihlawula ngaphantsi xa abanikezeli benethiwekhi abasebenzisa
- Akukho zithunyelwayo ezifunekayo ukuze zibone ingcali
- Ugunyaziso oluphambili lufunekayo kwiinkonzo ezithile
- Amalungu angaba noxanduva lokuncitshiswa, i-copays kunye ne-coinsurance
Imibutho e-Exclusive Provider (EPOs)
Ii-EPO ziyafana kodwa zinqanda ngaphezu kwe-PPOs.
- Akuncinci kubaboneleli bee-network ngaphandle koxakeka
- Akukho zithunyelwayo ezifunekayo ukuze zibone ingcali
- Ugunyaziso oluphambili lufunekayo kwiinkonzo ezithile
- Amalungu angaba noxanduva lokuncitshiswa, i-copays kunye ne-coinsurance
4. Izicwangciso zeNkonzo (POS)
Izicwangciso ze- POS ziphambano phakathi kwamacebo e-PPO kunye nezicwangciso ze-HMO. Izicwangciso ze-POS zinikezela ngeenkonzo zangaphandle-nkonzo, nangona kunjalo, ezinye zazo zingancinci, zinciphise okanye azifumaneki.
- Ababoneleli nabangaphandle be-network bavunyelwe, izigulane zihlawula ngaphantsi xa abanikezeli benethiwekhi abasebenzisa
- Ukudluliselwa okufunekayo kubone ingcali
- Ugunyaziso oluphambili lufunekayo kwiinkonzo ezithile
- Amalungu angaba noxanduva lokuncitshiswa, i-copays kunye ne-coinsurance