View Full Version : 8GM - Triple Option

Not Mike
10-01-2002, 11:34 PM
OK, this just doesn't make sense to me.....

You have an HMO and a POS (with an OON benefit)...

If the HMO has the highest benefits AND the lowest premiums (to incent people to join), how in the world do the highest users/worst risks end up in the POS program???

If I'm a high user and I can get MORE benefits for LESS dollars, why in the heck am I going to take the POS just to avoid the network? Is it just due to the HMO backlash? That people just don't like HMOs?

Dr T Non-Fan
10-01-2002, 11:42 PM
Yes to all.
The "high users" tend to use the high cost doctors out of the network. They like to use specialists and not wait for the gatekeeper to approve it. These people are also known as hypochondriacs.

POS is the appropriate term. More of a consultant-designed organism made for a particularly large and valuable group. More trouble than they're worth IMO. 'course, don't quote me on the exam. This forum is not part of the syllabus.

Not Mike
10-01-2002, 11:55 PM
Thanks for the info....

This note also kind of implies that in order to be a POS, an HMO has to take the risk for the in- and out- benefits, which kind of makes it sound like you can't self-insure a POS. That's not true, is it? (Maybe it was at some point)

Anyway, maybe I'm just too smart a consumer but this high-user doesn't mind jumping through hoops to get his 100% coverage.....

10-02-2002, 10:45 AM
I agree with you, Not Mike. The part where they said the HMO has the highest benefits must be a mistake. HMO's are full of limitations, whereas POS's are not. Never before have I seen anyone say that HMO's benefits are the best. Maybe compared with the price they are the best. Anyway, I'm treating it as a typo.

10-02-2002, 06:21 PM
HMO's benefits are the best (100% coinsurance instead of say 90% coinsurance). Now, actually receiving those benefits . . . that's another matter. Remember, if providers are being reimbursed through capitation, they have an incentive to never see the patient. In an HMO if a patient asks the doctor for an expensive procedure, the doctor may look for less expensive methods to treat the patient. If a patient really wants expensive care, they won't take the chance of hoping an HMO doctor approves it. So they will choose the POS plan.

10-02-2002, 06:38 PM
The problem is with the word "benefits". If they mean the extent of what's covered, HMO's are the worst. If they mean the extent of benefits that $x can buy you, then HMO's are the best.