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HMOs Unique Features And Lingo

Provider, Also Known As "Contracting Provider"

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HMOs contract with doctors, hospitals, physical therapists, nurses, x-ray and lab technicians, and other medical personnel, to provide services for the HMO's members. In addition to setting the fee or the capitation that the HMO will pay the provider, the contract will also require the provider to follow the HMOs guidelines on procedures.

Guidelines can range from requiring pre-certification of all hospital confinements, to spelling out when to refer a member to a specialist, to which brand of medications should be prescribed.

Some contracts even spell out bonuses for physicians if their utilization (use of medical treatments) is lower than a pre-set amount. 

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