Yisiphi Isikhungo Sezempilo Esidinga Ukukwazi
Ukuqonda okuyisisekelo kwezinhlelo zomshuwalense wezempilo kwenza abasebenzi basehhovisi bezokwelapha bakwazi ukuxhumana kahle neziguli mayelana nezinzuzo zabo zomshuwalense wezempilo futhi baxoxe ngemininingwane ye-akhawunti yesiguli nabamele inkampani yomshuwalense.
Ukuba nokuqonda okuyisisekelo kohlobo ngalunye lomshwalense kuzonciphisa izinkinga zokufaka izimangalo nokuqoqa izinkokhelo. Kunezinhlobo ezimbili ezinkulu zezinhlelo zomshuwalense wezempilo:
- Umshuwalense Wesikweletu
- Izinhlelo Zokunakekelwa Eziphethwe
Umshuwalense Wesikweletu
Izinhlelo zomshuwalense wokuzikhokhela zenza ukukhokhelwa ehhovisi lezokwelapha ngokusekelwe kwendlela yokukhokhela imali. Kukhokhwa-ngensizakalo, ihhovisi lezokwelapha likhokhwa inani elibekiwe lohlobo ngalunye noma iyunithi yesevisi eyenziwe. Ukuvakasha kwehhovisi, ukuhlolwa kwelebhu, i-x-ray, noma enye insizakalo iyakhokhwa ngokuvumelana nesimiso semali. Le ndlela yokukhokha ivumela ihhovisi lezokwelapha ukuthi lithole ukubuyisela okuphezulu kwesicoco ngasinye sokunakekelwa.
Iziguli ezinezinhlelo zokuzikhokhela zikhokha izinsizakalo eziphuma ephaketheni futhi zifuna ukubuyiselwa kwemisebenzi ehlanganisiwe kusuka kumhlinzeki wabo womshuwalense. Ihhovisi lezokwelapha kuphela lihilelekile kumasevisi adinga ukugunyazwa ngaphambi .
Ngaphezu kwalokho, amacebo okusiza:
- Amalungu awawona enethiwekhi yezinyanga
- Azikho ukuhanjiswa okudingekayo kochwepheshe bokuvakashelwa
- Izinkokhelo zenziwa ngokusekelwe ekukhokhweni okujwayelekile, ngokwesiko nangokwemvelo (UCR).
Izinhlelo Zokunakekelwa Eziphethwe
Ukuphatha izinhlelo zokunakekela zifuna ukuphatha izindleko zokunakekelwa kwezempilo kwamalungu ayo ngokuhlela nokuhlela ukunakekelwa ngenethiwekhi yabanogada, ochwepheshe kanye nezibhedlela. Kunezinhlobo ezine zezinhlelo zokunakekelwa eziphathisiwe:
- Izinhlangano Zokulondoloza Impilo (ama-HMO)
- Izinhlangano Zokuhlinzeka Ezikhethiwe (ama-PPOs)
- Izinhlangano Ezihlinzeka Ngaphandle (EPOs)
- Izinhlelo zePoint-of-Service (POS)
Umehluko omkhulu phakathi kwalezi zinhlobonhlobo zamasu okunakekelwa okuphethwe kubhalwe ngezansi.
Izinhlangano Zokunakekelwa Kwezempilo (ama-HMO)
Isici esivela kakhulu ngezinhlelo ze- HMO yindlela yokukhokha kwayo. Izinkokhelo zesiguli, noma izinkokhelo zokuthunjwa, zikhokhwa, izinkokhelo zenyanga zonke ezithola ihhovisi lezokwelapha isiguli. Leli nani lihlala lingalingani kungakhathaliseki ukuthi bangaki ukuvakashela isiguli noma izindleko zezindleko ezithintekile ngisho noma bengakutholi ukunakekelwa nhlobo. Ezinye izici ze-HMO yizi:
- Kuncishiswe kubahlinzeki be-inthanethi ngaphandle kwezimo eziphuthumayo
- Ukudluliselwa okudingekayo kudingekile ukubona isazi
- Ukugunyazwa kwangaphambili kuyadingeka kumasevisi athile
- Amalungu akanayo ama-copay angasetshenzisiwe futhi aphansi
2. Izinhlangano Zokuhlinzeka Ezikhethiwe (PPOs)
Ama-PPO afana nezinhlelo zokuzikhokhela ngezindlela eziningi. Zombili izinhlelo ze- PPO kanye nezinhlelo zokuzikhokhela zikhokhwa ngemali yokukhokhela imali. Kukhokhwa-ngensizakalo, ihhovisi lezokwelapha likhokhwa inani elibekiwe lohlobo ngalunye noma iyunithi yesevisi eyenziwe. Ukuvakasha kwehhovisi, ukuhlolwa kwelebhu, i-x-ray, noma enye insizakalo iyakhokhwa ngokuvumelana nesimiso semali. Le ndlela yokukhokha ivumela ihhovisi lezokwelapha ukuthi lithole ukubuyisela okuphezulu kwesicoco ngasinye sokunakekelwa. Ezinye izici ze-PPO yizi:
- Abahlinzeki abangaphakathi nabangaphandle-abavumelekile, iziguli zikhokha kancane uma abahlinzeki abakhukhumezi basebenzisa
- Akukho ukudluliselwa okudingekayo ukuze ubone udokotela
- Ukugunyazwa kwangaphambili kuyadingeka kumasevisi athile
- Amalungu angaba nomthwalo wemithwalo yokudonswa kwemali, i-copays, ne-coinsurance
3. Izinhlangano Ezihlinzeka Ngaphandle (EPOs)
I-EPO ifana kodwa iyanqanda ngaphezu kwama-PPO.
- Kuncishiswe kubahlinzeki be-inthanethi ngaphandle kwezimo eziphuthumayo
- Akukho ukudluliselwa okudingekayo ukuze ubone udokotela
- Ukugunyazwa kwangaphambili kuyadingeka kumasevisi athile
- Amalungu angaba nomthwalo wemithwalo yokudonswa kwemali, i-copays, ne-coinsurance
4. I-Point-of-Service (POS) Izinhlelo
Amapulani e- POS ayiphambano phakathi kwama-PPO kanye nezinhlelo ze-HMO. Amapulani we-POS anikezela ngamasevisi angaphandle kwe-network, noma kunjalo, amanye awo angalinganiselwe, anciphise noma ayitholakali.
- Abahlinzeki abangaphakathi nabangaphandle-abavumelekile, iziguli zikhokha kancane uma abahlinzeki abakhukhumezi basebenzisa
- Ukudluliselwa okudingekayo kudingekile ukubona isazi
- Ukugunyazwa kwangaphambili kuyadingeka kumasevisi athile
- Amalungu angaba nomthwalo wemithwalo yokudonswa kwemali, i-copays, ne-coinsurance