SOP Manual for HMO Medical Centres


This industry comprises establishments called Health Maintenance Organization (HMO), the Healthcare Insurance provider having contract with network of healthcare practitioner (Doctors) and Hospitals across US offering number of Insurance plan to the subscriber who is willing to take wide range of services that includes out-of-network emergency service and Out-of-network dialysis.

For their subscribers, with minimal fee (monthly or annual), they can able to provide necessary access to appropriate healthcare, ambulatory service benefits within their network of hospitals. Mostly the premium subscribers will have added advantage in terms of healthcare service benefits and also both healthcare practitioner/providers have direct advantage of getting more patients to their clinic/hospital. The network of hospital is either owned directly or in collaboration by HMO. Federal Medicare Part D (Prescription Drug Coverage), Affordable care (Obamacare) also gets covered in HMO Plan.


For any Healthcare Insurance especially in US, there are 4 terms always you hear a most,

Out-of-pocket expenses – a small amount of charge paid for a service.

Co-pay (aka. Co-payment) – a small amount can be charged by your Insurance provider for each visit to Clinic, lab test or for each prescription.

Deductibles – a fixed amount of fee that the subscriber need to pay every year to avail the service before your Insurance provider starts to pay your healthcare services bills.

Prior Authorization (pre-Authorization) – For accessing certain medical services, the subscribers need to get permission from PCP and if not, the insurance company may deny to fee for the service that they availed.


HMO Insurance plans are more suitable for low income families due to popularity of lesser co-pay & out of pocket expenses. Those who need HMO healthcare Insurance benefits should supposed to work in particular network area to get access to Medical services coverage. If the situation is not absolutely an emergency, these HMO insurance plans will not cover out-of-network medical care. So, there is a necessity for an individual (subscriber) to choose healthcare physician within HMO network. Depending upon the type of Plan, the cost sharing will differ for each subscriber. Normally, Claims for service processed by your PCP or hospital within the network of HMO. If the subscriber has accessed out-of-network medical services, then subscriber should file the claims to his/her insurance provider for the service he/she availed. Home Health Services sets a maximum slab (out-of-pocket expense).


How is it works?  The subscribers need to select nearby suitable PCP (Primary care Physician) from the network of HMO where the Primary care Physician will be your first point of contact for all healthcare services. For any specialization treatment, the individual need to get referrals from his/her PCP for an appointment with specialist. The PCP will refer the patient to the specialist within HMO network of Medical centres however certain laboratory testing. Imaging and few diagnostic procedures does not need to be within network coverage. If suppose, your Primary care Physician left from HMO network, the subscriber will be duly informed to choose new PCP within the HMO network.

HMO has certain guidelines and it keeps monitoring its network of professional doctors to give adequate services to their subscribers. All basic primary healthcare coverage is listed in HMO plans, so the subscriber may not need to spend more for medical treatment. HMO has well established Case Management directory in which all the services, workload, reputation, patient history, frequency of visit are monitored and documented. Moreover, it gives support assistant to individual or group of patient for effective implementation of healthcare service.

HMO is regulated by both US State and Federal Law. The subscriber can choose a plan that will cover Federal Medicare and Medicaid Plans (Medicare is Federal funded; Medicaid is both Federal plus State funded government healthcare Insurance Program) under Managed Care. Overall about 60 Million people are enrolled in Healthcare Insurance in US. Other widely used Insurance plan compare to HMO are PPO (Preferred Providers Organisations), POS (Point-of-Service) but, the cost is more if the subscriber used medical service from out-of-network hospitals. HMO is more beneficial due to very lesser service fee.

Choosing a right Healthcare Insurance plan is depending upon what kind of services you are looking forward from these Insurance providers (i.e.., HMO, PPO, POS). There is a freedom for an individual to choose among the plans based upon the State which he/she is living and Premium amount (paid either monthly or annually). Every Healthcare Insurance plan as few advantage/disadvantage, so the choice is yours for protected happy healthier living.

Tags: SOP

Written by Bharath Ravi

Business Consultant whose qualification includes a Bachelor’s degree in the field of Mechanical specialized in Automobile & Manufacturing; Trained in Certified Supply Chain Professional (CSCP) Certification, Hands on Foundation Certificate in Business Analysis, BCS (UK) and Certified Professional for Requirements Engineering (CPRE-FL).

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