chapter 3

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Chapter 3

Managed Health Care


2

Managed Health Care

• Managed care provides reasonably priced health care for consumers and providers who agree to certain conditions.

• Currently being tested by growing “consumer-directed health plans.”


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Patients’ Bill of Rights Act 2005

• Utilization review activities

• Claims benefits processing, previous authorization, and internal reviews

• Independent external review


4

Health Insurance Overview

• Health care practices are responsible for filing claims for reimbursement

• Managed care contracts must be signed by health care providers

• Rules change often– It is important to stay up-to-date


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Health Insurance Overview

• All insurance plans must have:– Authorization, billing deadlines, claims

requirements, and a list of participating providers

• Specialists should be on mailing lists


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Managed Care Organizations

• Responsible for group of enrollees– Health plan, hospital, physician group, or

health system

• If services rendered cost less:– Physician profits

• If services cost more:– Physician will lose money


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Managed Care Organizations

• Fee-for-service plans reimburse providers

• Managed care methods have pre-set payments for service over a period of time


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Primary Care Providers (PCP)

• Participating providers are liable for supervising, organizing health care services, approving referrals for specialists and inpatient hospital stays.

• PCP serves as a gatekeeper.


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Utilization Management(Utilization Review)

• System of controlling health care costs and quality of care by evaluating care provided.


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• Preadmission certification– Review of necessary medical outpatient

treatment

• Preauthorization– Review for reimbursements


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• Concurrent review– Review of necessary medical inpatient

treatment

• Discharge planning– Utilization review organization (URO) are

contracted services that performs reviews


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Case Management

• Develops cost-effective patient care plans for difficult cases


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Second Surgical Opinions (SSO)

• A second doctor is asked to assess the need of surgery

• **Remember: – If mandatory by carrier:

• Place 32 modifier on E/M code • E/M service should be a new patient visit not a

consultation


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Gag Clauses

• Excluded from managed care contracts

• Ensures that all medical advice is given whether or not treatment is covered

chapter 3

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