Chapter 3

1. 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.”

3. 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

5. 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

6. 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

7. Managed Care Organizations • Fee-for-service plans reimburse providers • Managed care methods have pre-set payments for service over a period of time

8. 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.

9. Utilization Management(Utilization Review) • System of controlling health care costs and quality of care by evaluating care provided.

10. Utilization Management(Utilization Review) • Preadmission certification • Review of necessary medical outpatient treatment • Preauthorization • Review for reimbursements

11. Utilization Management(Utilization Review) • Concurrent review • Review of necessary medical inpatient treatment • Discharge planning • Utilization review organization (URO) are contracted services that performs reviews

12. Case Management • Develops cost-effective patient care plans for difficult cases

13. 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

14. Gag Clauses • Excluded from managed care contracts • Ensures that all medical advice is given whether or not treatment is covered