Chapter 3 Managed Health Care Copyright 2008 Delmar

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Chapter 3 Managed Health Care Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 3 Managed Health Care Copyright © 2008 Delmar Learning. All rights reserved.

Managed Health Care • Managed care provides reasonably priced health care for consumers and

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. ” 2 Copyright © 2008 Delmar Learning. All rights reserved.

Patients’ Bill of Rights Act 2005 • Utilization review activities • Claims benefits processing,

Patients’ Bill of Rights Act 2005 • Utilization review activities • Claims benefits processing, previous authorization, and internal reviews • Independent external review 3 Copyright © 2008 Delmar Learning. All rights reserved.

Health Insurance Overview • Health care practices are responsible for filing claims for reimbursement

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 4 Copyright © 2008 Delmar Learning. All rights reserved.

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

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 5 Copyright © 2008 Delmar Learning. All rights reserved.

Managed Care Organizations • Responsible for group of enrollees – Health plan, hospital, physician

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 6 Copyright © 2008 Delmar Learning. All rights reserved.

Managed Care Organizations • Fee-for-service plans reimburse providers • Managed care methods have pre-set

Managed Care Organizations • Fee-for-service plans reimburse providers • Managed care methods have pre-set payments for service over a period of time 7 Copyright © 2008 Delmar Learning. All rights reserved.

Primary Care Providers (PCP) • Participating providers are liable for supervising, organizing health care

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. 8 Copyright © 2008 Delmar Learning. All rights reserved.

Utilization Management (Utilization Review) • System of controlling health care costs and quality of

Utilization Management (Utilization Review) • System of controlling health care costs and quality of care by evaluating care provided. 9 Copyright © 2008 Delmar Learning. All rights reserved.

Utilization Management (Utilization Review) • Preadmission certification – Review of necessary medical outpatient treatment

Utilization Management (Utilization Review) • Preadmission certification – Review of necessary medical outpatient treatment • Preauthorization – Review for reimbursements 10 Copyright © 2008 Delmar Learning. All rights reserved.

Utilization Management (Utilization Review) • Concurrent review – Review of necessary medical inpatient treatment

Utilization Management (Utilization Review) • Concurrent review – Review of necessary medical inpatient treatment • Discharge planning – Utilization review organization (URO) are contracted services that performs reviews 11 Copyright © 2008 Delmar Learning. All rights reserved.

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

Case Management • Develops cost-effective patient care plans for difficult cases 12 Copyright © 2008 Delmar Learning. All rights reserved.

Second Surgical Opinions (SSO) • A second doctor is asked to assess the need

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 13 Copyright © 2008 Delmar Learning. All rights reserved.

Gag Clauses • Excluded from managed care contracts • Ensures that all medical advice

Gag Clauses • Excluded from managed care contracts • Ensures that all medical advice is given whether or not treatment is covered 14 Copyright © 2008 Delmar Learning. All rights reserved.

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