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

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

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

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

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

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