What is Managed Care plan - Medical billing

Managed Care is a system for organizing the delivery of health services so that:

• The cost of care is reduced.
• The quality of care is maintained or improved.

Managed Care programs try to control costs by:

• Encouraging members to obtain preventative care, such as annual physical examinations, mammograms and other wellness services.
• Working with you and your physician to make sure that the care you receive is cost-effective and medically necessary.
• Negotiating special rates and treatment guidelines with physicians and hospitals, called "preferred providers."
• Providing financial advantages for patients to use these preferred providers.

Most health plans now include at least some elements of managed care. But as you'll see, there is a wide variety of approaches to managed care.

The Basics of Choosing A Managed Care Plan

Many factors need to be considered when choosing your health plan. Some you control, and some you don't. For example, if you're employed, your employer generally determines what, if any, choices you have.

In this section, we discuss many of the criteria that people use to decide on their health coverage. You should decide which of these factors are most important to you and your family, and make your choice accordingly.

• Recommendations
• Quality of Care
• Financial Considerations
• Helping You Understand Your Health Care Options

  What are the Different Types of Managed Care Plans

Managed care plans usually fall into one of these general catagories:

 

Health Maintenance Organization (HMO): An HMO is a managed care plan that offers a full range of services for a fixed prepaid fee, rather than charging each patient for each service provided. You normally pay only a small copayment for your care. With some plans and for some services, you may also have to satisfy a deductible. Usually, you don't have to file claims.

With an HMO, you must obtain care only from that HMO's participating doctors.Each HMO recruits a network of participating physicians and other health care providers who agree to follow its guidelines and accept its reimbursement. When you and your family join the HMO, you choose a primary care physician (PCP) from the doctors in that network. This PCP is responsible for managing all your medical care and provides a referral to a network specialist whenever you need specialty care.

HMO plans typically fall into one of these two categories:

Staff Model: A staff model HMO has salaried physicians who provide services only to plan members. They offer care at a hospital, a clinic or health center in the community.

Independent Practice Association (IPA): An IPA maintains contracts with a number of physicians and/or physician group practices, who see patients in their own offices.

When you consider joining a managed care plan, you should:

• Look carefully at in-network and out-of-network coverage provisions.
• Review the duties of a primary care physician in detail.

 

Once you understand these features, you'll know what your obligations will be under whatever plan you're considering. This will help you make an informed decision before you incur any financial obligations or choose your doctor.

POINT OF SERVICE (POS) PLAN: POS plans function much like IPA's. You select a primary care physician who coordinates all care within the participating provider network, including specialist referrals.

With a POS plan, though, you can use physicians and hospitals outside the network or network specialists without a referral, if you're willing to pay more and file claims for reimbursement. For example, you might pay a $10 copayment for an office visit to a network physician, when you'd pay $10 plus 25 percent of the doctor's charge at a non-network physician.

PREFERRED PROVIDER ORGANIZATION (PPO): A PPO plan functions like a POS plan, but eliminates the primary care physician. As with the POS plan, you can use a health care provider outside of the "preferred provider" network for an additional cost. However, you can usually see any participating provider - whether primary physician or specialist - without a referral, at no additional cost.