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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.”
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
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
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
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
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
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.
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.
Copyright © 2008 Delmar Learning. All rights reserved.
10
Utilization Management(Utilization Review)
• Preadmission certification– Review of necessary medical outpatient
treatment
• Preauthorization– Review for reimbursements
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
Copyright © 2008 Delmar Learning. All rights reserved.
12
Case Management
• Develops cost-effective patient care plans for difficult cases
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