1. Seminar Unit 2

2. Managed Care Causes Creation Goals Guidelines

3. Managed Care Causes of Managed Care: Technological advances Rising healthcare costs Aging population Increase in malpractice suits Defensive medicine Creation of Managed Care: Rapid increase of healthcare costs Health insurance no longer affordable Government intervention Control healthcare costs

4. Managed Care Goals of Managed Care: Control cost and delivery of health services. Deliver high quality care in facility that manages/controls cost. Decide the medical necessity for treatment of illness. Ensure that medical care is delivered by most appropriate provider. Ensure that medical care is rendered in the most appropriate setting. Contract discounted reimbursement fees.

5. Managed Care Managed Care Guidelines: The provider is reimbursed for each procedure the usual and customary fee. The usual fee is the individual provider’s average charge for a procedure. The customary fee is determined by what a physician with the similar training in a similar geographical location would charge. Gatekeeper (primary care physician) Cost containment The most appropriate provider conducts patient care.

6. Managed Care Plans Types of Managed Care Plans: HMO: Health maintenance organization PPO: Preferred provider organization POS: Point-of-service plan What are the advantages / disadvantages?

7. Healthcare Limits System cannot support unlimited demands for care. Providers no longer manage practices. Practices are managed by accountants and managers. Medical and business values are merging.

8. Contracts Should list the following: Schedule of benefits: A list of medical services covered under the contract Preventative medical services and types of office visits Which procedures are, and are not, covered CPT codes: Procedure codes and rates for each service Time limit for submitting claims Which form to use for submitting claim Time limit for receiving payment and what reimbursement charges for late payment

9. Compensation & Billing Guidelines  The contract should clearly state how and when provider is to be paid.  The forms used for claims submission should be clearly stated.  All arrangements with regard to coordination of benefits and late payments should be clearly spelled out.  Be aware of any “rebundle,” which means to cover services in a single bundled fee.

10. Fees for service Deductible Co-pay Co-insurance Charged Amount Allowed Amount Contractual Adjustment/Write-Off

11. Discounting Fees The usual fee is the individual provider’s average charge for a procedure. The customary fee is determined by what a physician with similar training in a similar geographical location would charge. Calculate Patient Responsibility: Step 1: Contractual agreement/write-off. Subtract allowed amount from billed amount. Step 2: Carrier’s responsibility. Subtract any unpaid deductible or copay (if no deductible or copay, go to Step 3) Step 3: Patient responsibility

12. Patient’s Bill of Rights Information Disclosure: Right to accurate and easily understood information Choice of Providers and Plans: Right to choose healthcare provider Access to Emergency Services: If you are convinced your health is in jeopardy due to sudden onset of pain, accident, or illness, you may be treated without prior authorization and without financial penalty Participation in Treatment Decisions: The right to know your treatment options Respect and Nondiscrimination: The right to receive respectful, considerate and nondiscriminatory care Confidentiality of Health Information: The right to talk in confidence with your physician and to have your healthcare information protected Complaints and Appeals: The right to a fair, fast, objective review of your complaint

13. GOOD NIGHT! THANK YOU!