1. Managed Care Programs
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2. Managed Care Programs At the end of this course, you will:
This lesson will provide you with the basic understanding of the Managed Care programs available to patients.
At the end of this course, you will:
Understand the different managed care options that are available
Understand the relationship of managed care programs with the UC San Diego Medical Centers and Medical Group Practices
Understand basic terminology and the key components for each of these programs
Understand how UC San Diego manages these programs

3. What do we mean by Managed Care?
Managed Care is defined as health care that is provided in a coordinated manner with emphasis in preventative and primary care services. These types of plans were created to provide quality, cost efficient and effective health care.
Until the early 70’s patients with health insurance could choose to go to any provider including being able to self refer to specialties and this resulted in a very high cost and unmanaged health care system.
Managed Care was created to help manage the health care delivery system.

4. Critical concerns for Registration
1.) Determining which health plan the patient is covered by and selecting the correct coverage.
2.) Identifying the patient’s Primary Care Physician (PCP), Primary Medical group (PMG) or Independent Physician/Practice Association (IPA)
3.) Collecting PCP and referring physician information.
4.) Completing the required payor information
5.) Confirming that the patient is eligible and authorized to receive services here at UC San Diego.
6.) Collecting the patient’s co-payment.
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5. How do you identify if the patient has a Managed Care plan?
Each member of a Managed Care Plan is given an identification card that identifies the member and the health plan. Some cards will identify whether the Health plan is an PPO, Indemnity, EPO, HMO, or POS.
What information do you need to create the account?
Patient’s Name
Member Number
Group Number
Primary Care Physician
Effective Date of Coverage
Name of the PMG and or IPA
Co-payments for the various levels of service
Telephone numbers used for authorizations and inquiries
Address and phone number for PCP and or IPA/PMG

6. What types of Health Plans can be grouped under the Managed Care title?
PPO- Preferred Provider Organization
Indemnity- Fee for Service
EPO- Exclusive Provider Organization
HMO- Health Maintenance Organizations
POS- Point of Service plan
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7. PPO-Preferred Provider Organization
A PPO plan is a form of a managed care plan that gives you the freedom of choice and flexibility to choose a provider within or outside the network.
Providers within the network:
Less out of pocket costs for the patient
Providers outside the network:
Patient will have to meet the deductible and pay co-insurance based on higher charges.
Page 3, Examples of PPO Payor codes on page 3-4

8. After you determine the patient has a PPO plan and have selected a payor, what else do you have to do?
To ensure the bill is sent to the correct payor for PPO or indemnity plans, you must identify if there is a Third Party Administrator (TPA).
What is a TPA?
A Third Party Administrator (TPA) is an organization that has contracted with a third party payor or health plan to provide claims management, member services, and utilization management services.
Why do you have to select a TPA?
You have to select a TPA to ensure that the claims are sent to the organization responsible for paying them. Failure to do so will delay payment to the provider.
How will you know which TPA to select?
If a TPA is required, it is usually identified on the patient’s card under “ Send Claims to:” or on the health plan’s web site under “Contact Information / Customer Service”

9. What do we mean by Indemnity?
While few in number, there are still some commercial insurance plans. This is a fee for service insurance with higher premiums and out of pocket expenses. Under these plans, patients can self-refer to any provider without needing a referral/authorization.
There are many insurance companies that offer indemnity insurance coverage, but due to the high cost of the plan you may not see them often.
If you do not find the payor name under the coverage selection, use “Unlisted Commercial” and manually enter the name of the insurance and claims address.

10. What is an HMO?
A Health Maintenance Organization is a pre-paid health plan. Providers of an HMO plan are normally part of a network of physicians and facilities contracted to provide care to its assigned members. The members incur very little costs by allowing their care to be coordinated within the network. Services requested outside of the network are not usually covered unless they cannot be provided by a provider within the network. These services can be managed by the health plan or delegated to a primary Medical Group.

11. What is meant by “delegated services”?
HMO’s are paid on a fixed (capitated) payment system. Monies are collected per member per month (PMPM) regardless of what services are utilized. Some health plans choose to set up a contract to delegate business functions to a PMG/IPA. This is why sometimes you will have to contact the medical group vs. the health plan.

12. PMG/IPA
An independent group of physicians and health care providers, that are under contract to provide services to members of different HMO’s.
PMG- Primary Medical Group
IPA- Independent Physician/Practice Association
(The difference between the two is usually the size of the group/practice.)

13. What is a Primary Care Physician (PCP)?
PCP’s are usually physicians that practice in the fields of Internal Medicine, Family Practice, General Practice and Pediatrics. Some HMO plans allow for OB/GYN physicians to be PCP’s.
Each PCP is affiliated with a PMG or an IPA.

14. How do we manage HMO plans?
Our providers and clinic staff use the registration codes to determine if an authorization for treatment is needed. The registration staff can determine a payor based on the health plan, plan type, and payor category.
Coverage Categories:
UHMO- patient has an HMO plan, a UCSD PCP and UCSD listed as the assigned Medical Group
Referral HMO- patient has an HMO plan, a PCP and PMG outside of UCSD
Senior HMO- HMO plan under a senior category
Medi-Cal HMO- Medi-cal Managed Care
On Page 9 you will see a table with some examples of payor codes that are associated to HMO’s. Notice that the HMO that are associated with UCSD will all have UHMO listed as part of the plan name. If you look at your payor code list you will see that all of the UHMO’s are grouped together on page 4.

15. After you identify the coverage what else do you have to do?
Any time you select a non UHMO coverage, you will have to select a coverage with the IPA/PMG identified after verifying eligibility using one of the following resources: 1.) RTE 2.) Health Plan Website If the IPA/PMG is not listed in the database, use the “Out Of Network” as the IPA/PMG.

16. Why do you have to select an IPA/PMG?
HMO’s are divided in to two primary entities: Health Plan and IPA/PMG Health Plan approves and pays for Hospital Services (Medical Center Charges) IPA/PMG approves and pays for Professional fees (Medical Group Charges) Often these two organizations have two different mailing addresses. When the IPA/PMG is selected, a FSC is assigned that will identify the IPA/PMG address.
For UHMO patients the IPA is UCSD Medical group so nothing will need to be filled out. The IPA/PMG will need to be filled out for all non UHMO payors.

17. How do you know what IPA/PMG to select?
What happens if you pick the wrong IPA/PMG?
If the wrong IPA/PMG is selected and a claim is processed for a non covered patient, it will be denied.
The billing staff then has to determine the correct IPA/PMG in order to resubmit the claim, thus delaying payment.
Keep in mind that some HMO health plans have a 60 day requirement for filing claims.

18. What is an EPO?
Exclusive Provider Organization- is a health plan that has a primary care physician with an open network of providers selected by the health plan.
If patients choose to see a provider outside of their network, those services must be authorized from the health plan.
With this type of plan the health plan has not delegated the authorization function to a medical group.
Examples of payor codes for EPO plans are listed on page 12.

19. What is a POS? Tier One- HMO Coverage Tier Two- PPO Coverage
A Point of Service (POS) plan is the type of coverage that we refer to as a tiered plan. Patients can choose which tier to access at the time of service.
Tier One- HMO Coverage
Tier Two- PPO Coverage
Tier Three- Indemnity Coverage
Depending on the level of service the patient utilizes at the time of service, the rules managing that plan type will take effect. 19

20. How do you determine which level of their POS a patient is using?
1.) Ask the patient if they are seeking primary care services or specialty services.
2.) Determine if the patient is requesting the services from the primary care provider or the medical group.
3.) Ask the patient if the services are authorized or if they are self-referring. 20

21. How do we manage this plan?
In most cases:
HMO payor will be assigned when a patient is opting to use their Tier one benefits
PPO payor will be assigned when a patient is opting to use their Tier two/three benefits.
Examples of POS plans are listed below on page 13. Example of Blue Cross on payor code list for TIERone and or TIERtwo.

22. Managed Care Plan Overviews
PPO Plans- Have a network of providers to choose from, can go outside their network but have higher out of pocket costs. They have no specific PCP assignment and have TPA’s.
Indemnity Plans- Give patients maximum flexibility for choosing providers, premiums and out of pocket expenses are higher, and can self refer.
EPO Plans- Have a PCP, an open network of providers, cannot go outside of network unless an authorization is provided. They have no PMG/IPA.
HMO Plans- Have a PMG/IPA that manage their care, cannot go outside of network unless the service is not provided within their network, patients must choose a PCP that is in the network.
POS Plans- Tiered Plan (Tier 1, HMO/Tier 2, PPO/Tier 3, Indemnity)

23. What other coverage might the patient have?
At times a patient may be covered by more than one insurance plan. This is called dual coverage.
The most common cases are:
Covered under a spouses plan
A child that is covered under both parents’ health plans
Involved in an accident where there might be third party liability

24. If a patient has dual coverage can they choose which coverage to use?
No. The office of the National Association of Insurance Commissioners (NAIC) drafted model regulations that standardized how persons with dual coverage would have their benefits coordinated.
The purpose of the coordination of benefits (COB) is to prevent the duplication of payment for services. COB is not influenced by whether one of the plans is a Managed Care Plan or by which plan has the greater benefits.
Dual coverage can be used to cover out of pocket expenses or services that might not be covered by the primary health plan, but not co-payments. 24

25. When is a Managed Care Plan Primary?
A Managed Care Plan would be considered primary in the following situations:
1.) The patient is the subscriber of the policy.
2.) It qualifies under the “birth date rule” for children with dual (both parents) coverage. The rule states that when a child is covered by both parents’ policies, it is the coverage of the parent whose birth date occurs first in the calendar year. This is determined by the month and day of the birth only. If the parents have the same birth date it is the coverage which has been active the longest.
Note: For children regardless of whose coverage is primary, who ever brings the child in for care, is the guarantor for the account.
3.)There is a Federal, State, and or County coverage

26. How would a patient’s secondary coverage be used?
Secondary coverage will be used to pay what the primary payor does not cover.
If the service is not a covered benefit of the primary plan then the secondary plan can be billed if the benefit exists under that plan.

27. Verifying Eligibility
A patient’s ID card is not sufficient to verify eligibility. Using one of the real time methods is required to ensure eligibility by the Health Plan.
RTE- for eligibility information
Health Plan Websites- if information is not available via RTE we have established access with several health plans via the internet.
Health Plans’ phone numbers- can be contacted directly when eligibility cannot be determined via the above resources.

28. RTE response

29. Web Based: Eligibility Verification
Name

30. What authorization requirements exist for Managed Care Plans?
In general, most Managed Care plans require authorizations based on the type of health plan the member is enrolled in. Most HMO Health Plans require prior authorization for:
Inpatient Stays
Specialty Care Services
Outpatient Procedures
Some Ancillary Services

31. As a registration person what is your role to prepare the account for billing?
The patient information collected during registration is important and has a direct impact on the success of billing and collecting for the services provided.
Proper documentation of the information collected while determining the financial responsibility, verifying eligibility, and acquiring the authorization is key to ensuring that the account will be paid.

32. Example of Guarantor Notes documentation
Verbal authorizations or denials of services. This would include who you spoke to and their phone number. Any information that supports your payor selection that does not have a specific field. When any eligibility is received verbally. If the benefit information is unique for the current episode of care. Any other important financial information that will assist in the billing and collection process of the account. Note: Any other information that is not related to funding would be inappropriate to document in Guarantor notes.

33. What are the patient’s out of pocket responsibilities?
Patients are responsible for a co-payment for each occasion of service.
If the patient has a PPO they may have a deductible or co-insurance. This is NOT collected on an outpatient basis.
What do you need to collect at the point of service?
Fees will vary by policy and type of service being provided. RTE, patient insurance cards, and on line eligibility will identify co-payment amounts.
Make sure to document the amount to be collected at the time of service.

34. How do you ensure that the patient’s care is coordinated across UCSD?
A key aspect of the Managed Care plans is to focus on a patient’s PCP being involved in all aspects of the patient’s care.
Therefore the information collected at registration related to referral source, primary care physician, and referring physician is critical to coordinating a patient’s health experience.