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Managed Care System

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Managed care is a system for organizing the delivery of health services so that the cost of care is reduced and the quality of care is maintained or improved. The different types of managed care include health maintenance organizations, preferred provider organizations, gatekeeper PPOs, exclusive provider organizations, provider hospital organizations, and management service organizations. Health maintenance organizations are one of the most common forms of managed car. HMOs provide coverage both the coverage for care and the care itself. Preferred provider organizations are the second most common managed care alternative. In PPOs the insurance carriers contacts with the providers to provide services at a contracted rate. Exclusive provider organizations are a much smaller PPO. The patient must select a primary care provider and can use only those providers who are a part of the network or who are referred by the primary care provider. Provider hospital organizations are an organization of providers and hospitals that band together for the purpose of obtaining contracts from payer organizations. Management service organization is a separate corporation set up to provide management services to a medical group for a fee. The membership card should include the patients name and will contain a record number or other means of identifying the patient. There will be a magnetic strip on the back of the card that will have additional information encoded on it. The card may also list a plan number or type that indicates what services the patient is covered for. The will also be a number on the card to call in order for authorization of emergency treatments. The eligibility roster will show what patients are new to the program, what patients have had their coverage extended to the following month and what patients have had their coverage terminated. If a patient decides that he/she wishes to see another provider he/she may do so. The patient is required to fill out a request to transfer form. There will be a waiting period while the MCP determines if the new provider selected is contacted and to ensure that the member still qualifies for coverage. The member will have to have the request to transfer form and the medical record should be forwarded to the new provider, once approved. If the current provider needs a copy of the file, he should make one and mark it inactive and file with the other medical files. If the member has a compliant he/she can file the compliant with the provider or the group/IPA. Once a compliant is files the provider should attempt to resolve the issue through patient counseling, whether in person or on the phone. If unable to resolve the compliant the provider must file the compliant with the MCP, the complaint should be filed with the MCP with in one working day of receiving the complaint. If the provider was able to resolve the issues a letter must be sent confirming the resolution of the issue to the member. A copy of this letter and any supporting documentation must be mailed to the MCP. If the provider is unable to resolve the compliant with thirty days, the member must be given the opportunity to file a written compliant with the MCP. If the compliant concerns any aspect of medical care, it must be reviewed by the provider/group/IPA medical director. Most MCPs offer the member the ability to receive a second opinion. The member must ensure that the MCP approves the provider the member wishes to receive the second opinion from in order to ensure that the services rendered are covered. If the provider decides that he/she no longer wants to be a part of the MCP they terminate the contract that was in place between the two. If there are other providers in the group they will pick the pieces and care for the patients of the provider that has left. IF the entire group of providers terminates their contacts then the MCP will hire a new group of providers to replace the ones that have left.

References
Brown, S., Tyler, L. Guide to Medial Billing. 2013. Pearson Education, Inc. Chapters 7.…...

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