Managed Care
MR. WATSON: Recent surveys have shown that insurance company's costs have risen slower with managed care than with traditional reimbursement policies. Managed Care Organizations (MCOs) they combine both the financing and the delivery of health care services to contain costs. They do this by:
- selectively contracting with health care professionals and organizations
- establishing financial incentives for members to use providers in the plan
- controlling hospital admissions and lengthy stays
- standardized medical practice guidelines
- emphasizing disease prevention and health promotion programs
This is typical of HMOs, PPOs, EPOs, discussed in Chapter 16.
Managed care , controlling costs a few different ways:
- Policy designs. Having high co-pays and deductibles can help control costs.
- Medical cost management: KNOW THESE
- Case management : As a large claim unfolds with an insurance company, we have somebody working in the home office, like a doctor or a nurse. If you are going to have dialysis, if it makes more sense to us to have the machines taken to your house and it will save money, then that's what we're going to do. This person is a liaison, a go-between who works for the insurance company to compensate the insurance to provide the finest care that they can.
- Ambulatory surgery : Outpatient surgery, Drive thru..
- Mandatory second opinions : It is mandatory that you get a second opinion.
- Pre-certification review: Before you go in the hospital, even for an emergency you must notify the insurance company with-in a certain amount of time or it's not covered,
