Managed care plans generally provide comprehensive health
services to their members, and offer financial incentives for patients to use the providers
services to their members, and offer financial incentives for patients to use the providers
who belong to the plan. Examples of managed care plans include:
¨ Health maintenance organizations (HMOs),
¨ Preferred provider organizations (PPOs),
¨ Exclusive provider organizations (EPOs), and
¨ Point of service plans (POSs).
Managed care provisions - Features within health plans that provide insurers with a way
to manage the cost, use and quality of health care services received by group members.
Examples of managed care provisions include:
Preadmission certification - An authorization for hospital admission given by a
health care provider to a group member prior to their hospitalization. Failure to
obtain a preadmission certification in non-emergency situations reduces or
eliminates the health care provider’s obligation to pay for services rendered.
Utilization review - The process of reviewing the appropriateness and quality of
care provided to patients. Utilization review may take place before, during, or
after the services are rendered.
Preadmission testing - A requirement designed to encourage patients to obtain
necessary diagnostic services on an outpatient basis prior to non-emergency
hospital admission. The testing is designed to reduce the length of a hospital
stay.
Non-emergency weekend admission restriction - A requirement that imposes
limits on reimbursement to patients for non-emergency weekend hospital
admissions.
Second surgical opinion - A cost-management strategy that encourages or
requires patients to obtain the opinion of another doctor after a physician has
recommended that a non-emergency or elective surgery be performed. Programs
may be voluntary or mandatory in that reimbursement is reduced or denied if the
participant does not obtain the second opinion. Plans usually require that such
opinions be obtained from board-certified specialists with no personal or
financial interest in the outcome.