The Blue Plans, Private Insurance, and Managed Care Plans

You should always check the patients insurance card to find out key information about the specific insurance they have. Make a photocopy of both the front and the back of the card. You will use this information when billing, making inquiries, and authorizations. Every medical practice should have available the current provider manuals for every insurance carrier it is contracted with, including its state's Blue Cross/Blue Shield Plans. To discover silent PPOs, always pre-certify procedures, and look at patients' insurance card even if the patients are established. Keep on hand an alphabetic list and profile of all plans with which the practice has a signed contract. Always be aware of preauthorization requirements. If a managed care plan refuses to authorize payment for a recommended treatment, tests, or procedures, have the PCP send a letter to the plan, include medical documentation, such as office visit notes, lab reports, and x-ray reports, to support the insurance claim. When a referral authorization form is received, make a copy of the form for each approved office visit, laboratory test, or series of treatments. Then use the form as a reference to bill for the service. To create a managed care plan reference guide make a grid. Use a sheet of paper, and list each plan with the billing address vertically in a column to the left. Then list significant date horizontally across the top. Suggested titles for column categories are as follows: eligibility telephone numbers, copayment amounts, preauthorization requirements, restrictions on tests frequently ordered, participating laboratories, participating hospitals, and the contract's time limit for promised payment. Referring to this grid can provide specifics at a glance about each plan's coverage and copayment amounts. Keep this information in a three ring binder. A good procedure is to include this information on each patient's data sheet when benefits are verified.

KEY POINTS:

·         Providers must be contracted with Blue Cross/Blue Shield to receive payment as a member physician. Patients may have a traditional fee-for-service or one of many types of managed care plans. Plan benefits and coverage, as well as deductibles and copayments, vary.

·         Managed care plans are prepayment health care programs in which a specified set of health benefits are provided in exchange for a yearly fee or fixed periodic payments to the provider of service. Patients join the plan and pay monthly medical insurance premiums individually or though their employer. Patients pay a small copayment and sometimes a deductible for medical services.

·         Primary care physicians (PCPs) act as gatekeepers who control patient access to specialists and diagnostic testing services.

·         Health maintenance organizations (HMOs) have models, such as prepaid group practice model, staff model, network HMO, and direct contract model.

·         The Patient Protection and Affordable Care Act (the Affordable Care Act), and H.R. 4872, the Health Care Reconciliation Act) have provisions which include the following: forbids insurers form canceling insurance coverage (rescission), eliminates preexisting condition exclusions, ends lifetime limits on benefits, gives tax credits to small businesses that offer coverage, provides temporary insurance until 2014 for people who have been denied because of their health status, allows young people to remain on their parents’ insurance until age 26, requires insurers to use a high percentage of premiums for benefits instead of profits or overhead, makes some preventive measures free, and almost everyone is required to be insured or they will pay a fine.

·         Types of managed care plans are the exclusive provider organization (EPO), foundation for medical care (FMC), independent (or individual) practice association (IPA), preferred provider organization (PPO), silent PPO, physician provider group (PPG), point-of-service (POS) plan, triple-option health plan, provider-sponsored organization (PSO), and religious fraternal benefit society (RFBS).

·         Managed care plans, such as employee benefit plans (EBPs) purchased by employers, must comply with the federal regulations of Employee Retirement Income Security Act (ERISA) and do not fall under state laws.

·         The Quality Improvement Organization (QIO) program (formerly the peer review organization) evaluates cases to determine appropriateness, medical necessity, and quality care.

·         Utilization review (UR) is a process bases on established criteria for evaluating and controlling the medical necessity of services and providers’ use of medical care resources to curb expenditures.

·         Some managed care plans may require prior approval for certain medical services or referral of a patient to a specialist. Four types of referrals are formal referral, direct referral, verbal referral, and self-referral.

·         If a contract has a stop-loss limit, it means that the provider can begin asking the patient to pay the fee for the service when the patient’s services are more than a specific amount.

·         A managed care plan that has a withhold provision may retain a percentage of the monthly capitation payment or a percentage of the allowable charges to physicians until the end of the year to cover operating expenses.

 

 

*find links to resources on The Internet Resource tab.