What is Managed Care?
The term managed care can be used to refer to PPO products,
HMO products, EPO products, etc.
All physicians are individually credentialed through the
various plans. If a physician is not credentialed to see
that particular plan’s patients, no or reduced benefits
will be paid. Therefore, a first step regarding booking managed
care patients to a particular provider is the credentialing
process.
A PPO product is one that will pay claims as long as the
patient is seeing an in-network provider.
An HMO product is one that has a “gatekeeper”.
A gatekeeper is a primary care physician that directs the
patient for all other services. A visit to a speciality physician
or for specialized services must have a “referral” and/or
authorization. Some carriers allow this to be just verbal
referrals, others require that the referral be obtained on
paper and submitted to them. Failure to obtain referrals
on these patients will result in non-payment of claims.
Some HMO patients may self-refer to OB/Gyn through the
Open Access program for any OB/Gyn related diagnosis and
well-woman exams.
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