Managed Care

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UT Southwestern Health Systems

• Managed Care
• Training

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Managed Care Products

• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Point of Service (POS)
• Exclusive Provider Organization (EPO)
• Medicare Replacement/Risk

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HMO (Lock-In)

• Member must select a Primary Care Physician (PCP)
  to manage his/her care.
• Referral from the PCP must be obtained for most
  specialty services.
• Member must obtain services from a participating
  provider. (No out-of-network benefits.)
• Member owes a fixed amount (copayment) for each
  type of service. Copayment amounts vary by plan.

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PPO

• No Primary Care Physicians.
• Patients may self-refer to any participating
  providers.
• To obtain highest level of benefits, member must
  obtain services from a participating provider.
• Member may choose to obtain care from an out-of
  -network provider, in which case claims would be
  processed at a lower benefit level.
• Member could owe deductible, coinsurance,
  copayment, or any combination of these. These
  amounts vary by plan.

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POS

• Members are encouraged to select a PCP, but it is
  not required.
• Highest level of benefits are obtained by
  following the HMO guidelines.
• Care from an out-of-network provider would be
  processed at the lower benefit level.

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EPO

• PCP requirement varies by plan.
• PCP driven plans require a referral for all
  specialty services.
• Highest level of benefits are obtained by
  utilizing a participating provider.
• Care from an out-of-network provider would be
  processed at the lower benefit level.
• Member owes a fixed amount (copayment) for each
  type of service. Copayment amounts vary by plan.

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Medicare Risk

• Replaces the members traditional Medicare
  coverage.
• Normally covers more services than traditional
  Medicare.
• Operates like an HMO plan.
• Refer to HMO slide.

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Referrals

• Represents approval from the PCP and health plan
  for the member to receive specialty services.
• Required for HMO, POS (for highest level of
  benefits), and some EPO plans.
• No referral could result in no reimbursement.

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Authorization

• Also called preauthorization and precertification
• Represents approval from the insurance company,
  or their designated utilization management
  company, prior to services being rendered.
• Services requiring authorization vary by plan.
• No authorization could result in no reimbursement.

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Independent Practice Association (IPA)

• A group of physicians that have formed an
  association
• Referrals and authorizations are obtained from
  the IPA rather than the managed care company.

CCPN
PSN
PacifiCare
INOVA
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Carveouts

• Process by which the managed care company
  contracts with a specialty group or IPA to
  provide certain services to their members.
• The carveout network is paid in advance for
  services that may be necessary for the member.

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Terminology

• Network - A group of providers which a member
  must utilize in order to receive the highest
  level of benefits.
• Repricing - Applying the appropriate contracted
  rates to a claim. Responsible party may be the
  network or the payor/claims administrator.
• Claims Payor - Insurance company or third party
  administrator (TPA) responsible for claims
  payment.

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Credentialing

• All Providers must complete UTSHSs credentialing
  process to be participating under UTs Managed
  Care contracts.
• Delegated credentialing exists when the Managed
  Care company accepts UTs credentialing criteria.
• Some Managed Care companies require the provider
  to go through their own credentialing process
  prior to being effective with that plan.

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Reimbursement

• Fee Schedule
• Reimbursement based on the services rendered
  (i.e. set fee for each type of procedure).
• Discount
• Reimbursement based on a percentage off of the
  billed charge (i.e. 20 discount).

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Patient Liability

• Copayment
• A fixed amount per visit due from the patient.
  (e.g. 10 office visit, 100 inpatient hospital).
• Deductible
• Set amount due from the patient before the
  insurance company will begin paying. Deductibles
  normally must be met once per calendar year.
• Coinsurance
• Fixed percentage representing the portion owed by
  the patient.

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Resources

• Managed Care Guidelines (MCG) - Refer to handout
  for instructions for accessing
• MCO Participation Roster - Located on the S
  drive and on the MCG Table of Contents. (Refer to
  handout for instructions on accessing.)
• Individual Rosters - Located on the MCG.
• Helpful Hints discussed at Managed Care
  In-Services and published on MCG.
• Monthly Memo
• MCO Help Desk - [phone] or email MCO Help
  Desk.

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MCO Participation Roster
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Helpful Hints

• A contract between UT and a Managed Care company
  does not insure provider participation.
• Utilize rosters for verifying provider
  participation.
• Referrals and/or authorizations do not guarantee
  payment. Member must be eligible at the time of
  service and services must be covered by the plan.
• Referral and authorization requirements can vary
  by employer group. List provided on the MCG may
  not apply to all groups under that plan.

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UT Southwestern Health Systems
July 2003