What is Managed Care
What is managed care? A form of health insurance, it provides a structural way to try to control costs and improve quality by managing how you access care and what practitioners you’re allowed to see.
In managed care you get your services from a specific network of doctors, hospitals and specialists. Health plans like HMOs, PPOs, POS plans and EPOs each have their own rules for the referral process, out-of-network coverage and cost sharing. And there is a good chance that your primary care doctor, as coordinator or gatekeeper, kept you posted and helped navigate your care.
Cost management techniques that you’ll see include negotiated provider fees, utilization review (which questions if services are needed), prior authorization for some tests or procedures and case management for more severe conditions. These mechanisms are intended to minimize unnecessary services, as well as encourage preventive care, so you’re paying less out of pocket for more coordinated care.
Some pros of managed care, from your point-of-view include lower premiums or copays for in-network providers, easier access to preventive services, and continuity of care. You may also have benefits to help you manage your chronic conditions, such as diabetes or heart disease, so you can stay healthier and reduce time spent in the hospital.
The limitations you might face are limited options of providers, the necessity of referrals to meet specialists in certain plans and potential delays from prior authorization. Knowing how your plan’s network works, as well as its coverage rules and appeal process — the steps you can take to fight a decision made by your insurer — can help you work around these limitations and make more informed decisions about where you go for care.
The managed care nurse is a central component of the system. Case management, care coordination, disease management, utilization review and discharge planning by nursing staff, under the direction of-physicians, help assure that your care is clinically necessary and timely. These are the nurses who talk to you, your doctors and payers about what treatment will be provided to you, teach you about possible treatments and monitor outcomes.
When you select or use a managed care plan, review provider directories, inquire about referral and authorization requirements and keep documentation of denials or appeals. Managed care can help you get connected to coordinated, cost-effective care when there is good information and active communication to make it work – and achieve better health.
