Managed care plans are a type of health insurance. They have contracts with
health care providers and medical facilities to provide care for members at
reduced costs. These providers make up the plan's network. How much of your
care the plan will pay for depends on the network's rules.
One of the most characteristic forms of managed care is the use of a panel
or network of health care providers to provide care to enrollees. Such integrated
delivery systems typically include one or more of the following:
·
A set of designated doctors and health care facilities,
known as a provider network, which furnish an array of health care services to
enrollees
·
Explicit standards for selecting providers
·
Formal utilization review and quality improvement
programs
·
An emphasis on preventive care
·
Financial incentives to encourage enrollees to use care
efficiently
Provider networks can be used to reduce costs by negotiating favorable fees
from providers, selecting cost effective providers, and creating financial
incentives for providers to practice more efficiently.
A survey issued in 2009 by America's Health Insurance Plans found that patients
going to out-of-network providers are sometimes charged extremely high fees. Other
managed care techniques include disease management, case management, wellness
incentives, patient education, utilization management and utilization review.
These techniques can be applied to both network-based benefit programs and
benefit programs that are not based on a provider network. The use of managed
care techniques without a provider network is sometimes described as
"managed indemnity."
Managed care organizations (MCOs)
There is a continuum of organizations that provide managed care, each
operating with slightly different business models. Some organizations are made
of physicians, while others are combinations of physicians, hospitals, and
other providers. Here is a list of common MCOs:
·
Group practice without walls
·
Independent practice association - IPA
·
Management services organization - MSO
·
Physician practice management company
THE EYE OPENER TO RISK MANAGEMENT
OPERATIONS
MCAR – MANAGED CARE REPORTS
Timely solutions to
funding, claims, pharmacy & distributions
We are
proud to introduce MCAR REPORTS a complete set of management reports for IPAs,
MSOs and PCP Practices that have Risk Agreements with HMOs Plans. The MCAR
Reports give you complete awareness over what is happening with every HMO Plan
that your organization participates in risk operations.
MCAR -
MANAGED CARE REPORTS is an online service available created from data files
downloaded from HMOs servers. Within 24 to 48 hours our team produces all
reports needed to manage your risk business. MCAR Reports are viewed from our
secured HIPPA compliant servers however most reports are downloadable in EXCEL
format files.
MCAR
Reports services can range from only generating reports to having our
management team assisting clients in managing the risk operations.
Clients
can select MCAR Report services “A LA CARTE” choosing monthly reports needed
and/or consulting services they prefer.
Here are some of the options available:
Here are some of the options available:
·
Control
over HEDIS requirements, alerting what measures apply to each member of the HMO
panel and most importing identifying what measures are pending per member in
the reporting period.
·
Summary
analysis of funding and expenses including expected distributions, in minutes
you know what is going on with your risk operation.
·
A
PCP Analysis that shows performance for each PCP in the network from funding,
expenditures to net amount after medical expenses. A simple and easy report
that enables you to identify and compare all PCP’s performance.
·
MCAR
produces a detailed analysis of charges payments and adjustments from
Institutional, Professional and Pharmacy claims.
·
A
key report - Summary Report showing what each member is costing the panel, a
brief breakdown of medical expenses also showing when was the last time the
patient came to the office, if ever.
·
A
detailed analysis showing all activities for every member - HEDIS measure
status, diagnosis codes with MRA evaluation plus each line item of expenses –
YOU CAN VIEW THE PRECISE COST OF EACH MEMBER OF THE PANEL.
·
STOP
LOSS verification.
·
MCAR
Reports claims module – “The ADJUDICATOR” scrubs your professional,
institutional and pharmacy claims and also prepares a contestation report
requesting adjustments from the Plan.
The
ADJUDICATOR module employs the most sophisticated scrubbing techniques
following CMS and AMA guidelines in processing professional and pharmacy
claims.
FOR MORE INFORMATION PLEASE
CONTACT:
HPP Management Group, Corp.
Developers of the AccuChecker
Product Line
Phone: (305) 227-2383
Email: sales@accuchecker.com
Website: http://www.accuchecker.com
Details at : http://www.accuchecker.com/MCAR.aspx
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