Page 89 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

 Arrangement with selected providers to furnish a comprehensive set of

healthcare services to members

 They use primary care physicians as gatekeepers or managers of referrals for

specialty care or hospitalization.
 They provide a defined, comprehensive set of health services to a voluntarily

enrolled population

 They limit or eliminate out-of-pocket expenses to the enrollee, as long as they
seek care from the HMO panel hospitals

OTHER CLAIMS MANAGEMENT TECHNIQUES

A significant aspect of Managed-Care Organizations is the ability to contain costs by

using certain management techniques to manage cost-effective care. Through

utilization management, Managed-Care Organizations will be able to manage and
monitor the quantity, necessity, and appropriateness of healthcare intervention.

Utilization review is a tool used in utilization management and has clear advantages

over the traditional practice of retrospective claims audits. The appropriateness of the
medical treatment required can be reviewed upfront and even before the patient is

admitted.

Followings are the example of common utilization review methods:

Pre-authorization or Pre-certification admission

Prior to admission, the patient must seek approval that the admission is covered. It

will be reviewed by the Managed-Care Organizations to determine if the proposed

treatment is medically necessary and, if so, will be approved. If the proposed
treatment is deemed not medically necessary or can be treated as an outpatient, the

admission will not be approved.

88 | P a g e