Page 90 - MEDICAL AND HEALTH INSURANCE
P. 90
MEDICAL AND HEALTH INSURANCE
Case management
Case management is used for serious and complicated medical intervention such as
cancer, major accidental injury, amongst others. The case manager will manage each
case separately and check that the treatment is delivered in the most cost-effective
manner.
Concurrent review
Concurrent review elaborates the necessity of continued hospitalization in a hospital
setting. It also reviews the length of stay and appropriateness of the treatment for the
medical condition.
Use of primary care physicians as coordinators and managers of care
Apart from utilization of management techniques, Managed-Care Organizations also
use gatekeepers in managing claim especially in cost control. The primary care
physician will provide the basic care and act as gatekeeper to authorize or refer to
specialist care for non-emergency cases. Essentially, this will provide control over
costs and appropriate utilization of healthcare services.
Settlement Methods
Paying the providers is an important aspect of cost control techniques in managed-
care plans. Compensation methods encompass risk-sharing and incentives can have
an effect on the provider behavior. There are various types of compensation
arrangements or settlement methods used in managed-care plans, as follows:
89 | P a g e
