Managed Care

FAQs for Managed Care

  • What are my risks from an informal "curbside consult"?

    Historically, the courts have looked for a formal physician-patient relationship as the basis for risk exposure. Court decisions have given increased consideration to factors such as whether:

    • A contractual agreement created a relationship,
    • Actions by your employees implied your willingness to establish a physician-patient relationship, or
    • Treatment or diagnostic decisions by your consulting colleague indicate substantial reliance on your advice.

    If your curbside consult takes on any of these characteristics, follow up on the patient's care as you would for a formal consult.

    Additional Resources

    1. Consultation Guidelines for Primary Care Providers [PDF]
    2. Curbside Consultations [PDF]
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  • How do I reduce the risks associated with an increased patient load?

    Clinicians seeing an increasing volume of patients might consider:

    • Reducing paperwork with electronic clinical information systems. Available systems automate processing of health insurance claims, produce medical outcomes information needed by managed care organizations, generate patient education materials, and generate reminders for routine and follow-up care for your patients.
    • Meeting regularly with office personnel to assess existing office systems and develop protocols for streamlining routine activities such as follow-up on missed appointments and referrals, telephone call documentation, and scheduling of diagnostic tests.
    • Employing continuous quality improvement and patient safety concepts that involve and educate office staff in changing requirements and procedures.
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  • What patient safety issues may arise when a specialist assumes a primary care role or vice versa?

    Specialists assuming primary care duties run the risk of overlooking problems outside their specialty. Physicians accustomed to treating only one aspect of a patient's needs must be especially vigilant about maintaining responsibility for the whole patient, both in preventive care and in following up on referrals to specialists. Clinicians whose roles and patient bases are changing might consider continuing medical education programs targeting those changes.

    Primary care providers may find they are doing things that were previously done only by specialists. Clinicians whose roles and patient bases are changing need clear guidelines (systemwide or personal) for when to refer. For those new practices that are being assumed, continuing medical education programs targeting those areas is also recommended.

    Additional Resources

    1. Consultation Guidelines for Primary Care Providers [PDF]
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  • What are my responsibilities if care I recommend is disapproved by a third-party payor?

    Insurance coverage does not dictate clinical needs or decisions. You must advocate for the care or treatment warranted by your patients' conditions. Be direct with patients and their managed care organizations (MCOs). Become familiar with the MCO's appeals and grievance process. If necessary, make an appeal, or prompt an appeal by the patient or employer. Move up within the MCO as necessary to reach a key decision maker. Ask to speak to a physician reviewer within the MCO, ideally one trained in the specialty in which treatment is sought.

    If treatment is still not approved, dispassionately make your case to the MCO's medical director in a letter. Do not "cc" state agencies, medical societies, or others as a technique of intimidation. Based on the outcomes of those advocacy efforts, you then need to obtain your patient's informed consent to, or refusal of, treatment. You may need to assist patients with alternative payment options. Include patients (and family members wherever possible and appropriate) in the decision process. Consider reasonable alternatives to a rejected treatment plan.

    Additional Resources

    1. Bedside Rationing of Health Care Services [PDF]
    2. Health screening test is not covered by the patient's MCO [PDF]
    3. Appealing an MCO's denial of coverage for recommended treatment [PDF]
    4. An MCO recommends that you observe specific practice guidelines [PDF]
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  • What are my responsibilities if I'm called regarding an unfamiliar patient in the ED?

    If you receive a call from an Emergency Department regarding an unfamiliar patient and

    1. this patient is new to your practice,
    2. the patient is someone listed on your managed care panel but whom you have not yet seen, or
    3. you are on that day's ED on-call list, your responsibilities are, basically, the same. When you are called, you are required to make and document appropriate decisions about the care of the patient and convey those decisions to appropriate personnel.

    Find out as much about the patient's condition as possible. Under federal law, ED personnel must do a medical screening on all patients to determine whether an emergency condition exists before asking the patient about insurance coverage. Depending on the medical situation, you can then decide what would be the most appropriate course of treatment:

    • Have the ED personnel treat the patient with your consultation and have the patient call your office for follow-up
    • Ask the ED personnel to call in a specialist to treat the patient and have the patient call the specialist's office to schedule a follow-up appointment if necessary
    • Decide to go to the emergency department to treat that patient.
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  • Can I transfer a "difficult" managed care contract patient?

    Check with the MCO before taking any action to terminate your relationship with a patient. Specific legal criteria must be applied before any determination is made for "disenrollment" of the member.

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