WHAT IS MANAGED CARE?

Managed care is the lowering of health care costs by limiting access to either services or providers.

Managed care cuts costs in two ways:
First, by paying providers limited sums of money. Most commonly this is done by giving a primary care physician (PCP) (your "regular" doctor) only a certain amount of money per patient per month. So, no matter how many times you see him in a month, he only receives the set amount for you. This is called "capitation."
Another way of limiting payments is a "provider list", which is a list of providers who have agreed to accept a lower rate for being on the managed care company's panel. If a provider is not on the panel then very often you will not be covered for seeing that provider.

The second way that managed care companies cut costs is by limiting services. Patients cannot simply go to see a specialist but must be referred from either the company or the PCP. By limiting access to specialists or tests, the company saves money. Also, many companies have "bonuses" or "withholds". A bonus is an extra amount of money at the end of the year a managed care company gives a PCP if she doesn't exceed a certain number of referrals; a withhold is an amount of money that is in a fund the managed care company holds that the PCP will not get if she exceeds a certain number of referrals. In some cases, a doctor can receive 140% of her base capitation amount if she limits referrals.

Managed care companies also have "gag clauses", which may be part of a physician's contract. These clauses limit your doctor from telling you about alternate treatments that the company does not pay for, even if you might need them. Managed care companies may also limit the drugs your doctor can prescribe for you.

The first thing to realize is that the managed care company is not working for you. It is working to maximize its profits and that means that any time it can avoid paying for a service it will.

WHAT SHOULD YOU DO IF YOU CAN'T GET YOUR BENEFITS?

1) Have your provider go through the entire appeals process. It is important you make certain he goes through all the steps.

2) If the provider cannot get services, go through your own appeal process. Once again, do not give up if you are unsuccessful at any level. It is important to understand that the company may deny benefits at lower levels even though it will ultimately give benefits upon appeal knowing that many people will not go through the entire process, thus saving the company money.

3) Contact an attorney. This is particularly important if time is of the essence. The entire appeals and grievance process could easily take six to eight months. By that time you or a family member could be harmed. The mere presence of an attorney and the prospect of being sued makes everyone take notice. This is especially the case if your hospital or doctor is under pressure from the managed care company to reduce services to you. Remember, with capitation or reduced fees there is an incentive for the provider or hospital to limit services since they will not get any more money by seeing you more often or providing more services. If you get an attorney involved, the hospital or provider may become concerned about a lawsuit and either pressure the insurance company more forcefully or provide the services.

4) Contact your State Insurance Department ( in New York: 800-358-9260). Often they will be able to obtain benefits. Even if they can't, it is important to report abusive practices.

5) Make certain you get everything in writing. Whether it is from your provider, the hospital, or the insurance company, ask for everything in writing, including a copy of your records. Also get everyone's name and number.

WHAT IF YOU ARE INJURED OR IF A FAMILY MEMBER DIED BECAUSE THE COMPANY WOULD NOT AUTHORIZE BENEFITS?

First of all, don't simply say: "Forget it, there's nothing I can do." Contact an attorney and begin the process of initiating a lawsuit. Most of the time this will cost you nothing since the attorney will take your case on "contingency." This means that if you are successful, the attorney gets a portion, usually between 25% and one-third of recovery less the costs. And, if you should be unsuccessful, you owe nothing to the attorney.

It is important for you to remember that medicine has changed. If you have managed care or belong to an HMO, your provider now has conflicting interests. You are not his sole concern because he has to deal with the managed care company, maintaining his relationship with them, and with the potential financial risks for providing too many services

WHAT SHOULD YOU SAY TO YOUR PROVIDER?

Since health care has changed and your doctor may have a financial interest in limiting services, you must try to protect yourself.

1) Express your concerns to your provider. By making him aware of them you will be subtly communicating that you will not accept anything less than the services you are entitled to.

2) Ask your doctor about her financial arrangements with the managed care company. Ask your doctor if she has any arrangement, like capitation or a withhold, to limit your care or not to refer you.

3) Ask your doctor about a "gag clause" that may restrict him from telling you about alternative treatments.

4) Ask your doctor about whether she is limited in prescribing medications to you.

5) Make certain that your provider doesn't give up and follows through with every appeal.

6) Make certain your doctor documents everything about your treatment and its necessity. Benefits can be denied more easily if the need for them is not well documented.

Remember: It is unfortunate but with managed care you must fight for what is rightfully yours.

(c) 1998 by David L. Trueman