Managed Care

Over half of Americans who have insurance are members of Managed Care plans, which include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service plans (POSs).

1. What is managed care?

   Managed care is an approach to health care that takes the cost of services into account. Its goal is to provide high-quality health care at a reasonable cost. Managed care plans provide services (treatment) to their members (patients) through a network of doctors, hospitals, laboratories, and pharmacies that are selected by the plan and under contract to work with the plan.

2. What is a “gatekeeper” and how can such a mechanism affect my care?

   Managed care is centered around the primary care physician, usually your family doctor or internist or pediatrician. This doctor provides most of your routine care, and controls your access to other doctors (specialists). Therefore, the primary care doctor is referred to as a “gatekeeper” for your care.

3. What is a case manager, and do I need one?

   A case manager is a person hired by your local insurance plan or hospital to monitor your ongoing care. It is often in the best interest of a cancer survivor to ask for a case manager to oversee their care. This ensures that there will be a person familiar with your case and care. Ask the case manager for his or her cell phone, direct phone number, pager number (if they have one), and, if needed, a number to call outside of normal business hours.

4. What kinds of problems do survivors have with managed care?

   Sometimes the plan or your primary care doctor declines to refer you to a specialist because they decide the specialist’s care is not medically necessary. Or, the plan refuses to pay for a certain test or treatment, especially if they consider it to be experimental or unproven. Sometimes the doctor you’re used to seeing is not under contract to the managed care plan, and his or her services are not paid for by your plan.

5. What should I do if I have trouble getting my care paid for by my managed care plan?

   To be most satisfied with your managed care plan, you will need to take an active role in working with the plan. You should make sure you are getting all of the benefits you are entitled to under your plan. To make sure your claims are paid fairly:

   • Send in your medical claims promptly.
   • Keep copies of all paperwork.
   • Make sure that you follow the insurance company’s rules, such as whether you must call a toll-free number before you go to the hospital.
   • Appeal (ask the company to reconsider) every time the company does not pay a health claim that is covered by the policy or does not pay as much as you think it should. You do not have to take “no” for an answer. Always:
     • Send the claim back with a letter explaining why the treatment was necessary and why your doctor’s charges were reasonable. Keep a copy of the letter for your records.
     • If the company rejects your claim again, ask that a doctor, instead of a clerk, look at your claim. Send it back with a letter that says, “I would like to request a review of this denial of coverage by the peer review physicians.”
     • If you call your insurance company, always get the name of the person you speak with and keep notes of what he or she tells you.
     • If the company still rejects your claim and you believe they are wrong, get the help of a state or federal agency, social worker, cancer support group, or an attorney.
     • Don’t give up.

 

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