Edward J. Goldberg, MD
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Edward J. Goldberg, MD

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Guide to Managed Health Care

More and more of our patients are covered by "managed care" health insurance. Managed care plans can usually be identified by the acronyms HMO, PPO, MCO, PHO, OHP and the like. Our Physicians are increasingly being asked by insurance companies to see managed care patients. They are often asked to sign managed care insurance company contracts, in which we agree, in exchange for having patients insured by the plan referred to us, to abide by strict plan guidelines.

Most managed care plans have requirements for us to follow. Should we fail to follow those requirements, we can be prohibited from seeing patients covered by that plan. You, likewise, could incur increased healthcare costs - costs not covered by your insurance.

Managed care plans often have one or more of the following requirements:

1. WE SEE ONLY THOSE PATIENTS WITH INSURANCE REFERRALS FROM A PRIMARY CARE PHYSICIAN (PCP)

2. THERE IS A CO-PAY OBLIGATION BY THE PATIENT, AND;

3. PRIOR AUTHORIZATION AND/OR A SECOND OPINION IS NEEDED BEFORE SURGERY IS PERFORMED.

4. IF WORKMAN'S COMPENSATION, AN AUTHORIZATION IS REQUIRED.

There is a good chance that your insurance plan has one or more of those managed care requirements. If it does, we are obligated to follow them. These requirements may not always be pleasant for your medical treatment as timely as you would like; but they may be a part of your managed care program.

Here are some common features of managed care plans:

1. Prior Referral Before Treatment

An increasing number of managed care plans require that you first obtain an insurance referral from your primary care physician (PCP) before being permitted to visit with us. These insurance referrals may take seven (7) days or more, to obtain. Specialists who diagnose or treat managed care patients without prior referrals may not be reimbursed by the insurance plan for their services and risk being excluded from seeing plan patients at all. Patients who see specialists without insurance referrals risk being 100% responsible for the costs.

2. Co-Payments

Co-payments are the portion of the fee for services for which the member is responsible. Insurance companies believe that having the insured patient responsible for a portion of the total bill will affect the patient's decision to see a doctor. Our Contracts with managed care companies place upon us a responsibility to collect the required CO-payments at the time of service.

3. Prior Authorization

Being insured under managed care creates the responsibility of obtaining authorization from the insurance company before surgery or hospitalization. We are willing to assist in obtaining the necessary authorization. In some cases, the managed care company requires the opinion of a second physician before surgery is authorized. Obtaining authorization, or arranging for a second opinion, may create lengthy delays.

4. Third Party Pay Responsibility

The cost of medical care for some patients may be covered by some source other than their private insurance company. On-the-job injuries, and injuries received in a motor vehicle accident, are a couple of examples. Despite third-party responsibility for the payment of medical expenses, we are still required by our managed care contracts to obtain the managed care referral for treatment and prior authorizations before services are performed. As such, patients still need to obtain this referral before being seen.

Medical Care Delivery Is Changing

We are no longer able in non-emergency situations to schedule and treat patients as we used to do. Managed care insurance programs require all of us, patient and physician alike, to obtain referrals or permission before a patient can be treated. Please understand that we are trying to make the system work as it is designed. We are pleased to have you as a patient; however, before we can treat you it may be necessary to comply with the managed care guidelines of our insurance company.

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