Managed Care

I attended a telephone conference sponsored by Cancer Care called "Managed Care: What you need to know" in June, 1998. The speaker was Kim Calder, Associate Executive Director of the National Alliance of Breast Cancer Organizations (NABCO).

Fee-for-Service vs. managed care means there are three parties rather than two. The choice of providers is limited to those in the Health Maintenance Organization (HMO), and you and the provider have less control over medical decisions.

There is lots of managed care jargon. It is very important to understand all the alphabet soup. Ask lots of questions when things are not clear. Understand the type of plan you have and the role of health professionals in your plan. With HMOs, providers are divided into generalists (family doctors) and specialists. Family doctors are the gate-keepers. They decide how much service you need from a specialist.

Understand how your plan works. Plans are controlled by law, type and group size. Know and read your Membership Handbook or Guide. Understand your rights and responsibilities. It is not your doctor’s responsibility to know how your plan works. The doctor may participate in several different plans.

The advantages of managed care plans include lower out-of-pocket cost, no claim forms, and lower premiums. Checkups and preventive care are covered. HMOs are good at keeping people healthy, but not very good at helping people with chronic illnesses like VHL and cancer. The disadvantages include the fact that only the sevices of the 'network' provider are covered. You must obtain authorization to see a specialist, medical decision-making is subject to review and approval of the plan, and problems arise when patients have complex health problems.

When a request for service is denied, you should file an appeal or grievance. It is very important to follow the guidelines given for appeals in your membership handbook. Secure support from your family physician, specialist or their office personnel and focus on the decision being appealed. Appeals are usually worth the time and effort, and doctors are usually good at justifying their request for treatment. If legal action is necessary, make sure there is good evidence of the need. A letter from a lawyer is often helpful -- even if it’s your brother-in-law. However, if further legal advice or action is needed, make sure you have someone with expertise in insurance claims.

Helpful Numbers:

• Your local Bar Association for a lawyer with expertise in insurance issues
• Your state's Department of Insurance (in the blue pages of U.S. telephone books)
• Patient Advocate Foundation 1-800-532-5274