Suite 603
Los Angeles, CA 90017
(213) 977-1215
fax (213) 977-0404
Hours: M-F 9:00-5:00
_____________________
Home Page
About Us
-Our Staff
-Directions
-Contact Us
-Links
Our Services
-ENT Articles
-BOTOX® Cosmetic
-Audiology and
Hearing Aids
-Assistive Listening
Device Store
For Our Patients
-Office Forms
-VNG Instructions
-Privacy Policy
Legal Disclaimer
Site Map
Copyright© 2010
LA ENT, Associates.
All rights reserved.
Managed Care: A Primer for Patients
by Richard W. Clark, M.D.
Many of our patients have chosen a managed care type of health insurance plan.
There are a number of different managed care plans, and the Los Angeles Ear,
Nose & Throat Associates participates in some of them. Managed care plans are
significantly different from the more traditional types of health insurance, and
it is not surprising that many patients find it difficult to understand their
benefits.This article is intended to answer the most common questions we receive from patients about managed care plans in general. If you have more specific questions about your plan, please ask our staff. We are eager to help.
Simply stated, a managed care plan is one in which medical costs, including doctors fees, hospital charges, and prescription costs, are held in check by closely managing the type of services that a patient receives. "Managing" is accomplished by requiring you to see your Primary Care Physician for all your medical needs, and by completing a process called "prior authorization" before you are allowed to see any specialist physicians or undergo certain tests.
A Primary Care Physician (PCP) is a General Practitioner, Internist, Family Practitioner, or Pediatrician who has signed an agreement to work with your managed care plan. As a patient in a managed care plan you must first see your PCP. Most plans allow patients to choose their PCP from an approved list. The number of PCPs on this list varies from plan to plan. The more PCPs that have signed up with your plan, the greater your choice.
To control costs, it is necessary for your managed care plan to make certain that all medical services are absolutely necessary. Accordingly, managed care plans require that all patients see their PCP for all of their medical needs. (The major exception to this rule is the right of women to see their gynecologist, as long as the gynecologist is a member of the managed care plan.) If your PCP determines that special tests, medications, or a referral to a medical or surgical specialist are necessary, he may be allowed in some cases to authorize the test or referral by himself. More often, however, as a further guard against overuse of tests and specialist visits, the PCP is required to first submit a request for these services to the plan. The plan – usually a committee – will then review the request and will either approve or deny the request. This process is known as requesting prior authorization for a service or specialty referral. In an emergency, authorization can be obtained rapidly. However, most authorization requests are for routine care, and the length of time required for approval of any referrals or services varies according to your plan.
Absolutely. It is essential for the patient covered by a managed care plan to understand that authorization must be obtained before he can see a specialist. Without prior authorization, he may be personally responsible for all the costs of the visit.
Authorization almost always includes strict limits as to the number of visits that you may make to the specialist, along with the services he can provide. For example, if your PCP refers you to a specialist and a month later you want to see the same specialist again, you'll probably need to first see your PCP once again and repeat the authorization process - even if you're seeking care for the same problem or condition. For example: You are referred to the Ear, Nose and Throat specialist for nasal allergy. During the exam you ask: "As long as I’m here, could you please check my hearing?" No. Unless authorization for a complete ear evaluation with hearing test was included, you'll need to see your PCP again and ask for another referral for a hearing evaluation. Your plan will not pay for special tests without specific authorization.
Yes and no. If you are referred to a specialist, you may have the option of selecting from a list of participating specialists, or you may be assigned a specialist. Remember that not all specialists have signed up to participate with every plan. However, you may not visit any specialist without a referral from a PCP, unless you want to assume the costs for the visit.
If the specialist determines that special tests or procedures are necessary, he will notify your PCP, who will then start the authorization process once again. It then becomes your plan’s responsibility, not the specialist’s, to decide whether or not to authorize the specialist’s recommendation. Contact your PCP, not the specialist, if you want to know the authorization status of any of the specialist’s recommendations.
Unless you have authorization for a follow-up visit, it is the policy of the Los Angeles Ear, Nose & Throat Associates that you contact your PCP for any medication refills.
Many managed-care plans require that you pay a co-payment at the time of your visit to the specialist. The typical co-payment is from $5 to $30. This must be paid before you can be seen. Since it costs, on average, $5 to $10 to send out a statement, it is customary to request your co-payment at the time of service.
Managed care is intended to control health care costs. Although as a patient you give up your option to see the specialist of your choice whenever you desire to do so, it may be worthwhile if you're benefiting from lower premiums. It is crucial that you read your plan carefully. If you understand that managed care means that your plan tightly manages your access to specialty physicians, tests, procedures, and some medications, then you're well underway to understanding how your plan works.
